Vol 1 No 1

Review of Global Medicine and Healthcare Research Vol. 1 No. 1 Proceedings of the 3rd International Online Medical Conference (IOMC 2010) Editors: Forouzan Bayat Nejad Mostafa Nejati Mensura Kudumovic Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 2 Review of Global Medicine and Healthcare Research (Vol. 1 No. 1) Proceedings of the 2010 International Online Medical Conference (IOMC 2010) DRUNPP Publishers 2010 ISSN: 1986-5872 Websites: http://www.iomcworld.com/rgmhr/ http://www.iomcworld.com/2010/ IOMC 2010 Conference Advisory http://iomcworld.com/2010/committees.htm Board/Scientific Committee Members: Conference Reviewers: http://iomcworld.com/2010/reviewers2010.htm Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 3 Editorial Review of Global Medicine and Healthcare Research Forouzan Bayat Nejad & Mostafa Nejati * * IOMC 2010 Conference Managers Email: [email protected] On behalf of IOMC 2010 Conference secretariat and the International Online Medical Council (IOMC), we would like to thank everyone who contributed to the conference and made it another success, specially the Conference Advisory & Committee Board Members, Reviewers, Panelists & Judges, and the conference participants & presenters. Having said that, we are glad to inform you about launching of this new periodical publication entitled “Review of Global Medicine and Healthcare Research”. It will mainly cover the papers from IOMC Conferences. The IOMC secretariat has already tarted to index this publication and its papers in renowned databases, whcich we will later update you on it accordingly. Thank you once again and we wlook forward to seeing you in IOMC 2011. For more information, please visit our official website at http://www.iomcworld.com/ Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 4 Table of Contents  OPTIMUM NUMBER OF ANTENATAL VISITS AMONG ANTENATAL MOTHERS TO REDUCE LOW BIRTH WEIGHT BABIES AS AN OUTCOME ................................................... 9  VENTRICULAR ARRHYTHMIA RISK IN ELDERLY HEART FAILURE PATIENTS ........ 18  TRAJECTORY OF ALCOHOL USE AND RELATED PROBLEMS AMONG UNIVERSITY STUDENTS IN BELARUS................................................................................................................. 30  STUDY OF ANTHROPOMETRY IN INDIVIDUALS HAVING PARENTAL HYPERTENSION ............................................................................................................................... 41  TRANSCULTURAL DIFFERENCES IN ALCOHOL USE AMONG SLAVIC, ARABIAN AND NIGERIAN STUDENTS: A CASE STUDY IN BELARUS ............................................................ 56  DETERMINANTS OF QUALITY OF LIFE FOR JAMAICA WOMEN ..................................... 65  TOTAL PHENOLIC CONTENTS OF SELECTED FRUITS AND VEGETABLES COMMONLY FOUND LOCALLY IN MALAYSIA ...................................................................... 81  THE ROLE OF INFORMATION TECHNOLOGY IN PREVENTING MEDICAL ERRORS 89  KNOWLEDGE OF FIRST YEAR MEDICAL STUDENTS ON HIV/AIDS ................................ 96  VALUE OF PLEURAL FLUID ADENOSINE DEAMINASE IN TUBERCULOSIS ............... 104  HIP RESURFACING ARTHROPLASTY FOR SEVERE OSTEOARTHRITIS SECONDARY TO LEGG-CALVÉ-PERTHES DISEASE - A CASE REPORT AND CURRENT LITERATURE REVIEW ................................................................................................................. 119  ROLE OF TITANIUM PROSTHESIS IN OSSICULOPLASTY................................................. 125  EFFECTS OF HOMEOPATHY REMEDY SYZYGIUM JAMBOLANUM ON GLUCOSE LEVEL, LIPID PROFILE AND HISTOLOGY OF PANCREAS OF STREPTOZOTOCIN INDUCED DIABETES RAT ............................................................................................................ 135  CHANGING DEMOGRAPHICS OF RHEUMATIC HEART DISEASE IN WESTERN WORLD: A CASE REPORT OF MITRAL STENOSIS AND BRIEF REVIEW OF LITERATURE................................................................................................................................... 146  NUTRITIONAL ASSESSMENT OF DIALYSIS PATIENTS AT A MALAYSIAN NATIONAL KIDNEY FOUNDATION CENTER ............................................................................................... 155  Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 5 NUTRITIONAL ANEMIA IN MEDICAL STUDENTS ............................................................... 163  THE RISK FACTORS OF DEVICE-RELATED INFECTION IN NURSE PRACTICE ......... 170  CURE FOR HEMOPHILIA: GENE, STEM CELL OR TRANSPLANT? ................................. 179  EFFICACY OF PROPHYLACTIC MEASURES FOR MALARIA ........................................... 195  THERAPEUTIC AND CLINICAL APPLICATIONS OF L-CARNITINE AND ITS CONGENERS AS A POTENT NUTRIGENOMIC MEMBRANE MOLECULAR ANTIOXIDANTS IN HEALTH AND DISEASE ........................................................................... 215  DETERMINANTS OF SCHOOL DROPOUTS IN CHILDREN ................................................. 232  SELF MEDICATION WITH H1-ANTIHISTAMINES AND PAIN RELIEVING AGENTS AMONG THE EDUCATED YOUNG ADULT PEOPLE OF BANGLADESH ......................... 246  DATE RAPE DRUG AWARENESS AMONG COLLEGE GIRLS ............................................ 255  THE DILEMMA OF ENTERAL AGAINST PARENTERAL NUTRITION FOR THE SURGICAL PATIENT – A REVIEW ............................................................................................. 264  PULMONARY LUNG FUNCTIONS IN SUGARCANE HARVESTERS WHO SMOKE ....... 276  INFLUENCE OF PROTEASE INHIBITORS ON THE PHARMACODYNAMICS OF GLICLAZIDE IN RATS .................................................................................................................. 284  ANAEMIA PREVALENCE & SOCIO-DEMOGRAPHIC ASSOCIATES AMONGST PREGNANT WOMEN ..................................................................................................................... 298  WHITE PHOSPHORUS BURN: CASE REPORT ........................................................................ 303  THE ROLE OF ANTHOCYANIN AND FLAVONOIDES IN PATIENT WITH DIABETES MELLITUS - TYPE II ...................................................................................................................... 305  ILIZAROV FOR PELVIC FRACTURES ...................................................................................... 316  STUDY OF PSYCHIATRIC MORBIDITY AMONG PULMONARY TUBERCULOSIS PATIENTS ......................................................................................................................................... 322  STUDY OF SLEEP DISTURBANCES AFTER MINOR HEAD INJURY ................................. 340  SEROPREVALENCE OF HEPATITIS B AND C AMONG BLOOD DONORS AND A PROFILE OF HEPATITIS B SEROPOSITIVE BLOOD DONORS .......................................... 352  VERY LATE RECURRENCE OF EWING'S SARCOMA – A WORTHY CHALLENGE ..... 363  Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 6 TUBERCULOUS PERICARDITIS – A CASE REPORT AND REVIEW OF LITERATURE 366  EFFECT OF ALPHA LIPOIC ACID ON OXIDATIVE STRESS AND VASCULAR CELL ADHESION MOLECULE LEVEL IN DIABETES MELLITUS INDUCED RATS ................. 370  PARA PHENYLENE DIAMINE POISONING-CLINICAL MANIFESTATIONS & SHORT TERM PROGNOSIS ........................................................................................................................ 379  CLINICAL PROFILE OF KALA-AZAR (VISCERAL LEISHMANIASIS) IN NORTH BIHAR383  DENGUE HEMORRAHGIC FEVER – CORRELATION OF IGG & IGM VALUES & PLATELET COUNT ........................................................................................................................ 391  ROLE OF OXIDATIVE STRESS AND ANTIOXIDANTS IN CHILDREN WITH IDA ......... 395  PERCEIVED STRESS AMONG TOMORROW’S ATTORNEYS IN MANSOURA, EGYPT 397  A HOSPITAL BASED CROSS SECTIONAL STUDY OF MUCOCUTANEOUS MANIFESTATIONS IN THE HIV INFECTED ............................................................................ 398  A STUDY ON TUBERCULOUS PLEURAL EFFUSION ............................................................ 400  RISK FACTORS FOR BREAST CANCER AMONG WOMEN ATTENDING A TERTIARY CARE HOSPITAL IN SOUTHERN INDIA .................................................................................. 402  LIVER TRAUMA: OPERATIVE AND NON-OPERATIVE MANAGEMENT ........................ 404  EVALUATION OF FALCIVAX AGAINST QUANTITATIVE BUFFY COAT (QBC) FOR THE DIAGNOSIS OF MALARIA .................................................................................................. 405  SEVERITY OF MENOPAUSAL SYMPTOMS AND THE QUALITY OF LIFE AT DIFFERENT STATUS OF MENOPAUSE: A COMMUNITY BASED SURVEY FROM RURAL SINDH, PAKISTAN........................................................................................................... 407  PERCUTANEOUS VALVE REPLACEMENT: WHERE DO WE STAND? WHERE ARE WE GOING? ............................................................................................................................................. 409  EVALUATION OF SERUM LEVELS OF INTERLEUKIN-6 AND INTERLEUKIN-8 IN PATIENTS WITH RECURRENT APHTHOUS ULCERATIONS ............................................. 410  SERUM INTERLEUKIN-6 AS A SEROLOGIC MARKER OF CHRONIC PERIAPICAL LESIONS; A CASE-CONTROL STUDY ....................................................................................... 411  NOVEL IN SITU GEL SYSTEM FOR EFFECTIVE TREATMENT OF BACTERIAL CONJUNCTIVITIS .......................................................................................................................... 412  Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 7 COMPUTER TOMOGRAPHY ANGIOGRAPHY AND DIGITAL SUBTRACTION ANGIOGRAPHY AS TWO VALUABLE METHODS IN THE EARLY DIAGNOSIS AND TREATMENT OF INTRACRANIAL ANEURYSMS - A COMPARATIVE STUDY .............. 415  COMPARISON OF CLIPPING VS COILING AS METHODS OF TREATMENT IN POORGRADE SUBARACHNOID HEMORRHAGE.............................................................................. 416  COMPARING DIFFERENT ANTIEMETIC REGIMENS FOR CHEMOTHERAPY INDUCED NAUSEA AND VOMITING ............................................................................................................ 417  INFLUENCE OF ALPHA-LIPOIC ACID ON STREPTOZOTOCIN INDUCED DIABETIC CARDIOMYOPATHY IN ADULT MALE ALBINO RATS: A BIOCHEMIACAL AND MICROSCOPICAL STUDY ............................................................................................................ 419  A NOVEL PSYCHOPHYSIOLOGICAL MODEL OF THE EFFECT OF ALCOHOL USE ON ACADEMIC PERFORMANCE ...................................................................................................... 420  DEVELOPING A TRANSGENIC MARKER TO RESEARCH HUNTINGTON’S DISEASE IN DROSOPHILA MELANOGASTER ............................................................................................... 422  IMPLICATIONS OF WEIGHT GAIN DURING PREGNANCY IN PAKISTAN .................... 423  NARAKAS CLASSIFICATION OF OBSTETRIC BRACHIAL PLEXUS PALSY REVISITED425  OUTCOME OF MACROSOMIC INFANTS IN A LOWSOCIOECONOMIC GROUPS........ 430  Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 8 when other variables held constant. Antenatal records of each mother were reviewed according to the selection criteria. compared to mothers with visits less than eights. 1 (2010) 9 . and the majority of them were Malays (62. nonsmokers and majority of them (83%) of them were between the ages of 18 to 34 years. Malaysia Email: [email protected] %). married (96. Review of Global Medicine and Healthcare Research .Optimum number of antenatal visits among antenatal mothers to reduce low birth weight babies as an outcome  Hematram Yadav Department of Community Medicine International Medical University Bukit Jalil. This study shows that mothers with less than eight visits had twice the risk of having low birth weight babies as compared to mothers with eight visits and more.edu. Kuala Lumpur.my Nor Ani binti Ahmad Public Health Institute Jalan Bangsar. The mean gestation week at delivery was 38.1% having at least secondary education level.97 kg. with 70. the antenatal care services are provided by both public and the private sectors. married. Face to face interview was also done to collect other data. 1 No.Vol. Conclusion: Mothers with less than 8 antenatal visits had twice the risk of having low birth weight than the normal birth weight babies. This study showed that the minimum number of antenatal visits required for low risk mothers to reduce the low birth weight incidence was 10 antenatal visits although the mothers wanted to have about 7 visits. The odds of having low birth weight babies among mothers with ten antenatal visits reduced by 91%.5%). The prevalence of low birth weight among low risk mothers in the district was 9.45 weeks. conducted in the Kuala Muda District of Kedah in Malaysia.5 years. This study aims to determine the optimum number of antenatal visits required for low-risk mother taking the low birth weight as the outcome indicator.7%. Malaysia Abstract Introduction: In Malaysia. Discussion: Majority of the mothers had at least secondary education. while mean birth weight of baby at birth was 2. Ministry of Health. Materials and methods: It is a cross sectional study. Results: The average age of the pregnant mothers was 28. Using the low birth weight as an outcome indicator it is proposed that the low risk mother need to have only 10 visits as the benefits are the same after 10 visits. Based on the report. health clinics with or without Family Medicine Specialist. Conditions are then monitored or treated to ensure a safe delivery and better outcomes. resulting in up to 16 visits during pregnancy with little or no distinction between high and low-risk mothers. the category of staff providing the service. The suggested visits include. Mathai9 had suggested a reduced number of antenatal visits for low-risk pregnancy in under-resourced settings. the minimum number of goal-oriented antenatal visits in the low risk women should be at least four. with little adaptation made for differing local circumstances. maternal and child health. in many of these developing countries where resources for reproductive health care are sparse or used inefficiently. had proposed to reduce the number of prenatal visits for low-risk nulliparous women to 10 visits and for low-risk. the care often consist of irregularly spaced visits with long waiting time and poor feedback to mothers. antenatal visits. with the traditional model. monthly until 28 or 32 weeks' gestation. the National Institutes of Health Expert Panel on Prenatal Care. 1 (2010) 10 . pre-eclampsia and altered fetal growth. However. and also hospital with or without an Obstetrician.1 The rationale of this schedule is based on the theory that regular visits with predefined content enable midwives and doctors to detect conditions in the mother and the baby that may threaten their health. the traditional model of antenatal care has become the recommended standard. Even at the public sectors.2 In 1989. Malaysia Introduction Traditionally. antenatal visits were scheduled as. In the developing world. then fortnightly until 36 weeks. Various studies3-8 had noted no significant difference in the obstetric outcomes of low risk pregnancies when comparing the new model. 1 No. However.Vol. community health clinics. and accurate determination of gestational age using available tools. the schedule of antenatal visits is not ordered by a set of clearly defined maternal or foetal requirements. at 32 weeks to identify pregnancyinduced hypertension. the antenatal care services are provided by both public and the private sectors.e. first visit during first trimester with the purpose of eliciting details of previous pregnancy outcomes and maternal diseases. the basic services provided are similar. and weekly thereafter until delivery. identify and treat women with anemia and syphilis. In Malaysia. which advocate less antenatal visits. and various other factors. low birth weight.Key words: antenatal care. According to this routine. parous women to 8 visits. from their traditional 14 visits. monitoring of maternal and fetal conditions to look for any complication which needs referral for further management if at the peripheries. the services available at the health centre. i. and at 36 weeks to Review of Global Medicine and Healthcare Research .2 The assessment done during the antenatal visits depend on various factors such as the health status of the pregnant women. In 1998. but by a routine established in United Kingdom in 1920s. Subsequent visits include: at 22 to 28 weeks to record blood pressure and symphysis-fundus height measurements. different set of services are provided based on the site of care namely. Malaysia in 2000. and Thailand to compare the standard model of antenatal care with a new model. 1 (2010) 11 . The mothers’ preference of number of ante natal visits for low risk pregnancies will be also determined. Malaysia. Using EPI INFO 6 for a cross sectional study with 10% prevalence of low birth weight. to be done within one year. a multicentre randomized controlled trial10 was conducted by WHO in 53 clinics in Argentina. Odds Ratio was set at 2. From 1996 to 1998.13 Over the years. 12noted that there is no association between number of visits and maternal intrapartum complication or birth weight of the babies.15 This study aims to determine the optimum number of antenatal visits required for low-risk mother taking the low birth weight as the outcome indicator. the exact optimum number of antenatal visits for low-risk pregnancies should be identified. Based on significance level which was set at 0. four antenatal visits appeared to be the minimum that should be offered to a low risk pregnant women. Kedah. based on the Model of Good Care. 1 No. i. Materials and Methods This study is a cross-sectional study.14 However in order to assess whether it is necessary to reduce the number of visits for low risk pregnancy locally. Based on the sample size Review of Global Medicine and Healthcare Research . and so it can be implemented without major resistance from women and providers of health care at reduce cost. Cuba. which meant a different of twice the risk of having low birth weight was considered as significant. The study revealed that the provision of routine antenatal care by the new model seemed not to affect both the maternal and perinatal outcomes.e. who were coded white or green during last antenatal check-up based on the colour coding system for Risk Approach Strategy currently used in Ministry of Health. Saudi Arabia.Vol. An antenatal visit is defined as an intentional encounter between pregnant women and a midwife or doctor to assess and improve maternal and fetal well being through out pregnancy and prior to labour 16 The required sample size was calculated based on the prevalence of low birth weight in Malaysia (9. conducted in the Kuala Muda District. The Report of the National Research Priorities in Reproductive Health for Malaysia during the Sixth Meeting of the Regional Advisory Panel (RAP) for Asia and Pacific in 2002 had identified several areas for research purposes. antenatal visits of eight or more are considered as adequate care.0.9 visits in 2001. The result showed that women in the new model had a median of five visits compared with the eight visits in the standard model. The study population consists of all low risk mothers.7% in 2000).4 visits per mother in 1975 to 8.05 with 95% confidence interval and 80% power of study. the estimated sample size was 737 subjects. A study in Perak. The frequency of antenatal visit had been identified as the Priority One. In Malaysia. the average number of antenatal visits per pregnant mother had improved tremendously from an average of 4.identify malpresentations and initiate appropriate action such as referral for external cephalic version for breech presentation. In 1999 Cochrane review11 had concluded that based on various trials evaluating the number of visits. The white and green code is an identification of low risk pregnant women. transferred cases. There were 87 non-responders due to defaulted follow-up resulting in 88. those mothers who received postnatal care (at one month postpartum) in all the health centres in the district. Data was analysed using summary statistics. multiple pregnancies. and the majority of them were Malays (62. and consent forms were attached to eligible records. Data was collected using the Data Collection Form which consist of two sections. Consent from the mothers was taken at the registration at the clinics for postnatal check-up at one month postpartum. family income). social problem (marital status. with 70. and the number of comprehensive antenatal visits.1% having at least secondary education level. The socio demographic profile of the non-participate mothers including mothers who defaulted follow-up were taken to compare with the profile of the participating mothers to avoid any bias in the study. Systematic random sampling from the sampling frame was done.5 years. (table 1) Review of Global Medicine and Healthcare Research . parity. The raw data was stored as both hard copies and in software using Statistical Package for Social Science. mothers who gave birth after 1st August 2003 and before 31st March 2004. The Odds Ratio was calculated followed by Logistic Regression to look for interaction or confounding. SPSS Version 11.Vol. 1 No. followed by every second case. married (96.required. The exclusion criteria included high risk mothers (coded either yellow or red during last check-up). and those who received antenatal and/or postnatal care at private clinics.5 %). socio economic status (education levels. were checked by the researcher and the assistants according to the selection criteria. body mass index in the first trimester (as a proxy of pre-pregnancy BMI). Before the implementation of the study. either in or out. smoking). Written consent of every selected mother was sought before the interview. 737 mothers were selected using systematic random sampling during the period of the study. Among the independent variables studied included. 1 (2010) 12 . The first case was selected randomly.5%).05. followed by bivariate analysis using Chi-square test. and also adjusted odds ratio. Inclusion criteria of the subjects included low risk mothers based on the colour code given during last antenatal check-up. who were under postnatal care by the clinic staff. The significance level of the statistical test was set at 95% Confidence Interval and α was set at 0. inter pregnancy interval. mothers who gave birth before 22 weeks. the researcher briefed the assistants about the objective of the study and trained them in conducting the interview. Results The average the age of the mothers was 28. first section which required face-to-face interview and the second section which required extracting data from the identified records.5.2% response rate. Antenatal records of each mother. 97 kg. with the dependent variable of low birth weight. Variables Number (%) Mean (SD) 1. The prevalence of low birth weight among low risk mothers in the district was 9. n=650 Variables Age in years Ethnic Malay Chinese Indian Others Education level No formal education Primary school Secondary school Tertiary level Household income (44.0%) 64 (9.19) 9. Bivariate analyses was done.08) 172 (26.4%) 120 (18.09) Parity Inter pregnancy interval (in month) Colour Code White Green Gestation week at first check-up (in week) BMI in first trimester (kg/m2) Number of antenatal visit SD: Standard Deviation BMI: Body Mass Index Table 2 shows the first check of these mothers was about 12.47 (0.9%) 80 (12.5%) 621 (95.21) 22.7% (63 mothers).5%) 23 (3. age.5%) 17 (2. 1 (2010) 13 . to look for association between independent variables and low birth weigh among low risk mothers and it showed that there was a significant association between the number of antenatal visit.Table 1: Socio demographic profile of the mothers. and 38 mothers (5.81 (0.8%) had pre-term deliveries.3%) 494 (76.5%) 12.66 weeks (about three months) and the average BMI was around 22. 1 No. inter pregnancy interval.58 (0.21) 360 (55.6%) 12 (1.06) 23.8%) RM1 542.5%) Table 2: Obstetric Profiles of the low risk mothers.Vol.61 627 (96. parity.5%) 153 (23.45 weeks. This study also revealed that the mean gestation week at delivery was 38. Low risk Review of Global Medicine and Healthcare Research .66 (0.5%) 29 (4. while mean birth weight of baby at birth was 2. n=650.09 (0.71) Marital Status Married Unmarried/widow/divorcee Ever smoke during pregnancy No Yes SD: standard deviation Number (%) Mean (SD) 28.53 (0.5%) 478 (73. Table 3 shows the result of logistic regression. compared to mothers with visits less than eights.08.Vol. the odds of having low birth weight babies among mothers with ten antenatal visits reduced by 91%. Other variables were found to be not significantly contributed to the occurrence of low birth weight infants. and all the significant variables were independent variables.049 – 1. 1 (2010) 14 . compared to those after the first trimester (p=0. To find the minimum number of visit that had the lowest percentage of low birth weight. 9 visits. 10 visits.027). Crude OR: 2.63).076 0. interpregnancy interval.10).282 Review of Global Medicine and Healthcare Research . the odds of having low birth weight reduced by 94%.18.844. 95% Confidence interval: 1. Among mothers with 12 visits.163) 0. when other variables held constant. and smoking status. Crude OR: 2.0%. Analysis was done only for mothers. Among the low risk mother who had antenatal care in first trimester. 12 visits.141 – 1. body mass index at booking of less than 18.58. pre-term delivery. 95% CI: 1.238 (0. This study also shows that ethnic Indian mothers are having a higher prevalence of low birth weight (p=0. compared mothers with visits less than 8. Result also noted that the Hosmer and Lemeshow test was not significant (p=0.mothers with less than eight visits were noted as having twice the risk of low birth weight compared to mothers with more than eight visits (p=0. and > 13 visits. which showed an average ‘percent of variance explained’ of 18%. the odds of having low birth weight infants among ever smokers were 15 times of non-smokers. which indicate a well-fitting models. In addition. 8 visits. Low risk mothers who had ever smoked during the pregnancy were noted to have about three times higher risk of having low birth weight infants compared to mothers who were non. 1 No.499 (0.20 – 3. and parity. age.013 0.5 kg/m2 had significantly higher percentage of low birth weight infants (p=0. and result of the logistic regression had noted no significant interaction or confounders.24 – 4. Furthermore. Body Mass Index (BMI) at first trimester. with other variables being held constant. 95% CI: 1. Table 3: Logistic regression analysis of the number of visit and low birth weight Variables Antenatal visit Less than 8 visits 8 visits 9 visits Adjusted ORa (95% CIb) 1 0. 13 visits.000) compared to the Malay and Chinese mothers. Antenatal visits were recoded into eight groups namely.788 (7) 3. Crude Odds Ratio: 2. antenatal visit which is a continuous variable was changed to a categorical variable. Result of the analysis had noted that R2 was 0.146 (1) 1. Logistic Regression was done with low birth weight as the dependent variable.157 (1) p value 0.smokers (p=0. when other variables held constant. when other variables held constant. < 8 visits. A significantly higher prevalence of low birth weight was also noticed among mothers who initiated antenatal care during first trimester. 11 visits. compared mothers with visits less than 8.041. who initiated care during first trimester.006.60). df =8) while. classification table showed an overall percentage of 88. Logistic regression analysis had also noted that the odds of having low birth weight infants among Indian mothers were six times of Malay mothers.01 – 6.008. Other covariates included were ethnicity.28.771) LRc Statistic (dfd) 17. the odds of having low birth weight infants among mothers with 11 antenatal visits reduced by 86%. when other variables held constant. 059 (0.542 (0.288 (2) 0.059 (1) 0.066 More than 13 visits 0.671 5 years and > 0.721 (1) 0.8% of the mothers were either primigravidas.00 Pre-term delivery Pre-term 1 Term 0.180 (1) 0.835) 0.10 visits 0.370 (0.190 2-5 years 1.023) 10.7% of them had ideal Body Mass Index (BMI).103 (0.145 (0.999 35 yrs and > 0.603 (1) 0.468) 8.011 – 1.511 (2) 0. and 61.999 Inter pregnancy interval Primip 1 2.18 Result of the face-to-face interview of the mothers in this study noted that 92. 1 (2010) 15 .840 (0. Review of Global Medicine and Healthcare Research .352 (0.204) 2.595 – 13.288 (1) 0.000e Others 0 Smoking Status Smokers 15.010e 12 visits 0.866 Para 1-4 1.592 Para 5 and > 0.600 (1) 0. 500.999 Parity Primip 1 0. Fifty three percent of the low risk mothers initiated care during first trimester.226 18. Eighty three percent of the mothers in this study were between the ages of 18 to 34 years.2% of the mothers were satisfied with the current schedule of antenatal visits. were non-smokers and their household income was between RM500 to RM1.206 25 kg/m2 and > 0.205 – 3.489 (0.771 18 – 34 yrs 0.308 (1) 0.00 0. Based on the status at the initiation of antenatal care. Discussion Majority of the mothers had at least secondary school education.124 (0.320 – 5.009 – 1.5 – 24.05 b CI: Confidence Interval ddf: Degree of Freedom r2 =0. 1 No.749 Indian 6.983 (1) 0. The mean number of visits preferred by the mothers in the study population for low risk pregnancies was 7.776) 15.159) 3.763) 1.520 (2) 0.091 (0.769 (1) 0.9 kg/m2 0.00 0.00 (1) 0.003e 13 visits 0.809 a c e OR: Odds Ratio LR: Log Likelihood Ratio significant at p<0.015 (2.972 (2) 0.001e Non smokers 1 Pre-pregnancy BMI < 18.179 (2.033 – 0.096 Age < 18 yrs 1 0.559 (1) 0.009 – 0.770 (0.373) 0.400) 1.018 -0.210 – 1.5 kg/m2 1 2.6% had inter pregnancy interval of more than two years but less than five years.004e 11 visits 0. at booking of antenatal care.00 0.00 0.Vol.001 Chinese 0.953 – 78.448 – 14. and 49.102 (1) 0.000 0.635) 6.512 (3) 0.103 – 1.866) 0. or para one to four. 95.348 – 6.091 Ethnic Malay 1 17.257 (1) 0.400) 2.375) 8.23 visits.285 < 2 years 2.862 (0.851 (1) 0. they were married.386 (1) 0.154 – 3.439) 0. 28. p=0. 1 (2010) 16 . 1 No. This study shows that mothers with less than eight visits had twice the risk of having low birth weight babies as compared to mothers with eight visits and more (Crude OR: 2. 95%CI: 1. When the mothers were asked the number of antenatal visits the mothers wanted about 7 visits.2%) had eight visits or more. twice during second trimester. However that Review of Global Medicine and Healthcare Research . 63 (9. which is once during first trimester. The maximum number of visits now is around 12 to 13 visits per mother. Being an Indian mother. However the mean number of visits preferred by the mothers in the study population for low risk pregnancies was 7. Out of 650 babies.Low birth weight was taken as the obstetric outcome for this study. which was generally below 10% (7% in 1999). 10 antenatal visits can be considered as an optimum number of visits. history of ever smoked during pregnancy. (n=240) revealed a low birth weight prevalence of 2.9%16 which was much lower than the national figure. Presently. Logistic regression analysis to look for the minimum number of antenatal visits required for low risk mothers had noted that mothers with antenatal visits of 10.10. and once at term. maternal and fetal morbidity). It must be noted however that reduction in antenatal visit need not necessarily reduce the incidence of low birth weight. Prevalence of low birth weight during the study period was similar to the national level. Based on low birth weight alone as the outcome indicator. and Caesarean section). This study shows that the prevalence of low birth weight is higher among Indian mothers and mothers who had low BMI at the first trimester. It also shows that the mother with less than 8 antenatal visits had twice the risk of having low birth weight than the normal birth weight babies. Ministry of Health suggests a minimum of seven visits during antenatal. and low BMI at booking in the first trimester. For instance McDuffie4 noted that a reduction of antenatal visits for low risk mothers from 15 visits to 12 visits did not resulting in any adverse obstetric outcome significantly (pre-term delivery. Sikorski5 had also noted no significant different in the obstetric outcomes (Caesarean section for hypertensive disorders. were significantly associated with higher prevalence of low birth weight babies. Using the low birth weight as an outcome we propose that the low risk mother need to have only 10 visits as the benefits are the same after 10 visits. three times during third trimester. 11.23 visits.25 – 4. and 12 were associated with significantly lower chance of having low birth weight infants compared to mothers with less than eight visits when other variables held constant. The minimum number of antenatal visits required for low risk mothers to reduce the incidence was 10 visits. Another study by Binstock3 which reduced the number of visits from 11 to eight had also noted similar findings.006). Reduction in the number of visits may reduce the cost and improve quality of each visit. low birth weight.Vol. The mean number of antenatal visits for the study population was 9. with the reduction of visits from 11 to 9 visit.58 visits and the majority of them (84. A recent study on the effectiveness of reducing numbers of antenatal visits for low risk mothers in Kuantan in 2002. Conclusion This study shows that the low birth weight is high in the ethnic Indian mothers as compared to the Chinese and Malay mothers in the study area.7%) of them were low birth weight babies. Quality Assurance Investigation Manual for Family Health Programme. 1 No. Norsihimah Wahid. 1994. Ghazali Ismail. 2000. 312 (7030): 546-553. Annual Report 2000. Khan-Neelofur D. Maternal and Child Health Unit. 1996. Sikorski J. Pg 5. 15. Clement S. 17th Edition. Report on National Research Priorities in Reproductive Health Seminar. (Unpublished report). Ministry of Health Malaysia. 1996. et al. Candy B. 357: 1551-1564. 3. The Lancet. Mathai M. 87100. Ba’aqeel H. 2002. Obstetric by Ten Teachers.Vol. Wilson J. Effect of Frequency of Prenatal Care on Perinatal Outcomes among Low-Risk Women: A Randomized Controlled Trial. 13. 7. 28th October 2002. Villar J. The J of Am Med Assoc. Sikorski J. in conjunction with the Sixth Meeting of the Regional Advisory Panel (RAP) for Asia and Pacific. Malaysia. et al. Acta Obstet Gynecol Scand. 2001. Ministry of Health. November 2001. Division of Family Health Development. et al. References 1. Issue 2. October 1993. Jewell D. Validity of Colour Coding as a Risk Approach Strategy Assessment Tool in Antenatal Management in Larut Matang District. and Gynae. et al. Sanders J. 1996. 106: 367-370. 14. 5. Bergsjo P. Review of Global Medicine and Healthcare Research . Arnold 2000. 4. 1998. Clement S. 2. 76:1-14. Focused Visits and Continuity of Care. A Randomized Controlled Trial Comparing Two Schedules of Antenatal Visits: The Antenatal Care Project. 39: 1-6. Villar J. McDuffie R S. 9. 1997. Study of Maternal and Perinatal Outcome between Traditional and New Model of Antenatal Visits among Low Risk Women in District of Kuantan. Pattern of Routine Antenatal Care for Low Risk Pregnancy (Cochrane Review). WHO Reproductive Health Library 1999. 10. 348(9024): 364-369. WHO Antenatal Care Randomized Trial for the Evaluation of a New Model of Antenatal Care. Campbell S. (Dissertation 2001). British J of Obst and Gynae 1999. Beck A. Alternative Prenatal Care: Impact of Reduced Visit Frequency. Oxford Update Software 12. British Med J. 16. Wolde-Tsadik G. 11. Munjaja SP. Villar J. 107: 1241-1247. A Randomised Controlled Trial of Flexibility in Routine Antenatal Care. Scientific Basis for the Content of Routine Antenatal Care. et al. The Lancet. Randomised Controlled Trial of A Reduced Visits Programme of Antenatal Care in Harare. 6. 8. Issue 4. Binstock M A. Bischoff K. British J of Obst. 1 (2010) 17 . Piaggio G. Routine Antenatal Care for Low Risk Pregnancy in Under-resourced Settings. Kuala Lumpur. Lindmark G. 275(11): 847-851.the number of visits may not only be important but the quality to detect the risk factors and to reduce bad outcome of the mother is equally important. Lees C. The J of Reproducitve Med. Nystrom L. Sharp D. In: The Cochrane Library. Does Reducing the Frequency of Routine Antenatal Visits have Long Term Effects? Follow up of Participants in a Randomized Controlled Trial. 118±11 ms.Ventricular arrhythmia risk in elderly heart failure patients Ioana Mozos *. Aim: We hypothesized that aging increases electrical instability in post-infarction heart failure patients. difficulties in delineating the end of T wave and no clear consensus about normal values for Tpe. 20%). Tpeak-Tend interval and significant lower values for RMS40 (Root Mean Square) (10±2 μV vs. aged 72±5 years. LAS40 (Low Amplitude Signal) (73±19 ms vs.Vol. 64-lead body surface mapping and 12-lead ECG. 1 No. Conclusion: Ventricular arrhythmia risk is increased in elderly post-infarction heart failure patients compared to adult patients. p=0. heart rate corrected QT interval (QTc: 543±37 ms vs. Results: In the elderly patients group: 92% had late ventricular potentials (vs. 528±65 ms.01). 47% of the adult patients). p<0. p=0. They were included in two groups considering their age: 15 adults. p=0.000151). 438±34 ms. 1 (2010) 18 .042). M. body surface mapping Review of Global Medicine and Healthcare Research . 33% multipolar isointegral QRST maps (vs. Email: [email protected]) .de Abstract Background: Post-infarction heart failure is associated with electrical instability and sudden cardiac death risk due to structural inhomogeneities. Methods: 27 post-infarction heart failure patients underwent: Signal Averaged ECG.038). Study Limitations: The main limitations were: the small number of patients. Cristescu Department of Pathophysiology University of Medicine and Pharmacy “Victor Babes” Timisoara. p=0. Keywords: heart failure. Romania * Corresponding Author. Tpeak-Tend interval. Hancu. p<0. aged 52±5 (mean±SD) years and 12 elderly patients. There were significant higher values in the elderly group for: SA-QRS duration (138±10 ms vs. A. mean QT interval (QTm: 449±37 ms vs.01). 20%).38±12 ms. maximal QT interval (QTmax: 450±49 ms vs. 22±9 μV. 413±54 ms. QT interval. late ventricular potentials. aging. 25% ventricular arrhythmias (vs. is potentially a diseased heart (Swynghedauw. 2005). The changes of the senescent heart result from the general process of senescence. 1 (2010) 19 . Senescence is. The Tpeak-Tend interval (Tpe) has been reported to predict life-threatening arrhythmias in the long QT Review of Global Medicine and Healthcare Research . Papacosta. Chiulan. 2008. Berkwits. and their prevalence increases in the presence of structural heart disease. Ertl. one of the leading causes of mortality. considered an interfering factor for cardiac remodeling (Diez &. the use of multiple drugs. Hancu & Cristescu. Cardiac failure is mainly a disease of the elderly (Swynghedauw. which could cause syncope. myocyte number is decreased (due to necrosis and apoptosis in the left ventricle). functional and vascular changes (Beers. Zareba. 2003. 1999). 2007). 2005). The senescent heart. 1999) and ventricular arrhythmias are common in elderly.Vol. 1999). 2008). Gorun. Sudden cardiac death. Identifying patients at risk for these arrhythmias remains a major challenge in preventive epidemiology. and is caused mainly by fatal ventricular arrhythmias. markers of an electrophysiological substrate for reentrant ventricular tachyarrhythmia and sudden cardiac death. focal collagen deposition and increased vascular stiffness (Beers et al. 2006). also. but their size is increased. ventricular arrhythmias and sudden cardiac death. SAECG is used to detect ventricular late potentials (LVP). Macfarlane & Whincup. LVP are thought to originate from slow-conducting areas of the myocardium and are low-amplitude. Structural inhomogeneities cause repolarisation heterogeneities. Jones. high frequency waveforms in the terminal part of the QRS complex (Cain. or sudden cardiac death (Sohaib et al. Aging is considered a cardiovascular risk factor and is usually associated with increased cardiovascular pathology. 2004). and this plays a crucial role in the genesis of arrhythmias and impairment of systolic and diastolic function.Background Electrical instability in post-infarction heart failure patients is due to the structural inhomogeneities: fibrosis (fibroid tissue replaces the necrotic infarction area) and ventricular remodeling. 2009). body surface mapping (BSM) and 12-lead ECG (Mozos. Camm & Borggrefe. remains a health problem of epidemic proportions (Kunavarapu & Bloomfield. Arthur & Trobaugh. the action potential duration and relaxation are prolonged and there are degenerative changes of the conducting system. cardiac arrest. 2008). even in the absence of coronary insufficiency. Electrical instability is assessed using noninvasive methods like: signal averaged electrocardiography (SAECG). Zipes. 2007. Fibrosis renders the myocardium stiffer and mechanically and electrically heterogeneous. A prolonged QT interval predisposes to the development of ventricular tachyarrhythmia such as torsades de pointes and ventricular fibrillation. reentry. The senescent heart is comparable to left ventricular overload. The long QT interval was associated with all-cause mortality and cardiovascular mortality (Sohaib. especially coronary heart disease. Morris. some structural. The most important age-associated cardiovascular changes are: increased left ventricular wall thickness. Mozos. the senescence of the endocrine system and the senescence of the vessels (Swynghedauw. 1 No. Hancu. Nesterenko & Antzelevitch. 2006). Cerotti. any symptoms of an inflammatory process. Armstrong. in normal persons. 1986). heart failure diagnosed according to the ESC Guidelines 2008 (Dickstein et al. atrial fibrilation or flutter at the moment of investigation. 64-leads body surface mapping and 12-lead ECG in the Functional Exploration Laboratory of the Pathophysiology department of the “Victor Babes” University of Medicine and Pharmacy. Aim Considering the high prevalence of cardiovascular disorders in elderly patients and the age-associated cardiovascular changes. Review of Global Medicine and Healthcare Research . 35:2-4) and were approved by the Ethics Committee of the University. aged 52±5 years. The inclusion criteria were: old myocardial infarction diagnosed according to the ESC /ACCF /AHA /WHF Universal Definition Criteria (Thygesen. multipolar QRST map. White. The investigations conform to the principles outlined in the Declaration of Helsinki (Cardiovascular Research 1997. Horacek & Smith. 1 No. electrolyte imbalances. BSM has multiple advantages compared to conventional electrocardiogram in providing diagnostic informations to detect electrical activity changes and allows the most complete visualization of the heart activity mapped on the body surface. the second group of 12 elderly patients. 2007). Methods Patients: 27 post-infarction heart failure patients. Alpert. Aime. except the age. 2008) and a written consent of the patient. Hevia et al. Montague. 1 (2010) 20 .syndrome. The exclusion criteria were: bundle branch block. systemic inflammatory processes. There were no significant differences between the two groups considering their main characteristics. active infections and trauma. 1997) have. Rovida & Negroni. aged 72±5 years. only two extremes: a maximum and a minimum.Vol. 2004. with more maxima and minima reflect the regional heterogeneity of the repolarisation process and arrhythmia vulnerability (Gardner. The clinical characteristics of the patients are included in table 1. underwent: SAECG (time-domain analysis). stage B and C. and is considered a measure of transmural dispersion of repolarization (Fish. a dipolar character. from the ASCAR clinic from Timisoara. They were included in two groups considering their age: the first group was made of 15 adults. A complex. we hypothesized that aging influences electrical instability in post-infarction heart failure patients and ventricular arrhythmia risk is increased. Isointegral QRST maps (De Ambroggi. Di Diego. PC=premature contractions. Atrial fibrillation: 13% (2) LV Ejection fraction Associated diseases 44±8% RVH: 13% (2). in the V intercostal space. RVH=right ventricular hypertrophy. 3chronic kidney disease 4 (33%) PC: 20% atrial (3). C3 – at Review of Global Medicine and Healthcare Research .Table 1: The characteristics of the study population Characteristics Age (years) (means±SD) Sex M:W MI survival (years) MI location: Anterior/inferior/anterior and inferior CV risk factors Adult patients (15) 52±5 3:2 1-6 9/5/1 Elderly patients (12) 72±5 3:1 2-9 8/3/1 smokers 20% (3). COPD: 20% (3). CV=cardiovascular. ACEI=angiotensin conversion enzyme inhibitors SAECG SAECG. Unstable angina: 8% (1). obesity 25% (3) PC: 17% atrial (2). C2 – on the left midaxillary line. 1 No. History of arrhythmias Sinus tachycardia: 53% (8).Vol. obesity 20% (3) smokers 42% (5). F – on the left leg. in the V intercostal space.on the right leg. 33% (4) M=men. 8% (1). COPD: 8% (1). LV= left ventricular. C1. HT 42% (5). 40% (6) 50% (6). chronic kidney disease (20%) Therapy: ACEI Calcium blockers Beta blockers Class III antiarrhythmics Digitalis 80% (12). The single use electrodes were applied as follows: R – on the right arm. MI= myocardial infarction. 33% (4). Unstable angina: 13% (2). Atrial flutter: 20% (3). was performed using a Siemens-Megacart electrocardiograph. 42% (5). 33% (5). L – on the left arm.on the right midaxillary line. COPD=chronic obstructive pulmonary disease. 13% junctional (2). 1 (2010) 21 . W=women. Atrial fibrillation: 8% (1) 53±6% Ventricular aneurism: 8% (1). N. HT 33% (5). 17% ventricular (2). HT=hypertension. 40% (6). The start of the Q wave and the end of the T wave were marked using a cursor.the bottom of the sternum. as previously described (Mozos et al. 2008). who weren’t informed about the clinical data. y (connecting leads C3 and C4) and z (connecting leads C5 and C6) (Mozos et al. The ECG signals from the 64 thorax leads . The time integral of the QRST intervals were calculated. from the start of the QRS complex through the end of the T wave. 1 No. 9 columns were placed in the antero-lateral part of the thorax between the right mid-axilary line and the left mid-axilary line. to assess the number of extreme positive values (maxima) and extreme negative values (minima). 2006. The noise level was: 0.6 μV.the square root of the last 40 ms of the signal).„Low Amplitude Signal”) and RMS40 („Root Mean Square”.98 was selected. The maps were displayed in a rectangular format. Three orthogonal bipolar leads resulted: x (connecting the leads C1 and C2). C6 – in the IV intercostal space. Review of Global Medicine and Healthcare Research . The following parameters are essential for the existence of LVP: SAECG QRS duration (SA-QRS). 2008). We considered a patient having LVP. QRST isointegral maps represent the QRST areas for each lead. and 4 colomns on the posterior part of the thorax. multiplexed with a sampling rate of 5 ms and digital converted with a 10 bits resolution. C4 – on the left iliac crest.3-0. by two independent observers. were amplified using adjustable amplifiers. Mozos et al. LAS40 (the duration of the signal at the end of the QRS complex with an amplitude below 40 μV . LAS40>38 ms and RMS40<20 μV (Mozos. and filtrated with a bidirectional filter. processed and mediated. 36MB RAM memory. 1 (2010) 22 . Isointegral maps provide a distribution of the sum of potentials over a specified time interval. C5 – posterior. on the right side of the spinal column. on the left side of the sternum (the normal position for V2). Mozos et al 2008). The ECG signal recording electrodes were placed around the thorax on 7 rows (placed at a fixed distance of 5 cm) and 13 columns.Vol. which corresponds to the surface of the thorax. if two of the following criteria were positive: QRS duration >120 ms. in the IV intercostal space. coloured monitor and printer. were recorded using the central Wilson electrode as a reference. A correlation coefficient between 0. Body surface mapping The 64 electrodes vest was applied to each patient . 2007. The signal derived from the 300 beats was amplified. as a section on the right midaxillary line. as an incorporated network in the electrodes vest.90 and 0. Isointegral maps were then analyzed. The data were processed using a Pentium computer with a 400 Mhz frequency. on the mid-scapullary and paravertebral lines. Perugia score (Schillaci et al. 1994). 2008. 2009) were assessed. 2006). Hancu. an agreement was obtained. The measurement of each parameter in each lead was obtained by averaging two consecutive beats. 1990) . the R-R distance. 1 No. Review of Global Medicine and Healthcare Research . Surawicz. The QT interval was corrected for rate using using the Bazett formula (Bazett. 2009). Cornell voltage criteria (R in a VL + S in V3: >28 mm in men. Van der Bilt. Gettes. Left ventricular hypertrophy Left ventricular hypertrophy was diagnosed considering at least one of the five following ECG criteria: The Romhilt-Estes scoring system (a score of 5 diagnoses LVH and a score of 4 diagnoses probable LVH) (Romhilt & Estes.1985) the diagnostic criteria based on the Framingham Heart Study data (Levy. et al. QTmax (the maximal QT interval duration in all 12 ECG leads) (Rautaharju. SokolowLyon voltage criteria (SV1 + RV5/R V6 >35 mm) (Sokolov & Lyon.1949). The Bazett’s formula is the most popular heart rate correction used in clinical practice. Rautaharju et al. or in which the T wave had low amplitude or was isoelectric. Wilde. The Tpeak-Tend interval (Tpe) is the interval from the T wave peak to the end of the T wave (Hevia et al. where QTc is the heart rate corrected QT interval and RR. De Jong.12-lead ECG 12-lead ECG was assessed using the same Siemens-Megacart electrocardiograph at a paper speed of 25 mm/sec. 2008). QTc (heart rate corrected QT interval) and QTm (mean QT interval duration in all 12 leads) (Mozos. The leads in which the end of the T wave couldn’t be determined exactly.Vol. 1920): QTc = QT/√ RR. obtained the measurements and in case of a difference of >20 ms in each measurement. 1968). 2009). The Tpe value reported was the maximum obtained by two observers in all leads. The end of the T wave was defined as the intersection of a tangent to the steepest slope of the last limb of the T wave and the baseline (Postema. The Tpe was measured in each lead and obtained from the difference between QT interval and QTpeak interval (from the beginning of the QRS until the peak of the T-wave). >20 mm in women) (Casale et al. Two independent observers. were eliminated. A QT threshold of 450 ms was used to differentiate normal from prolonged QT intervals (Postema et al. who weren’t informed about the clinical data. Costea & Cristescu. 1 (2010) 23 . The QT interval duration was manually measured from the earliest Q wave onset over all 12 leads. „Low Amplitude Signal”.Statistics Statistical analysis was performed using the t Student test.000151 p<0. Results Late ventricular potentials were present in 47% of the adult post-infarction heart failure patients and 92% of the elderly patients. RMS40.000547 p=0. QTmax= maximal QT interval. All SAECG parameters were significant different in the two groups (table 2): SA-QRS duration and LAS40 were significant increased in the elderly patients group and RMS40 was significant increase in the adult post-infarction heart failure group. Review of Global Medicine and Healthcare Research . heart rate corrected QT interval duration in the 12 ECG leads.038 p<0. PVC=premature ventricular contractions. SA-QRS=SAECG QRS duration. QTmax and QTc were significant prolonged in the elderly group. the Bravais-Pearson linear correlation coefficient (r) and the relative risk (RR). QTm=the mean. The mean QT interval duration (QTm). 27% of the adult patients and 42% of the elderly had a QTm longer than 450 ms. QTc and Tpe.042 p=0. 1 No.the square root of the last 40 ms of the signal . QTmax. SCD=sudden cardiac death. LAS40=the duration of the signal at the end of the QRS complex with an amplitude below 40 μV .01 LVP=late ventricular potentials. LVH=left ventricular hypertrophy. LAS40.01 p<0.Vol. 1 (2010) 24 . QTc=heart rate corrected QT interval. RMS40=„Root Mean Square”. VF=ventricular fibrillation The values are expressed as means±SD for: SA-QRS.01 p=0. QTm. Table 2: Parameters in the two post-infarction heart failure patients groups: the adult group and the elderly Parameter LVP SA-QRS LAS40 RMS40 QTm QTmax QTc QTm>450 ms Tpe LVH (ECG) Ventricular arrhythmias Multipolar maps Adult group (n=15) 7 (47%) 118±11 ms 38±12 ms 22±9 μV 413±54 ms 438±34 ms 528±65 ms 4 (27%) 150±16 ms 6 (40%) 3 (20%) PVC 3 (20%) Elderly group (n=12) 11 (92%) 138±10 ms 73±19 ms 10±2 μV 449±37 ms 450±49 ms 543±37 ms 5 (42%) 150±20 ms 6 (50%) 3 (25%) PVC and VF (SCD) 4 (33%) Significance (p) p=0. biphasic or overlapping on a U wave (Zareba. bifid. and 1 (8%) of the elderly died suddenly (ventricular fibrillation). This is the reason why we used QTmax. LVH=left ventricular hypertrophy Table 4: The correlation between: LVP criteria (SA-QRS. QTm=mean QT interval duration. Considering all 27 patients. Table 3: The relative risk for ventricular arrhythmias RR for ventricular arrhythmias 2 17 10 5. 2009). when the T wave is flat. Parameter SA-QRS LAS40 RMS40 QTm r=the Bravais-Pearson correlation coefficient r 0.3 (20%) of the adult post-infarction heart failure patients and 2 (17%) of the elderly had a history of premature ventricular contractions. the lead showing the longest QT should be used (Rautaharju et al. leads in which the end of the T wave could not be assessed.Vol. Review of Global Medicine and Healthcare Research . were eliminated.81 LVP Multipolar isointegral QRST maps QTm>450 ms LVH RR=relative risk. The presence of LVP. 2007). a QTm>450 ms and left ventricular hypertrophy (according to ECG criteria) also predicted ventricular arrhythmias (table 3).76 0.62 Study Limitations The QT interval is considered a practical measure of repolarization duration that could be obtained from routine ECG recordings. the best predictor for ventricular arrhythmias was the appearance of multipolar isointegral maps. When the QT interval is measured in individual leads. LAS40 and RMS40).78 -0. Despite this presumed simplicity. QT measurement remains a challenge both for clinicians and for specialized ECG labs and the most frequent difficulties consist of delineating the end of T wave.66 0. This is the reason why. 1 No. QTm and age of the patients. Significant differences exist in the duration of the QT interval when measured in the individual leads. 1 (2010) 25 . LVP=late ventricular potentials. However. if confirmed in larger groups. 2008). but the differences were not statistical significant between the two groups. left ventricular hypertrophy and obesity (Crouch. between the two groups (p<0. 2008. There were significant differences only considering age. Bazett HC (1920). 2006). Sudden cardiac death occurs most frequent in patients with an EF below 40% (Zipes et al. SAECG and 12lead ECG recordings. there is no clear consensus about the normal values for Tpe (Hevia et al. late ventricular potentials and QTm>450ms were significant associated with ventricular arrhythmias. including drugs that affect repolarization. 1 No. Sohaib et al. considering EF. can be valuable in current clinical management of post-infarction patients and might support the selection of post-infarction patients at high risk of life threatening ventricular arrhythmias. 2008. multipolar isointegral QRST maps. QTm>450 ms and ECG-LVH are good predictors of ventricular arrhythmia in post-infarction heart failure patients. Tribouilloy et al. therefore the results need to be confirmed in larger groups. 2008). Other causes of QT interval elongation are: heart failure. 7. Some of the drugs could have influenced the results: amiodarone. 2007). diuretics. Late ventricular potentials. calcium channel blockers and beta blockers produce QT lengthening (Sohaib et al. of the time-relations of the Review of Global Medicine and Healthcare Research . 2006). Another limitation of our study is the low number of patients. Riera et al. 2007). we found that multipolar maps. 1 (2010) 26 . Only two patients had an EF<30% (from the elderly group). The results of our study. 353-370. Some patients were taking antiarrhythmic drugs at the time of BSM. References 1. Zareba. Conclusion Electrical instability and ventricular arrhythmia risk are increased in elderly postinfarction heart failure patients compared to adult patients. A shorter QT interval was observed in diabetics and current smokers (Sohaib et al. hypertension. But there were some studies considering that the prognosis of patients with heart failure with preserved ejection fraction was similar or worse compared to that of patients with reduced ejection fraction (Bhatia et al. Zareba. The ECG is still considered a standard method for the detection of left ventricular hypertrophy in epidemiological studies.Because of lack of studies involving large populations. Limon & Cassano. and remains widely used because of its availability and low cost.005).Vol. Despite therapy. 2006. 2003. We used multiple ECG-LVH criteria to increase sensitivity and specificity of LVH diagnosis. An analysis electrocardiogram. it has limited value because different rating criteria are used to diagnose LVH. 2008. Heart. 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Length of the QT interval: determinants and prognostic implications in a population-based prospective study of older men. Zipes DP. 29. Roden DM. Moss AJ. Gregoratos G. Klein G. Papacosta O. Zareba W (2007). Lyon TP (1949). Cardiology Journal. Belarus Abstract Background: The problem of alcohol use is a major public health problem in the general students’ population in Belarus. university students. Methods / Study Design: A total of 2460 university students from four different campuses in Minsk (Belarus) were explained the study aims and objectives. Of them. The use of strong strength alcoholic beverages is related to a high risk of alcohol related problems. Aims & Objectives: We therefore screen and compare the prevalence of alcohol use and related problems among juniors and seniors in Belarusian universities. Belarus Review of Global Medicine and Healthcare Research . MAST. Participants were administered questionnaire.Trajectory of Alcohol Use and Related Problems among University Students in Belarus Menizibeya O. Conclusion: The level of alcohol use and related problems in the general Belarusian students’ population are high and show increase in order of increase in the year of study. The level of alcohol problems increases with increase in the year of study. 100 students could not complete the questionnaire satisfactorily. 1599 respondents enrolled for the study. Pereverzev Department of Normal Physiology Belarusian State Medical University. Keywords: Trajectory. 1 (2010) 30 .com Yury E. Minsk. CAGE and other alcohol related questions. Welcome Belarusian State Medical University. Belarus Email: [email protected]. alcohol use. Belarus Vladimir A. Razvodovsky Group of Narcologists Grodno State Medical University. The cut-off point on the AUDIT was set at 8. Minsk. 1 No. Grodno. containing the AUDIT. alcohol problems. than the use of weak alcoholic beverages in the students’ population. Results / Findings: The screening results confirm a high level of alcohol use (87. A total of 1499 (average age = 21) students were considered for analysis.66%) and related problems in the students’ population. 2008). Elissa et al. Caetano et al. 2007. 1998. low academic performance. Hays et al. Jernigan 2001. 1998). 1989. 1994 & 2002). alcohol dependence (Wechsler et al. Wechsler et al. 2004. 2006. 2005. Jernigan 2001. Joseph et al. According to some researchers one of the major risks for health is associated with heavy alcohol use (Babor et al. Brown 2004. 1 No. 18% of women and 11% males reported alcohol use only in the university years (Mangus et al. Manuel et al. Dong-Eok et al. Elissa et al. Brewster 1991. 2007. 1993. Claussen et al. as no intervention program is carried out and since no data show any problem. Emmanuel et al. Welcome et al. Emmanuel et al. Brewster 1991. Federico et al. there is a dearth of scientific data addressing the problem of students’ alcohol use. this concerns the students’ population.Vol. 2000. do Amaral et al. and this is a major problem that border the general public (Razvodovsky 2008. one of which might be the increase in stress that is experienced by students in course of their study in the university (Weitzman et al. Thomas et al. Catherine 2004. O'Brien et al. This has contributed partly to the increase in the prevalence of alcohol use and related problems.Introduction Alcohol use is a factor of risk for health and reduces life expectancy by 15-20 years (Babor et al. In the global scale alcohol causes approximately 1. inasmuch as recent epidemiological data show high level of alcohol related problems among students (Adewuya 2005. 2008). Welcome et al. with subsequent consultation and therapeutic intervention. In particular. Brown 2004. Manuel et al. 2000. Flaherty et al. Analogical screening exercise performed in Spain showed that out of a total of 545 students that participated over 70% use alcoholic beverages. Alcohol abuse by students is associated with a complex range of problems – asocial behavior. Mangus et al. It was reported in a screening survey involving 548 graduate students in Oregon that18% of them use alcohol often (3 or more times per week). 2000). 1994 & 2002. 2004. Wechsler et al. Jernigan 2001. Carmen et al. Alcohol abuse is a major problem in the general students’ population in many countries (Adewuya 2005. Paschall et al. psychoses. 1993. A screening result that will address the prevalence of alcohol use and related problems. Wechsler et al. Frone 1999). Welcome et al. 2005. In Belarus. 1998. 2003. 1994 & 2002). 21% were bingers (5 or more drinks per session). 1995.4 liters of absolute ethanol (Carmen et al. 2005. 2000. 2003. Catherine 2004. 1989). Kypri et al. Welcome et al. 2008). Kypri et al. According to leading scientific data approximately 4% of global burden of disease is associated with alcohol misuse (Babor et al. 1999). Catherine 2004. 2000. The cases of alcohol related liver cirrhosis. including the rate in which alcohol use and related problems increase with Review of Global Medicine and Healthcare Research . alcoholic intoxication etc have been shown to increase in middle adulthood. This problem might be related to many factors. 1998. Jernigan 2001). 1993. Catherine 2004. injuries. 1 (2010) 31 . 2004. 2005. 2006.8 million deaths yearly (Babor et al. 2003. Many researchers have noted that the level of alcohol use and related problems is higher among seniors compared to freshmen (Flaherty et al. 2004. High level of alcoholism in the society calls for the necessity of carrying out preventive measures aimed at early diagnosis of alcohol related problems. Their average alcohol use by one student per year was 8. Mangus et al. Federico et al. Finnell 1975. 2008). 1994. 2005. 2008. the students’ population is easily accessible. 1998. 2005. O'Brien et al. 1995). Weitzman et al. Syria. The CAGE as an instrument of screening has a sensitivity of 85-94% and specificity of 79-88% (Bohn et al. and since every data suggest that screening for the prevalence of alcohol use in the student’s population is of great benefit to public health (Kypri et al. A score of 2-4 on the CAGE test is considered clinically significant. Nigeria. Belarusian State University. 2008). 1998. which are used in epidemiological research aimed at early detection of problems related with alcohol use are the AUDIT (The Alcohol Use Disorders Identification Test). 1998. Jernigan 2001. 2008). A total score of ≥8 defines the presence of alcohol related problems and a necessary referral to a specialist (Katharine et al. Guilty and Eye questionnaire) (Babor et al. Some proportion (5-8%) of foreign students from Iran. 2008). Belarusian National Technical University. and CAGE (the Cut. 1993. 1993. Pakistan. Ghana etc also study in these universities. 2008). Helen et al. 1999. 1998. Welcome et al. Jernigan 2001. Welcome et al. 1995. 1993. Besides. There are four major universities (Belarusian State Medical University. Welcome et al. The AUDIT is a structured interview of 10 questions with a sensitivity of 92% and specificity of 93%. 1998. and Belarusian State Agrarian Technical University) in this city. 1998. with the highest number of students from all over the country. The AUDIT gives a more accurate result in comparison with the CAGE and MAST (Welcome et al. 1 (2010) 32 . Average Corpuscular Volume of erythrocytes. 2008). Mangus et al.both age and year of study in the university will be of great importance (Flaherty et al. Katharine et al. 2003. Katharine et al. Saunders et al. Claussen et al. 1995). Even at a single positive answer the sensitivity of the CAGE test equals 62% (for comparison with the sensitivity of laboratory tests: GGT. Materials and methods Study population: Minsk is the capital city of Belarus. Students in these universities are both Christians (95%) and Muslims (4%). other are Review of Global Medicine and Healthcare Research . we therefore. The sensitivity and specificity of the MAST is 90% and 80% respectively (Welcome et al. 1995. Annoyed. 2008). Thomas et al. Katharine et al. Saunders et al. 2004). Bohn et al. Jernigan 2001. 2005. Welcome et al. 2003. Kypri et al. Katharine et al. The MAST is used for express diagnosis of alcoholism in expertise condition (Welcome et al. Jordan. The commonly used psychometric instruments recommended by WHO.Vol. 1993. Catherine 2004. It correlates with both the MAST and CAGE (Gache et al. Manuel et al. 2004). Joseph et al. screen for the prevalence of alcohol use and related problems in the general Belarusian students’ population and trace the rate of rise of alcohol use and related problems in course of their study in major universities in Minsk. 1 No. 1993. Bohn et al. 2005. where students from all over the country study. According to research MAST sometimes gives a lot of false-positive results (Bohn et al. 1998. The AUDIT is a validated and superior screening instrument and corresponds with the DSM-IV and ICD-10 definition of alcohol dependence and abuse (Janca et al. MAST (Michigan Alcohol Screening Test). 2008). Welcome et al. 2006. Belarus. The Michigan Alcohol Screening Test is one of the most used tests for analysis of alcohol related problems. Manuel et al. initial signs of alcoholism. 2000. and its anamnesis (Welcome et al. liver transaminase – 30-36%). The CAGE test is aimed at disclosing dissimulative symptoms of alcoholism. 2008). Mangus et al. p >.5% Christians. 68. Hays et al. only those who agreed to participate were considered for interview in their various universities. only 1599 students (average age 21yrs) agreed to participate in the study. In these universities the population of female students is about trice that of the male students.Vol. The students with scores of 8-40 on the AUDIT were classified in group № 1 (the problem group).71% (n=1030) females and 31. as well as in percentages. and 22 from Belarusian State Agrarian Technical University) could not complete the questionnaire satisfactorily. p < . CAGE. 1993. 23 from Belarusian National Technical University.05). 237 from Belarusian State University. MAST and other alcohol related questions. a tendency to increase was noted in the male population (χ2 =5. Results From the screening results shown in table 1. Welcome et al.8. 2008). All volumes of alcohol used are given in values of absolute ethanol. In total. 29 from Belarusian State University. 1995. Students who disagreed to participate were 207 students from the Belarusian State Medical University. Questionnaires were distributed equally among students of all universities and in all courses. Sampling size and technique: The interview was carried out in four consecutive days in the different universities. 255 from Belarusian National Technical University.5% of the participants were Muslims and 92. 1 (2010) 33 . A total of 2460 students at random were explained the study aim.05. Procedure: The Ethics and Research Committee of the various universities approved the study protocol and informed consents were obtained from the respondents after the aims and objectives of the survey had been explained. and 162 from Belarusian State Agrarian Technical University. Out of the 1599 respondents that participated in the study. 2005. 100 (26 from the Belarusian State Medical University. Annoyed. A standard drink was set at 8g of absolute ethanol. Results were calculated as means and standard error of means. The probability value for significance was set at p < .0 version for Windows and the Chi square. while 2 to 4 score on the CAGE is considered clinically significant. The MAST (Michigan Alcohol Screening Test). Guilty and Eye questionnaire) were used simultaneously as a measure for problems related with alcohol use because of their high sensitivity and specificity (Claussen et al.29% (n=469) males. 2008). χ2 (Bland 2000). Scores of ≥8 on the AUDIT define problematic alcohol use (Welcome et al.non-religious – 1%. 1 No.001). AUDIT (Alcohol Use Disorders Identification Test) and CAGE (the Cut. Students with 1-7 score on the AUDIT were classified as the nonproblem group (group № 2). but there was a significant increase among females (χ2 =22.48. 7. containing the AUDIT. Data analysis: Statistical calculations were performed using the SPSS (The Statistical Package for the Social Sciences) 16. Measures: A total score of 3 or more on the MAST was considered problematic alcohol use. Statistically. Review of Global Medicine and Healthcare Research . %. the proportion of alcohol users are significantly higher among seniors. M±m. Gache et al. so only 1499 students were considered for analysis. All 1499 students were administered questionnaire. 37% 96.68 ± 0.83 ± 0.51 3.21 0.1 in the I-II courses to 4.04 0.11 % alcohol users 82.90% (n=40) 6.40% (n=39) 29.15 0.6 23.60 ± 0.79 ± 0. The data shown in the table indicate that the frequency-quantity of alcohol use are significantly higher Review of Global Medicine and Healthcare Research .67% 84. feeling of guilt) are shown in table 3.5 21.07 1.75% (n=28) 19. the male to female ratio of the problem drinkers on the AUDIT increased from 3. 1 (2010) 34 . in comparison with students of I-II courses. as well as the proportion of problem alcohol users did not change in relation to the increase in the year of study.10 0.35% (n=59) 11.29 0. the gender differences in the level of alcohol related problems increases according to the increase in the year of study.04 MAST 1.48 ± 0.9 in the V-VI courses (Table 2).5 AUDIT 5.01% (n=37) 47.98 ± 0.79 ± 0.09% (n=17) As a distinction from the males. The frequency-quantity block (frequency of alcohol use. The differences between students of I-II and V-VI courses were statistically significant according to the results in all three tests. For example.43 ± 0. as well as different problems related with alcohol use (loss of control.Vol.3% to 33.38 ± 0. The number of male problem students increases according to the order of increase in the year of study (Table 2).36% (n=57) 13. hangover. as well as the proportion of problem alcohol users among the females was lower.96% (n=25) MAST 17. the number of problem drinkers on the V-VI courses on the AUDIT increased from 28.78 ± 0.46%. So. injuries.40% (n=39) 4.45 ± 0. In this case.2 18.08% 87.67% (n=40) 11.07 ± 0.76 ± 0.9% on the MAST (Table 2).33% (n=26) 6.2 20.58 ± 0.58% 84.90 ± 0.67% (n=43) 9.08 ± 0. CAGE and MAST Course Sex I-II III-IV V-VI M (n=150) F (n=415) M (n=201) F (n=336) M (n=118) F (n=279) Average age 19.08 2.32 Average score CAGE 0. blackouts. dose per session and monthly dose).06% The average scores on the AUDIT.08 0.68% (n=27) CAGE 26.46% (n=56) 9.10% (n=44) 31. 1 No.4%.50 3.67% to 47. CAGE and MAST Parameters I-II III-IV V-VI Sex M (n=150) F (n=415) M (n=201) F (n=336) M (n=118) F (n=279) AUDIT 28. the average scores on the tests.80 3.21 9.67% to 31.37 ± 0.08% (n=46) 28.17 6. Table 2: Proportion of problem drinkers in various courses on AUDIT. CAGE and MAST among the males tend to increase in respect to the increase in the year of study.38 ± 0.46% (n=15) 33. on the CAGE from 26. In general.36% (n=37) 8. and from 17. among the females the average scores.08 0.20% 92.05 1.1 22.Table 1: The proportion of alcohol users in various courses and their average scores on the AUDIT. among the moderate female alcohol users such tendencies were not recorded. ver. % 47.6 Dose/ month (ml) 238.9 209.62 37.00 18. hangover.9 50.47 2.64 1.7 ml) by 1.4 ml) exceeded the dose per session of the females of group № 2 (23.% % 37.92 1.57 67.2 1.63 66.4 3.8 221.8 times.3 23.1 30. dose per session as well as the monthly dose of alcohol use.93 62.89 58.1 23.3 4.03 1.5 1.36 4. At the same time.19 25.53 3.09 Blacko Injuri uts. the dose per session of alcohol use by males of the group № 1 (51 ml) was more than the dose per session of males in the group № 2 (26.8 41.7 ml) by 1.61 1.12 69. the frequency.9 times.6 49. and injuries with increase in the year of study. The average monthly dose of alcohol use by the females of the problem group (170. Table 3: Dose and frequency of alcohol used by the problem (group № 1) and nonproblem drinkers (group № 2) and the proportion of alcohol related problems according to the AUDIT Course Sex Groups № 1 (n=43) № 2 (n=107) № 1 (n=40) № 2 (n=375) № 1 (n=59) № 2 (n=142) № 1 (n=37) № 2 (n=299) № 1 (n=56) № 2 (n=62) № 1 (n=27) № 2 (n=62) Freque Dose/ ncy/m session onth (ml) 4.84 44.9 23.84 5.2 1.4 1.21 4.Vol.4 times. Among the females of the problem group.7 times.4 ml) by 5.74 66. 1 No.4 53.69 61.3 4.42 4.16 56.65 2.6 1.50 2.4 ml) exceeds analogical parameter for the moderate female drinkers (31.71 45.23 1.% 62.97 8.63 69.18 7.2 32.0 35.03 33. Among the males of the problem group there is a tendency of rise of the proportion of alcohol related problems.9 38.63 26.60 42.5 52.3 41.57 57. compared to the moderate male drinkers (group № 1).07 M I-II F M III-IV F M V-VI F Review of Global Medicine and Healthcare Research .95 45.00 1.15 16.41 13.78 6.3 240.8 115.03 15.6 4.0 25. the dose per session of alcohol use by the females of group № 1 (42.6 26. 1 (2010) 35 .55 65.5 27.65 3. The average monthly dose of alcohol use by the males of the problem group (223 ml) was more than analogical parameter for the moderate male alcohol users (39. On the average. precisely loss of control.29 34.0 1.78 38.4 155. compared to the moderate drinkers.26 7.5 ml) by 5.28 48.34 2.76 9.07 Guilt. alcohol related problems such as loss of control. On the average.45 63.6 36.67 18.04 22.5 4.75 56. blackouts and injuries increase according to the increase in the year of study.04 65.51 40.% es. The problem female drinkers had significantly greater frequency-quantity of alcohol use.07 67.among the males of the problem group (group № 1).6 Loss of Hango control.47 0.00 4.9 30.22 9. Discussion The present screening results show a high level of alcohol related problems in the general students’ population in Minsk. where they are not subjected to the control of their parents. It is also necessary not to forget the fact that risk factors like stress which are linked to academic activities may play important role in the pattern of alcohol use among students (Frone 1999. fortified wine (7-17%).99% (n=8) 2.39% (n=68) 7.39% (n=18) (n=469) group № 2 (n=244) 55.34% (n=59) 11. 2006). Wechsler et al. A total of 37.02% (n=22) 10. 1994 & 2002). Table 4: Alcoholic beverages used by the problem and non-problem alcohol users Parameters beer/dry wine beer/fortified wine vodka *beer/wine/vodka Males group № 1 (n=158) 43.04% (n=68) 8. may organize their leisure according to their discretion (Thomas et al. but by the peculiarities of socialization.3% problem male drinkers and 25% problem female drinkers use mainly vodka. 2008) It is interesting to state the motives of alcohol use that were reported by the students.00% (n=61) Females group № 1 (n=104) 65.59% (n=732) 6. The highest level of alcohol related problems was experienced by the male students of V-VI courses and showed increase in order of increase in their ages (Table 1).32% (n=51) 0. This data show that the use of strong strength alcoholic beverages leads to a high level of alcohol related problems.66% (n=26) 25.The data in table 4 confirm that the level of alcohol related problems among students is determined not only by the frequency and dose of alcohol use. Belarus. For more than 90% of the respondents. 1 No.00% (n=26) 1.92% (n=2) (n=1030) group № 2 (n=808) 90.32% (n=135) 9. Welcome et al. Among the female students such peculiarities in the age linked increase in alcohol related problems were not recorded (Table 1). but also the types of alcoholic beverages. Among the moderate drinkers vodka (as well as weak strength alcoholic beverages) use accounted for only 10.10% (n=17) *Composition of alcohol in the various alcoholic beverages: beer/dry wine (<7%). 2008). vodka (~40%) (Welcome et al. A total of 32% respondents use alcohol as a result of its sweet qualities. Joseph et al. 2004. Welcome et al. Scientific data have suggested Review of Global Medicine and Healthcare Research . 2004. 1 (2010) 36 .7% males and 1% females. 2008). One main ways by which students may pass time under those conditions is to use alcohol (Wechsler et al. 1994 & 2002. A total of 15% of the respondents use alcohol to get drunk.23% (n=13) 37. the main motive of alcohol use was reported as the tradition to use alcohol on different social occasions. Weitzman et al.69% (n=8) 25. Many students leaving in hostels.Vol. Many researchers have acknowledged the fact that males are more disposed to alcohol abuse than females. These differences allow us to assume that the increase in alcohol related problems among males is not likely conditioned by age. since females have alternative ways of socialization (Jernigan 2001. 1 No. Jernigan 2001). The increase in the level of alcohol related problems with increase in the year of study in the university may be evidence of the fact that alcohol use is a tradition in the students’ subculture. and hangover was extremely minimal. 2000. 2008). Review of Global Medicine and Healthcare Research . but also the duration of alcohol use (the time dependent effect of alcohol use). Among the moderate male drinkers alcohol related problems such as loss of control. the proportion of problem alcohol users of I-II and III-IV courses on the АUDIT and CAGE was significantly higher than the data on the MAST. Worthy of attention is the fact that problem students (relatively high proportion of both males and females) prefer both weak and strong strength alcoholic drinks.Vol. It can also be assumed that the AUDIT may give falsepositive results in a number of cases. 1998. Study Limitations: The limitations of this study include the fact that some respondents with alcohol related problems may have under-reported them in the AUDIT. alcohol problems. Babor et al. For example. Joseph et al. This may have affected the significance value of the results. Catherine 2004. Jernigan 2001. these discrepancies are conditioned by different sensitivities of the various screening instruments. the proportion of students of V-VI courses in the problem group according to the AUDIT was more than analogical value on the CAGE and MAST.that young males may use alcohol more frequently (than the females) as ways of reducing stress (Caetano et al.1% females: Table 2 and 4) of all students need the intervention of a specialist (psychiatrist) according to WHO recommendation (Babor et al. Frone 1999. It is important to note some differences concerning the results of the various screening instruments. Jernigan 2001). compared to the non-problem drinkers who use mainly weak strength alcoholic beverages (Table 4). 2006). Probably. although lower and higher cut-off points have been suggested in other studies (Adewuya 2005. At the same time.7% males and 10. Another probable explanation for the increase in the level of alcohol related problems with increase in the year of study is the dose-time dependent effect of alcohol – the negative effect of alcohol use increases with increase in “time” and dose of alcoholic drinks (Welcome et al. Another limitation of this study is that the questionnaire was administered ones and so the reliability indices of the various tests were not assessed. As a result of this many students at the end of their studied is likely to have instead of the diploma. alcohol related problems are largely related to the use of strong strength alcoholic drinks than the use of weak strength alcoholic drinks by students. 17.5% (33. Thus. 2000. Overall. The increase in the level of alcohol related problems among problem male drinkers according to the increase in the year of study allows us to talk about the possibilities that the increase in alcohol related problems is determined by not only the dose. MAST and CAGE. 2008). 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Health and Behavioral Consequences of Binge Drinking in College: A National Survey of Students at 140 Campuses. Saunders J. 181-185. Dotsenko EA. Lee H. Health risk factors and health promoting behavior of medical. A campus-community coalition to control alcohol related problems off campus: An environmental management case study. Tobacco and Alcohol Use Among 1996 Medical School Graduates. Lee JE. Secondhand effects of student alcohol use reported by neighbors of colleges: the role of alcohol outlets. Indeed. India * Corresponding author. Anthropometric measurements were taken. as in the developed world. Hypertension is a chronic condition of concern due to its role in the causation of Coronary Heart Disease. varying from 18 to 25 years. The findings of present study suggest need of monitoring the anthropometry of children of hypertensive parents.76 years (SD ±2.8% of total deaths. Triceps Skin fold Thickness Introduction Hypertension is estimated to cause 4. Maharashtra State. Keywords: Waist-hip Ratio. Males with BMI of 25 or more were 35. hypertension accounts for more than 5.Study of Anthropometry in Individuals Having Parental Hypertension Apoorv Jain *. Increasing trend of hypertension is a Review of Global Medicine and Healthcare Research . 63% were male and the average age was 19.6% females from the study group had their waisthip ratio equal or more than the Standard cut-off. hypertensive parents. These figures are more dramatic in the formerly socialist economies countries1.4% from the Study group and 12. WHR and Triceps Skin fold Thickness with the development of Hypertension in future. Wanjari Jawaharlal Nehru Medical College Datta Meghe Institute of Medical Sciences (Deemed University) Sawangi (M). A family history of hypertension has been shown to be a risk factor for the subsequent development of disease. Among the participants studied. Hypertension. 1 (2010) 41 . Hip waist ratio in children of hypertensive and normotensive parents.01) with a median of 20 years.Vol.com Abstract The adverse association of cardiovascular risk factors in both children and adults with parental history of disease is seen.3% from the study and only 5.5% from the control group. stroke and other vascular complications. Email: jainapoorv@gmail. BMI. BMI.5% of current global disease burden and is as prevalent in many developing countries.5% from the control group.4% disability adjusted life years all over the world. Females with BMI of 25 or more were 26. 58% males and 52. Health care providers have an important role to play in educating families and children about approaches that are useful in preventing hypertension. 1. This study is aimed to compare any observed differences in the mean BPs. Wardha. To conclude. the study shows a positive relation of increasing BMI. Triceps fat distribution was more in females of study group. Blood pressureinduced cardiovascular risk rises continuously across the whole blood pressure range. A cross sectional study was conducted among the 100 students of a University. 1 No.9% of years of life lost and 1. Anil K. Nutritional status was assessed by means of body mass index. diabetes10. particularly when both parents had hypertension. Essential hypertension. George Smith has also confirmed positive association of weight and Blood Pressure15. a major risk factor for cardiovascular disease (CVD). 2002 “Reducing Risks.4. Data were also obtained on waist circumference. It is one of the major risk factors for cardiovascular mortality. 95%CI 1. which accounts for 20-50 percent of adult deaths.9 for males. family history. is prevalent in the adult population3. and obesity11.Vol. It is the commonest cardiovascular disorder. In all the strata of BMI. birth weight and pubertal development. with more universal application in individuals and population groups of different body builds. The World Health Report. Body mass index was associated with hypertension. The waist-hip ratio is used as an indicator of body-fat distribution. both among the boys (OR = 13. Obesity is a common phenomenon occurring in the young adults of today.8 for females and 0. 95%CI 2. posing a major public health challenge to population and socio-economic and epidemiological transition. height. 11. In fact hypertension in adults may be preceded by high blood pressure values in childhood12. In 48% children we found hypertension in family. Benchmark studies of waist–hip ratio as dominant cardiovascular risk factors were reported in Swedish men and women in 198417. Overweight and obesity is known to be a significant risk factor for hypertension.e. globally14. The waist–hip ratio is the preferred measure of obesity for predicting cardiovascular disease. A family history of cardiovascular disease (CVD) has been shown to be a risk factor for the subsequent development of disease. Further. 1 No. family history of arterial hypertension.5% of hypertensive’s had a waisthip ratio equal to or more than the cut-off point. Essential Hypertension is much more common in obese individuals. The adverse association of cardiovascular risk factors in both children and adults with parental history of disease is well recognized6. The study concluded that overweight. (2002)5 studied the obesity and coexisting hypertension. Children with positive family history of cardiovascular diseases have significantly higher body mass index13.4 v/s 23. Maria C et al 18 (2007) in the study investigated the risk factors associated with essential arterial hypertension in adolescents. Children with positive family history had significantly higher body mass index (25. Familial aggregation has been shown to occur for hypertension8 myocardial infarction9. Glowinska B et al.42-90. Deshmukh PR et al (2005)14 studied that higher abdominal fat is known to be a significant risk factor for hypertension and other related metabolic disorders. it is confirmed that change in the Body Mass Index (BMI) from higher range to lower side is associated with decreased cardiovascular risk16. exhibited a robust association.25-78.3% of hypertensive’s had BMI of 25 or more while 38. 1 (2010) 42 . obesity and family history of hypertension (father and mother with hypertension) were the principal risk factors for arterial hypertension in adolescents. i.21). Obese persons are approximately 6 times as likely to develop heart disease as normal weighted persons. and the girls (OR = 11.35. Height had a positive association with hypertension only among the girls.worldwide phenomenon2.8 kg/m2).94). hypertension was significantly higher in individuals having a Review of Global Medicine and Healthcare Research . Positive family history of cardiovascular diseases was found in 28% families. Promoting Healthy Life” has identified obesity as one of the ten leading risk factors. In contrast. 0.32. and in 8% families it was premature cardiovascular disease.7. Hypertension is the most often prevalent atherosclerosis risk factor in families5. body mass index. To measure the anthropometric parameters of young healthy adults having parental history of Hypertension. significantly more boys were obese as compared to girls. 2. Weight in kg. Aim & Objectives 1. The participants were examined for various anthropometric parameters. Deemed University. skin fold thickness.R. 1 (2010) 43 .H. A group of 50 students having parental History of Hypertension constituted the Study group.Vol. The participants were the students from Jawaharlal Nehru Medical College of Datta Meghe Institute of Medical Sciences.V. Parental history of hypertension was recorded. Another 50 students having no parental history of Hypertension constituted the control group. 1 No. To correlate the anthropometric parameters of these individuals with those of the young healthy individuals who do not have parental history of Hypertension. Significantly more children from higher socio-economic status were obese and overweight than those from lower socio-economic status groups. past admissions for cardiovascular diseases and past or current treatment with cardio active drugs like antihypertensive. A personal history of smoking or other addictions and diet habits was also noted in all cases. Participants were evaluated according to pre-designed protocol. Methodology This is a study conducted in Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital (A. Deemed University. The study emphasized the need for using the waist-hip ratio for assessing the risk of hypertension in populations where majority of the population is thin as traditionally measured by BMI. Chhatwal J et al19 (2004) mentioned in their study that there are very few reports from the developing world on the prevalence of obesity among children even though in developed countries it has reached epidemic proportions. Any past history of Hypertension.).B. 100 Students were contacted for the study. All the participants were examined only once on a single meeting. The participants were matched across age (18-25) and sex. Deemed University. Review of Global Medicine and Healthcare Research . a 900 bedded tertiary teaching hospital of Datta Meghe Institute of Medical Sciences. The anthropometric parameters measured in the study were height in cm. waist hip ratio.waist-hip ratio higher than the cut-off point. amongst children from affluent families. No significant gender difference for obesity prevalence was seen among children from a less privileged background. etc and steroid was noted. This study has been approved from the Institutional Ethical Committee of Datta Meghe Institute of Medical Sciences. however. antilipidemic. However. All apparently healthy students of Faculty of Medicine of Datta Meghe Institute of Medical Sciences. etc.Body weight was measured (to the nearest 0.Vol. Deemed University. 6. 1 (2010) 44 . Body Mass Index .9 and for females it was 0.The body mass index. 4.1 cm. Exclusion Criteria: History of taking Cardio active drugs like antihypertensive. is recommended by the World Health Organization as the most useful epidemiological measure of obesity. and both were recorded to the nearest 0. for some subjects there is no single narrowest waist because of either a large amount of abdominal fat or extreme thinness. Inclusion Criteria: 1. and the person performing the measurement inspected the tension of the tape on the subject’s body to ensure that it had the proper tension (not too loose or too tight). A vertical pinch. 2. Height . 5. The cut-off used for the waist-hip ratio (WHR) for males was 0. In the present study. Students who leave the examination midway due to any reason.It was measured at the narrowest level and hip circumference was measured at the maximal level over light clothing. As the measurements were taken over light clothing.5 kg) with the subject standing motionless on the weighing scale. Waist Circumference . participants were asked to remove tight or loose garments and belts intended to alter the shape of the body. because in most subjects the narrowest waist is at the lowest rib.WHR was calculated as WC divided by hip circumference. parallel to the long axis of the arm is made at the level of mid-point between the acromial process of Scapula and the olecranon process of Ulna. The narrowest waist is easy to identify in most subjects.8 to define obesity20. and with the weight distributed equally on each leg. antilipidemic.1. It was measured from the left hand when it is totally relaxed. without any pressure to the body surface. Body Weight . 1 No.It was measured (to the nearest 0. we measured waist circumference immediately below the end of the lowest rib. Age group between 18-25 years of both sexes. 2. Waist Hip Ratio .5 cm) with the subject standing in an erect position against a vertical scale and with the head positioned so that the top of the external auditory meatus was level with the inferior margin of the bony orbit (Frankfurt’s plane). on the mid-line of the posterior surface of the arm. To reduce subjective error all measurements were taken by the same person. when the narrowest point of waist was difficult to identify (particularly in obese subjects). Wardha. Triceps Skin fold Thickness – Triceps skin fold thicknesses were measured by using a Harpenden caliper. Review of Global Medicine and Healthcare Research . or BMI (weight in kilograms divided by the square of the height in meters). using a non-stretchable measuring tape. 3. Vol. 1 (2010) 45 . chi square test have been employed to analyze the data and validate the findings.65) 50 (50. 1 No. the range of age went from 10 students (7 males and 3 females) of the age 19 to one male student of the age 25. Table 2: Distribution of participants in relation to Blood Pressure Male Hypertensive parents Normotensive parents Total 31 (49. Results Table 1: Characteristics of Study group – Age Distribution ( as on the day of the examination) Age 19 20 21 22 23 24 25 Males 7 7 23 18 5 2 1 Females 3 1 13 15 5 0 0 Total 10 8 36 33 10 2 1 Interpretation: Maximum number of participants (23 males and 13 females of age 21 and 18 males and 15 females of the age 22) belonged to the age of 21-22.00) 32 (50.20) Female 19 (51.00) 63 (100) 37 (100) 100 (100) Review of Global Medicine and Healthcare Research .Appropriate statistical tools namely percentage. However.35) Total 50 (50.80) 18 (48. Vol. 1 No. 63% were male (Table 2) and the average age was 19.01) with a median of 20 years.76 years (SD ±2. Table 3: Relation of height of the individual to Parental History of Blood Pressure in males Height Range 145-149 150-154 155-159 160-164 165-169 170-174 175-179 180-184 185-189 Total Hypertensive Parents 1 (100%) 0 0 1 (50%) 4 (44. 1 (2010) 46 . varying from 18 to 24 years.5%) 9 (53%) 4 (31%) 8 (62%) 4 (57%) 32 Total in the range 1 0 1 2 9 17 13 13 7 63 Percentage of Males 100 80 60 40 20 0 50 44 47 100 69 38 43 Normotensive Parents Hypertensive Parents Height Range in cms Review of Global Medicine and Healthcare Research .Interpretation: Among the 100 participants studied.4%) 8 (47%) 9 (69%) 5 (38%) 3 (43%) 31 Normotensive Parents 0 0 1 (100%) 1 (50%) 5 (55. 1 (2010) 47 . it moves more towards those females who have a positive parental history of Hypertension i. Table 4: Relation of height of the individual to Parental History of Hypertension in females Height Range 145-149 150-154 155-159 160-164 165-169 Total Hypertensive Parents 1 (33%) 1 (25%) 5 (50%) 11 (57 %) 1 (100%) 19 Normotensive Parents 2 (66%) 3 (75 %) 5 (50%) 8 (43%) 0 18 Total in the range 3 4 10 19 1 37 Interpretation: According to this study.Vol. Review of Global Medicine and Healthcare Research . as the range of height (in cms) increases.e. 1 No. the Study group.Interpretation: The findings show a random distribution of the range of Height and their relation to the Blood Pressure state of their Parents in Males. 1 No.69) 17 (94. Review of Global Medicine and Healthcare Research .49) 11 (35.01* (significant) Interpretation: Males with BMI of 25 or more were 35.52) 28 (87.48) 04 (12.Table 5 : Distribution of Body Mass Index in relation to family history of hypertensive parents Male Female Total Mass Body Mass Body Mass Body Mass Body Mass Index Index Index Index <25 >25 <25 >25 20 (64.55) 06 (6) 50 (50) 50 (50) 100 Body Index Hypertensive parents Normotensive parents 48 (48) Total p < 0.45) 31 (31) 5 (26.48% with history of Hypertensive parents.5% of males were having BMI of 25 or more with history of normotensive parents.Vol. 1 (2010) 48 . while only 12.51) 15 (15) 14 (73.31) 01 (5. 55% of females were having BMI of 25 or more with history of normotensive parents (Table 5).31% with history of Hypertensive parents.49) 09 (47. 1 (2010) 49 .66) 67 (67.06) 04 (12.37) ratio < cutoff1 Waist-hip 18 (58.Interpretation: Females with BMI of 25 or more were 26.34) 33 (33.94) 28 (87. 1 No.01* (significant) Total Normotensive parents 15 (83.51) 10 (52.00) 03 (16. Table 6: Distribution of Waist-hip ratio in relation to family history of hypertensive parents Male Female Hypertensive Normotensive Hypertensive parents parents parents Waist-hip 13 (41.00) 18(100) 100 (100) Review of Global Medicine and Healthcare Research .Vol.63) ratio > cutoff1 31 (100) 32 (100) 19 (100) Total p < 0. while only 5. Vol.66% with history of normotensive parents had a waist-hip ratio equal to or more than 0. 1 (2010) 50 .8.8 (Table 6).63% with history of hypertensive parents had a waisthip ratio equal to or more than 0.Interpretation: Among the male subjects.51% males with history of normotensive parents had a waist-hip ratio equal to or more than 0. while 58.9. 16. Interpretation: In females 52.9. Among the female subjects. 12.06% of the males with history of hypertensive parents had a waist-hip ratio equal to or more than 0. Table 7: Distribution of Triceps Skin fold Thickness in relation to the state of Blood Pressure of the Parents Units 6 7 8 Male Hypertensive Normotensive parents parents 1 0 2 0 1 3 Female Hypertensive Normotensive parents parents 0 0 0 0 0 0 Total 1 2 4 Review of Global Medicine and Healthcare Research . 1 No. whereas more range. ( 6 units to 16 units ) was seen in male students of Hypertensive parents. 1 (2010) 51 . 1 No.Vol. It also shows that fat Review of Global Medicine and Healthcare Research . Interpretation: The Triceps Skin fold Thickness of Females students having Normotensive parents was confined between the range of 12 units to 15 units on the Harpenden’s Caliper whereas the Skin fold thickness of Female students having Hypertensive parents ranged between 11 units to 18 units.9 10 11 12 13 14 15 16 17 18 Total 3 4 2 4 7 5 2 0 0 0 31 (100) 3 4 5 8 6 3 0 0 0 0 32 (100) 0 0 1 5 6 2 1 0 3 1 19 (100) 0 0 0 7 6 5 0 0 0 0 18(100) 6 8 8 24 25 15 3 0 3 1 100 (100) Interpretation: The Triceps skin fold thickness of Males students having Normotensive parents remained between 7 and 15 units. height. This shows that these 18 participants can be classified as obese which is a strong risk factor to develop Hypertension. birth weight and pubertal development. The observations of this study shows that the differences between the Triceps Skin fold Thickness in males and females of the Study and Control group was always more than 1 unit on the Harpenden’s Caliper used. This fact also shows the positive relation of the increasing Body Mass Index and its association for becoming an increasing risk factor to develop Hypertension in future. 1 (2010) 52 .Vol. Similarly. The cut off for the Waist Hip ratio (WHR) for Males to define obesity is 0. family history of arterial hypertension. This also proves that lower value of WHR provides less chances of developing obesity and thus Hypertension in future. when seen together in both the Sexes. the cut off for the Waist Hip Ration for females to define obesity is 0. Out of the 32 males in the control group. A similar co-relation was found in the study of Maria C et al 18 in the year 2007 where they investigated the risk factors associated with essential arterial hypertension in adolescents. the number of students who have their Body Mass Index greater than 25 are more in case of those students who showed a positive parental history of Hypertension (Study group) than in comparison to those who did not show positive parental History of Hypertension (Control Group). 18 have their WHR above the standard defined cut off mark for obesity and 13 males have their WHR below the standard mark. Out of the 6 females who have their Body Mass Index greater than 25. Height had a positive association with hypertension only among the girls. The Positive association of height with hypertension among girls as observed in the study given above is also seen in this study where as the Height range increases. Hence.8. it moves more towards those females who belong to the study group. it clearly showed that those students who have a positive parental history of Hypertension have more deposition Review of Global Medicine and Healthcare Research . The study comprises of 19 females in the study group out of which 10 have their WHR above the standard cut off and thus can be classified as obese.distribution under the Triceps was more in females having Hypertensive parents than Normotensive parents. out of the 31 males in the study group. Thus. those who have positive parental history of Hypertension. In this study.9. Nutritional status was assessed by means of body mass index. Out of the 18 females in the control group.e. only 3 have their WHR above the standard cut off defined to be declared as obese. 11 belonged to the study group i. Data were also obtained on waist circumference. This shows a positive relation of the increasing Body Mass Index and its association in becoming an increasing risk factor to develop Hypertension in future. Body mass index was associated with hypertension. children with positive family history of cardiovascular diseases have significantly higher body mass index.8 kg/m2).4 vs 23. 1 No. According to his study.Similar findings were seen in the study conducted by Głowińska et al13 in the year 2002. only 4 have their WHR above the standard cut off for obesity. (25. Being obese again predisposes such females to an increasing risk of developing Hypertension. Discussion Out of the Total 15 males who were reported to have the Body Mass Index greater than 25. 5 belonged to the study group. Rangbulla A. Osmond C. Bull AR. Limitation of the study Despite the attempt to obtain a complete assessment of parental history. International Society of Hypertension Writing Group. Fetal and Placental size and risk of hypertension in adult life. BMJ 1990.56(4):310-4 3. Kumbkarni S. Because we classified unknown responses as a negative history. Barker DJP. Indian Heart J.0 mm greater in those young adults with a positive parental history of hypertension. 2003 Nov.Vol.and sex-adjusted Triceps skin fold thickness was 1. there is no reason to suspect that this would result in artifactual risk differences. Kumar N. Prevalence of sustained hypertension and obesity in urban and rural school going children in Ludhiana. Health care providers. suggesting that. Mohan B. World Health Organization. Conclusion The findings of the present study suggest the need of monitoring the BP of children of hypertensive parents. 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. References 1. The findings echoed with the findings of Bruke et al7 in the year 1991 where they observed that Age. it would be more likely to increase the variability of the parental history measures and lead to an underestimate of the real risk factor differences between these groups. 301: 259-264. therefore have an important role to play in educating families and children about approaches that are useful in preventing hypertension. the reported history gives a reasonable estimate of family history for the diseases we have assessed in this paper29 . Therefore. 21(11):1983-92 2. the differences presented probably underestimate the true risk factor difference attributable to parental history. 1 No. This in future adds to the risk factor for developing Hypertension at older age. Another potential drawback of these data is the lack of validation of parental disease by medical record review. Even if some discordance occurs. Aslam N. as with any misclassification error.of fat under the skin. Wander GS. Review of Global Medicine and Healthcare Research . a substantial number of participants were unaware of their parents' disease status (especially paternal history). 1 (2010) 53 . 2004 Jul-Aug. rather. Whitworth JA. J Hypertens. Other investigators have detected a relatively good concordance (78%) between a reported family history and medical record validation. Sood NK. this tendency would bias our results toward the null. despite some imprecision. Burke GL. 1981. Bush PJ. Foster TA. familial hypertension and anthropometric parameters in a sample of 3-year-old children. Webber LS. Koput A. Friedman GD: Environmental and behavioral determinants of fasting plasma glucose in women. Koput A. Circulation. Blonde CV. Cardiovascular Disease and stroke 16. Giusti D. J Hypertens 1988. hypertension and diabetes Pol Merkur Lekarski.44: 381-386. Parental history and cardiovascular disease risk factor variables in children. Selby JV. Correlations between blood pressure values. Buffetti A. Currò V. 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Barrett-Connor E: Family history of heart attack: A modifiable risk factor? Circulation 1986. Nutr Rev 1986. 7. Khaw K. [Correlation between body mass index. Number 2. Newman B. 16: 215-219 5. 12. AR Dongre. Pediatr Med Chir.6:647-653 9. Głowińska B. 1 No. Hughes GH. Urban M. Does Waist-Hip Ratio Matter? – A Study in Rural India. [Correlation between body mass index. Głowińska B. Jacobs DR. George Davey Smith : IS 109 : The influence of developmental indices and blood pressure in young adults on risk of stroke and coronary heart disease in late adulthood. PR Deshmukh. Berenson GS.10:25-37. 11. Regional Health Forum – Volume 9. Pelargonio S. King M. Feb 2007. Garn SM: Family-line and socioeconomic factors in fatness and obesity: A matched co-twin analysis. Selby JV. 1 (2010) 54 . Health Educ Q 1989. Urban M. hypertension and diabetes Pol Merkur Lekarski.Vol. 1988 May-Jun. 1991. 2005 15. Review of Global Medicine and Healthcare Research . Bracaglia G.4. Roseman JM.12(68):108-14 6. 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Atherosclerosis risk factors in children and adolescents with or without family history of premature coronary artery disease. Cao RX. 19. Grone & Stralton. World Health Organization – International Society of Hypertension Guidelines for the Management of Hypertension. World Health Organization. 179: 580-5 18. Am J Epidemiol 1989. Kuschnir. Paul O. Kelishadi R. Amiri M. 27. Bashardoust N. MJA 2003. 29.83(4):335-342. Blood pressure aggregation in families. Naderi Gh. Guidelines Subcommittee. 1975. New York. 9: 36-40. 854: Physical status: The use and interpretation of anthropometry. Sarraf-Zadegan N. Bennett SA.17. Wang WJ. Forde OH. Maria C. The significance of physical. Thelle DS: The Troms. Clarke WR. 110: 304-309. 17:151–183. In: Epidemiology and Control of Hypertension. Risk factor associated with arterial hypertension in adolescents. Gao Q. Chhatwal J. Bai YM.13(3):231-5 20. Asia Pac J Clin Nutr. Verma M. J Hypertens 1999. 22. Waist-hip ratio is the dominant risk factor predicting cardiovascular death in Australia. Riar SK. 28. Trend of atherosclerosis’ risk factors in children of Isfahan. J Pediatr (Rio J). Gulnar A. Brandao AP. 21. 1 No. Hashemipour M. Dhaliwal SS. 375. Araujo EM. Ed. Garrison RJ. development on the blood pressure curve of children between 6 and 9 years of age and its relationship with familial aggregation. C. 1 (2010) 55 . Aggregation of blood pressure in the families of children with labile high systolic blood pressure. p. Brandao AA. 25. Schrott HG. Mendonça. J Hypertens 1989. Niu ZH. Holland WW. Feinleib M. Arabians and Nigerians) in Minsk. CAGE and MAST scores amongst the Slavs and Nigerians. A total of 16. as well as preference for alcoholic beverages among the students of all ethnicities were noted. Differences in the pattern of alcohol use and related problems exist among students of various ethnicities (Slavs. 63.Vol. Minsk. Similarities in the average AUDIT. involving a total of 1549 respondents: 1345 Slavic. Arabian And Nigerian Students: A Case Study in Belarus Menizibeya O. Belarus. MAST and other alcohol related questions. Higher scores were recorded only on the AUDIT and MAST for the Arabs. Belarus. Razvodovsky Group of Narcologists Grodno State Medical University. Welcome Belarusian State Medical University. Review of Global Medicine and Healthcare Research . The patterns of alcohol use might vary among students of different cultural backgrounds. Arabians and Nigerians in Minsk. Alcohol related problems were higher among the Arabs and Nigerians.08% Slavs. Belarus were examined. Minsk. 120 Arabian and 84 Nigerian students in Minsk. Belarus Abstract Background: Alcohol use by university students is a major public health problem in Belarusian campuses. Belarus Email: menimed1@yahoo. Aims & Objectives: Differences in alcohol use and related problems among undergraduates of various ethnic groups . Results / Findings: Overall.73% Nigerian problem drinkers were identified using the AUDIT.28% Slavic. All respondents were administered questionnaire containing the AUDIT. compared to the Slavs. Conclusion: The level of alcohol use and related problems in the general Belarusian students’ population is high. Pereverzev Department of Normal Physiology Belarusian State Medical University.50% Arabian and 22. 32. CAGE. 1 No. 91.Transcultural Differences in Alcohol Use among Slavic. Grodno.Slavs.82% Nigerians were alcohol users. Generally. the use of weak strength alcoholic beverages (beer) was higher in the students’ population of all ethnicities.com Yury E. 1 (2010) 56 .33% Arabs and 56. Belarus Vladimir A. Methods / Study Design: The study was randomized and anonymous. Weitzman et al. Wechsler et al. The pattern of alcohol use might differ among various ethnic groups. 2005. Annoyed. Weitzman et al.Vol. 2004). High level of alcohol problems in the general students’ population calls for the necessity of carrying out preventive measures aimed at early detection of alcohol problems. Dong-Eok & Jorge. Arabian. According to some researchers one of the major risks for health is associated with heavy alcohol use (Welcome et al. injuries. the students’ population is easily accessible. 1994. Gache et al. Catherine 2004). Presently. even in the same cultural settings (Catherine 2004. 2005. The most commonly used instruments are the AUDIT (The Alcohol Use Disorders Identification Test). traffic offences and accidents. 1998. Catherine 2004). Slavic. students.Key Words: Transcultural. 2008. Paschall & Freisthler. and every data suggest that screening for the prevalence of alcohol use in the student’s population. 1995). Introduction Alcohol use is a risk factor for health and significantly contributes to the burden of disease word wide (Razvodovsky 2008. 2004. A screening result that will address the prevalence of alcohol use and related problems in the general students’ population of various ethnic groups will be of great importance. certain psychometric screening instruments are widely used. Emmanuel et al. with subsequent consultation and therapeutic intervention. Also. In Belarus. Materials and methods Review of Global Medicine and Healthcare Research . 1 (2010) 57 . 1994. Recent epidemiological data have consistently shown that the level of alcohol problems is high among the students’ population (Wechsler et al. Belarus. The aim of this survey was to screen for the prevalence of alcohol use and related problems among university students of different ethnicities: the Slavs. for determining the level of problems related with alcohol use in the general population. Guilty and Eye questionnaire) (Welcome et al. Nigerian. 2004. Caetano et al. Federico & Diane 2007). there is a paucity of data addressing the problem of students’ alcohol use. Arabians and Nigerians in Minsk. 1 No. 2003). Expulsions from school. Belarus. In the general students’ population alcohol use results in low academic performance. in epidemiological research. and subsequent intervention is of great benefit to public health (Elissa & Toben 2004. 2008. and CAGE (the Cut. asocial behaviors. 2005). 2004). blackouts etc are all effects of alcohol use by students (Wechsler et al. Razvodovsky 2008. Hays et al. Weitzman et al. Manuel & Walt. as no intervention program is carried out (Welcome et al. 2008. This has contributed partly to the increase in the prevalence of alcohol use and related problems. Hays et al. 2008. alcohol use. 1995). MAST (Michigan Alcohol Screening Test). 1994. These instruments are highly sensitive (85-94%) and specificity (79-93%) for early detection of alcohol problems (Welcome et al. others were Russians (2%) and Ukrainians (1%). Students with scores ≥1 were considered as alcohol users (Welcome et al. 350 Arabians and about 12000 Slavs study in these universities. Non-problematic alcohol use was determined on the AUDIT from scores of 1 through 7. A standard drink was set at 8g of absolute ethanol (Welcome et al. Arabians and Nigerians study. 2005). Belarusian National Technical University and Belarusian State Agrarian Technical University) in Minsk. atheists and nonreligious (1%). χ2 and Student’s t tests (Bland 2000). 1549 students: 1345 Slavs (mean average age = 21 yrs) (352 males and 993 females). CAGE. Sampling size and technique: A total of 2210 Slavic. atheists/non-religious (1%). Presently. All questionnaires were distributed evenly among students of year one to final year of university education in all four major universities.5 yrs) (73 males and 11 females) agreed to participate. There are four major universities (the Belarusian State University.5 yrs) (89 males and 31 females) and 84 Nigerians (mean average age = 21. Abstinence was defined as a score of zero on the AUDIT. Measures: A score of ≥8 on the 10-item AUDIT defines alcohol related problems (Welcome et al. Results are displayed as means and standard error of means (M ± m). about 93 Nigerians. Majority of students in these universities are Christians (94%). Arabians were Iraqi and Saudi Arabian origin.Study population: Minsk is the capital city of Belarus with the highest number of students (foreigners and natives). The probability value for significance was set at p<0. Others are Muslims (5%). Gache et al. Students with scores of ≥3 on the MAST were defined as problem drinkers (i. the criteria of Pearson. Data analysis: All statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) 16. Arabians and Nigerians) on the AUDIT. 2008). While a majority of the Slavic students were Belarusians (97%). 250 Arabian and 90 Nigerian students at random were explained the study aims and objectives. Gache et al.e. The average scores were significantly Review of Global Medicine and Healthcare Research . Results The mean statistical results of all respondents (Slavs. 120 Arabians (mean average age = 21.0 version for Windows. 1 No. %. A score of 2 through 4 on the CAGE was considered clinically significant. All volumes of alcohol are given in values of absolute ethanol. where the native Belarusians. 1995). students with alcohol related problems). only those who agreed to participate were considered for interview in their various universities. 1 (2010) 58 .05. 2008. All Arabians and Nigerians are foreigners studying in Minsk. 2008. Procedure: The Ethics and Research Committee of the various universities approved the study protocol and informed consents were obtained from the respondents after the aims and objectives of the study had been explained. CAGE and MAST are given in table 1.Vol. All students were administered questionnaire containing the AUDIT. Arabian students were 98% Muslims and 2% Christians. 2005. Nigerian students were 99% Christians and 1% – Muslims. Overall. Hays et al. MAST and other alcohol related questions. as well as in percentages. 3% Muslims. Belarusian State Medical University. The participants: Slavic students were 96% Christians. CAGE and MAST Ethnicities Slavs Sex M (n=352) F (n=993) Total (n=1345) M (n=89) F (n=31) Total (n=120) M (n=73) F (n=11) Total (n=84) Alcohol users.08 (n=110) 15.83 (n=37) 23.87 0. Also. On the AUDIT.1 times (χ2=21.17 1.62% (n=19) Nigerians were problem drinkers (Table 2).50% (n= 39) Arabians and 22. 32.66 (n=18) 18. The total percentage of Arabian problem drinkers was significantly more than the Slavs by approximately 2. Table 1: Total average AUDIT.06 (n=18) 63.67 (n=38) 24.02).32 Overall.83 (n=31) 19.03 0.44 (n=54) 9. Table 2: Gender differences in the percentages of alcohol users and problem drinkers among the Slavs.77 (n=97) 16.33 (n=76) 61. M ± m AUDIT CAGE MAST 4.18 (n=2) 20.50 (n=39) 23.higher on the AUDIT and MAST for the Arabians.46 (n=208) 37.08 (n=33) 16. p<0. 63.13 (n=5) 31. Arabs and Nigerians on the AUDIT. compared to the Arabian and Nigerian females. CAGE and MAST scores of the Slavs and Nigerians (Table 1).35 (n=6) 30.45 (n=20) 5.Vol.71 (n=51) AUDIT 34. a significant proportion of both male and female Slavic students had higher alcohol users.94 ± 0.89 ± 0.0 times (χ2=19.05 6. CAGE and MAST scores of students of various ethnic groups Parameters Slavs (n=1345) Arabs (n=120) Nigerians (n=84) Average score.4 times (χ2=20.08% (n=1225) Slavs.005) on the AUDIT. % 94.10 2.18 (n=2) 20. But.20 ± 0.70. they had lower percentage of problem drinkers.70 ± 0. 1 No.76 ± 0.005) on the MAST.45 (n=19) Arabs Nigerians The number of alcohol users and problem drinkers was lower among the females of both ethnicities. Despite the higher rate of alcohol use by Slavic females.29 (n=17) 18.84 (n=98) 19.38. 91.33% (n=76) Arabians and 60.38 ± 0.14 0.28 (n=219) 35. p<0.60 (n=69) 11.56 ± 0.62 (n=19) Problem drinkers.58 (n=7) 32.32 (n=332) 89.71% (n=51) Nigerians were alcohol users (Table 2).64 (n=45) 54.66 (n=122) 9.005) on the CAGE and 3.08 (n=1225) 61.18 ± 0. 2.97. Review of Global Medicine and Healthcare Research .68 ± 0. there was no statistical significance. Although.38 4.55 (n=6) 60.88 0. a total of 16.14 (n=123) 34. compared to scores for the Slavs and Nigerians (p<0.93 (n=893) 91. There were no significant differences in the average AUDIT.28% (n=219) Slavs. the total number of problem drinkers among the Arabians was slightly more than the Nigerians.18 (n=2) 22. % CAGE MAST 27. p<0. compared to other ethnic groups (Table 2). 1 (2010) 59 . in respect to the percentages of problem drinkers no value for significance was recorded between the Slavs and Nigerians.96 (n=32) 22.80 (n=55) 58. The percentages of problem alcohol users among the Slavs on the MAST were lower than that of the AUDIT and CAGE (Table 2).29 (n=19) 18. compared to the Arabs and Nigerians.1 times respectively.77 20.08 46. Arabs and Nigerians.9ml.1 49.9 116.26 41.Vol. vodka and other spirits).04 (n=123) 21. 1 No. compared to the Slavs who use alcoholic beverages 2-4 times on the average.55 (n=15) 23.23 16. compared to only 10% and 12% for the Slavs and Nigerians respectively).53 25.0 Loss of control. SSAB – strong strength alcoholic beverages (vodka and other spirits).86 (n=29) ASAB. % 7.84 (n=4) N/B: WSAB – weak strength alcoholic beverages (beer). however weak strength alcohol users were significantly higher among the Slavs. blackouts. % 22. % 10. than the values for the Arabs and Nigerians respectively (Table 3).16 (n=149) 10. Only Alcohol users Ethnicities Slavs (n=1225) Arabs (n=73) Nigerians (n=51) WSAB. But no significant differences were noted between the Slavs and Nigerians (Table 3).25 Injuries.83 Analysis of the quantity of alcohol use showed no significant differences among students of all ethnic groups. WASSAB – weak/average/strong strength alcoholic beverages (beer. vodka/other spirits – ~40% (Welcome et al.8ml and 19.67 Blackouts.35 47. the percentage was also higher for both the Arabs and Nigerians than in the Slavic population by 2. Cases of some alcohol related problems like injuries.53 (n=12) SSAB. Table 4: Preference for different alcoholic beverages by different ethnic groups. 2008).29 (n=861) 46.Table 3: Quantity of alcohol use and percentages of some alcohol related problems among the Slavs.17 Hangover. Among average strength alcohol users. The percentage of strong strength alcohol users showed an increase among the Arabs (up to ~22%. % 12. wine – 7-17%. ASAB – average strength alcoholic beverages (wine). The use of average and strong strength alcohol or its combination was lowest is the general student population. 1 (2010) 60 .92 (n=16) 11.76 (n=6) WASSAB.51 (n=92) 20. although the amount was higher among the Slavs by 7. % 70.7 times and 3. The monthly frequency of alcohol use was also very low for both Arabs and Nigerians (1-2 times). Review of Global Medicine and Healthcare Research . From table 4. hangover and loss of control was more in the Arabian students’ population than in the Slavic and Nigerian population.1 104. % 27.96 (n=8) 7. Only Alcohol users Ethnicities Slavs (n=1225) Arabs (n=73) Nigerians (n=51) Dose/person/month (ml) 123. the use of weak strength alcoholic beverages was higher among students of all ethnicities.68 29. % 16. % 32. generally.58 (n=34) 56. wine. Composition of alcohol in the various alcoholic beverages: beer – <7%. The higher level of alcohol related problems in the Arabian students’ population. on days of wages.the absence within a society of common social norms and controls. as a result. Generally. 1998. 2005. Before entrance into the university (before arrival in Belarus) approximately half of all Arabian and Nigerian students reported abstinence. 2008. their means of socialization are affected. Emmanuel et al. compared to other ethnic groups) (Wall et al. Dong-Eok & Jorge 2004. as a result of their lack of experience regarding alcohol use (Caetano et al. 1998. Epidemiological data suggest that Muslims might experience high rate of alcohol problems in case of alcohol use. Discussion The cut-off point for problematic alcohol use in this study is in agreement with the recommended cut-off for the various screening tools in Belarus (Welcome et al. 1997). Wall et al. Frone 1999).g. alcohol dependence). the high Km enzymes of alcohol metabolism have been confirmed to be of low prevalence in Asian decent. which might subsequently result in alcohol use and abuse (Welcome et al. but relatively higher proportion of problem drinkers (Table 2) might be linked to many factors (see below). 2008. Under those conditions. It has been suggested that Muslims (as 98% of the Arabs in this study were Muslims) might find it very difficult to cope in a society where alcohol use is part of the daily life of the people (Catherine 2004. Arabians and Nigerians. there were no significant differences in the type of alcoholic beverages used as majority of the students of all ethnicities prefer weak strength alcoholic beverages like beer (Table 4). the Arabian students still had higher alcohol related problems compared to their Slavic counterparts. 1998. 1 (2010) 61 . Review of Global Medicine and Healthcare Research .Vol. compared to the Arabians and Nigerians with lower number of alcohol users. which might probably result in alcohol use (Caetano et al. According to Durkheim’s theory. 2005). 1997).g. This could likely be one of the reasons why even for approximately equal quantity of alcohol use among students of all ethnic groups. Catherine 2004. possibly resulting in self-destructive tendencies (e. for the sweet qualities of alcohol and to get drunk.The major factors that encourage alcohol use in the general students’ populations of all ethnicities were drinking to reduce bad mood. 1 No.. Caetano et al. 1998. compared to the Slavs and Nigerians might be partly due to their socialization peculiarities and even differences in biological constitution (for example. depression and alcohol abuse. they are more prone to experiencing greater effect of alcohol use. Religion also plays a major role in peoples’ attitude toward alcohol use. among the various ethnic groups – Slavs. 1998. Subsequently. Caetano et al. Heath 1995). Caetano et al. The high proportion of alcohol users and relatively low problem drinkers among the Slavs. Bloomfield et al. Leighton argued that rapid social change and disruptions (e. conflicting cultural values and fragmented communication) cause high stress levels that can result in deviant behaviors and psychological disorders. A low level of alcohol consumption in Muslim societies is a classical example of the protective influence of religion on alcohol use (Welcome et al. 2008). rapid cultural change causes a condition called anomie . people lack clear behavioral guidelines. In the same way. Dong-Eok & Jorge 2004). Biometrics & Epidemiology.28%). Arabian and Nigerian students’ population in Minsk. Conclusion The level of alcohol use and related problems among the Slavic. 1 (2010) 62 . CAGE and MAST) showed almost the same results (in regards to the percentage of problem drinkers) among the Arabian and Nigerian students’ population (Table 2). Review of Global Medicine and Healthcare Research . compared to the AUDIT and CAGE among the Slavic students’ population as seen in the screening results (Table 1 & 2). Allamani A. 2008. MAST and CAGE.Vol. Another limitation of this study is that the questionnaire was administered ones and so the reliability indices of the various tests were not assessed. This might have affected the reliability value of the screening results. It is probable. Belarus. Project Final Report. The proportion of problem drinkers on the AUDIT was higher among the Arabs (32. UK: Oxford University Press. Making general conclusion about the sensitivity of the various screening instruments used is rather difficult as a result of the limitations of this study. 1995. Bloomfield K. The use of weak strength alcoholic beverage (beer) is highest among students of all three ethnic groups. Gender. The fewer sample of both the Nigerians and the Arabians (especially the female respondents). Eisenbach-Stangl I. weak strength alcohol (beer) users were slightly higher than the Arabians and Nigerians. Bohn et al. Catherine 2004. Beck F. than the Arabians (63. compared to other ethnicities. Arabians and Nigerians) in Minsk. Oxford. 2005. This was the rationale for using multiple screening tests in this study. Belarus is high.33%) and Nigerians 56. Limitations: Some respondents with alcohol related problems may have underreported them in the AUDIT. There was a slight increase in the percentage of strong strength alcohol users among the Arabs. 1995). Csemy L. An Introduction to Medical Statistics (3rd ed. Charité Universitätsmedizin Berlin. This was because a fewer number of Arabians and Nigerians (and especially very few females) study in Minsk (Belarus).08%) was higher. All three screening tests (AUDIT.73%). References Bland M (2000).82%. Berlin: Institute for Medical Informatics. could have affected the reliability and significance of the results.). Gache et al. compared to the Slavs (16.It has been noted in earlier studies that the MAST might show minimal sensitivity when used for determining the level of alcohol related problems in some populations. compared to the Slavs. 1 No. Bergmark KH. Hays et al. Significant differences in the pattern of alcohol use exist between students of various ethnic groups (Slavs. Although among the Slavs. et al (2005). And that the CAGE might be highly sensitive among the Slavic population (Welcome et al. Culture and Alcohol Problems: A Multi-national Study. that the MAST is less sensitive. The percentage of Slavic alcohol users (91.50%) and Nigerians (22. Alcohol Res Health. Kranzler HR (1995). Westport. 29 (11). 22 (4). pp. Heath DB. 3 (1). 34 (3). pp. 31(2). 8. Kristen RB. A study of the relationship between parental alcohol problems and alcohol use among adolescent females in Republic of Korea. pp. Stephan DF (1998). Arfaoui S. Babor TF. Federico EV. Alcohol Clin Exp Res. Comparison of CAGE & AUDIT. pp. Miller MJ (1998). Dong-Eok S. Geneva: WHO. Nicholas R (1995). Landry U. and validity of the CAGE. Global status report on alcohol. Alcohol Health Res World. Emmanuel K. 23 (4). pp. pp. pp. International Handbook on Alcohol and Culture. pp. Mary BMD. 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Evaluation of the “a Matter of Degree” Program. Pereverzev VA (2008).   Review of Global Medicine and Healthcare Research . pp. 1672 -1677. Lee H. Dowdall G. pp. 27 (3). 64 (4). Prevalence of alcohol-linked problems among Nigerian students in Minsk. 562-565. Johnson ML. pp. 120-129. 1 No. et al (1997). Am J Prev Med. Wechsler H (2004). pp. Thomasson HR. Wall TL. Pоrt Harcourt Med J. Razvodovsky YE (2008). Cole M. 3. Castillo S (1994). Drug Alcohol Rev. Freisthler B (2003). JAMA. 27. Belarus and their academic performance.Vol. Alcohol metabolism in Asian-American Men with Genetic Polymorphisms of aldehyde dehydrogenase. Weitzman ER. Dotsenko EA. Welcome MO. All-cause mortality and fatal alcohol poisoning in Belarus. 1 (2010) 64 . 1970-2005. Ann Intern Med. Davenport A. Does Heavy Drinking Affect Academic Performance in College? JSAD.Paschall MJ. Peterson KP. 127 (5). Moeykens B. pp. Reducing drinking and related harms in college. Nelson TF. 272 (21). Wechsler H. 187-196. 1 No.020. -0.338 Jamaicans. with a mean age of 34.070) is the most influential factor followed by employment status (Beta = 0. This study is taken from a general study conducted by the Centre of Leadership and Governance. but it is about the independence.Determinants of Quality of Life for Jamaica Women Paul Andrew Bourne Department of Community Health and Psychiatry Faculty of Medical Sciences. Further examination of the sociodemographic determinants revealed that subjective social class (Beta = 0. the choices.152. Abstract Objective: The current study seeks to examine the quality of life (or subjective wellbeing) of Jamaican women by building a model that will capture sociodemographic and economic determinants of their quality of life.058. The University of the West Indies between July and August 2006 of some 1. income (Beta = 0.4 yrs. using the descriptive research design. religiosity(Beta = 0.139. 0.077).548.1. b=-0.7: Range 10: 10– 0. The 3 most influential variables are social class (4%). Conclusion: In summary. The model shows that 6 factors explain 18. The University of the West Indies. b=0. Mona.Vol. 1. with religiosity being the fourth most influential of the 6 factors.8 ±1. 0. income and religiosity. b=0. 95%CI:0.167. employment (2. the factors of quality of life of a Jamaican Woman are social class. Findings: The study reveals that the model explains 18. b=0. 0.015.594.5% (Adjusted R-squared) of the variability of quality of life of women. and multiple regressions were used to build a quality of life model for Jamaican Women. the sense of freedom. the administration of the governance of the nation (Beta = -0. employment.893. 1 (2010) 65 .214.725. Employment does not merely about the income. 95%CI:-0.101).676).348.691. 95%CI:0. 95%CI:0.094. Data were collected and stored using the Statistical Packages for the Social Sciences (SPSS).974). 95%CI:0.304. Method: The current study uses a sample of 723 women. the positive psychological attributes that this freedom gives as well as the self-advancement that it is likely to provide why this variable is of that importance in determining the quality Review of Global Medicine and Healthcare Research .198. 95%CI:0.9%) and income of a person. Jamaica Email: [email protected] Brief Synopsis: On an average the mean quality of life of Jamaican Woman is 6.203) and lastly by interpersonal trust (Beta = 0.5% of the variance in quality of life of this gender.380. 0. b=0. Department of Government. with social class being the most influential of all the variables. b=0. The survey was a stratified random sample of the fourteen parishes of Jamaica. with 6 variables accounting for this variance.155.33yrs ±13. 2 per cent for males and 14. The rationale that underpins the current work is principally driven by lack of academic literature on the subjective wellbeing or quality of life on the particular gender. 2004. wages or salaries. In 1991. One study examining a particular quality of life of an elderly man shows how medical practitioners over many years sought to address a particular issue that was eroding the wellbeing of a patient who had a certain physiological dysfunctions (Ali and colleagues 2007).7 million).9). Within this context. Gaspart. Easterlin 2001a. Jamaica. Review of Global Medicine and Healthcare Research . Can medical practitioners and social researchers assume that the quality of life of sexes is the same. The statistics reveal that men enjoy a 17 per cent higher employed labour force than females. 2001.e. income or wealth) (Becker et al. 2001b. purchase power party differs.2 per cent for females compared to 9. Stutzer and Frey 2003. researchers. Hutchinson et al. A primary rationale for this awareness is owing to the opportunity differential because of one sex in society. The current work does not provide all the answers. 21. Women health.. medical practitioners and policy makers need to understand the factors that influence quality of life of each gender as they are sex specify in enhancing the specificity that is needed to planning for the sex differential. and that 76 per cent of senior positions were held by males although 54 per cent of executive and managerial positions were held by females. Most studies on quality of life have incorporated gender as a predictive factor or a determinant of subjective wellbeing studies (or quality of life) (Bourne. the figure fell to 6. the unemployment rate was 22. 1995.4 per cent for males and in 2007. 2007. p. and this indicates the opportunity of greater economic resources. Smith and Kington 1997. Keywords: Quality of life. Cummins 2000. given that they are of the same species? Such a situation is simple.Vol. 1 (2010) 66 . Another good measure that has been used to evaluate betterment (quality of life) between the sexes is economic resources (i. crosssection study Introduction The current study seeks to examine the quality of life (i. gender culturalization is dissimilar as well as the disparity between gender opportunities. subjective or self-reported wellbeing) of Jamaican women by building a model that will capture sociodemographic and economic determinants of quality of life of this cohort. Grossman 1972). Summers & Heston 1995). 2009. In the Economic and Social Survey of Jamaica (2004.5 per cent for females. modify and refute research as this provide a platform upon which this is probable in the future. the publication showed that on an average the earnings of males (mean wage = $2. as the physiological composition of the sexes is different. Hambleton et al. If males are still receiving greater salaries compared females and they experience high degrees of employment. The more drastic reduction in the unemployment rate for women cannot constitute any form of betterment of females over their male counterparts as in 2007 the unemployment rate for female was twice more than that of males. 1998. developing countries.4 million) was 2 times more than that of females ($ 1. we cannot concur with Miller nor Chevannes or Gayle that they are marginalized despite the fact that they are living fewer years than females (Table 1. Diener 2000. 2005. Lyubomirsky 2001.1). 1 No. 2004. but it is catalysts upon which we are able to build. Murphy and Murphy 2006. 1985.e.of life of Women. “Females’ life expectancies are likely to remain above that for males [Elo 2001] for the foreseeable future. and data were collected every second year for a duration Review of Global Medicine and Healthcare Research . Thus with men receiving more than women. their material wellbeing is higher is later life. using survey data from 1988 to 1999. 1 (2010) 67 . economic) than men (Rudkin 1993 222). among both the population as a whole and the elderly” (Moore et al. 2005) and rural women of the reproductive ages 15 to 49 y4ears (Bourne and Rhule.Vol. It was found that men believed their health was better (2% higher) than that self-reported by females. worldwide men have a reluctance to ‘seek health-care’ compared to their female counterpart. 2009). Among the justification for the differential between life expectancy the sexes is linked with the health consciousness of women and their approach to preventative care. and more retired benefits compared to women ages 65 years and older. life expectancy for male is lower than of females.From a study. 1997. Brazil and Costa Rica. Moore et al. 1995b. This is particular true for females in the old aged cohorts (United Nations 2004. Unlike women. the researchers found that there is no general trend of economic marginalization of males in those societies (Omar Arias. which is evident from the some of economic indicators in Jamaica. with women having a lower psychological wellbeing and life satisfaction than men (Hutchinson et al.’s work used a sample of young adults (ages 15 to 50 years). (1997) added. what about our women? The importance of women in fertility as well as the fact that they have a greater life expectancy compared to their male counterparts (Table 1. Generally. Hambleton et al. 12). Moore et al. it is timely that a research be done on this cohort to unearth ‘what constitute their quality of life?’ Scholars who have done studies on different Caribbean nations like Bourne. A study conducted by McDonough and Walters (2001) revealed that women had a 23 percent higher distress score than men and were more likely to report chronic diseases compared to males (30%).0). and having a more durable possession than women. Studies on the same region have examined psychological wellbeing of the total population. 2007. 1 No. This finding is further sanctioned by Haveman et al (2003) whose study reveal that retired men’s wellbeing was higher than that of their female counterparts.e. a survey done by Rudkin found that women have lower levels of wellbeing (i. their works on the quality of life have been substantially on elderly people ( ages 60 years or older or 65 years and older) with no particular interest on a certain sex. from the United Nations statistical databases. and therefore omits the all other age cohort of Jamaicans. It follows in truth that women have bought themselves additional years in their younger years. Brathwaite. conducted in Argentina. Eldemire 1997. 1996. 1995a. 1997). The study was initiated in 1994. 1987b. Caribbean societies have patriarchal roots and so economic resources are primarily in the hands of males. Hutchinson et al. and it is a practice that they continue throughout their life time which makes the gap in age differential what it is – which is approximately a 4-year difference in Jamaica. Bourne and Rhule on the other hand did not example the gamut of women as they excluded urban and semi-urban women. 1994. McDonough and Walters used data from a longitudinal study named Canadian National Population Health Survey (NPHS). but of the quality of life of female? How are they living in Jamaica? Is there is disparity between the quality of life of the sexes? However. because men usually received had more material resources. 2001). 2005. 1987a. On the other hand. 3. SSj . Thus. Et. Bt.use of medical care. Thus. compared with 77. 16). MCt. Ht = H* (Ht-1. asset income (At. This study is taken from a general study conducted by the Centre of Leadership and Governance. and all sources of household income (including current income)(Smith and Kington 1997. and further modified by Smith and Kington 1997. [1]) by Michael Grossman reads: Ht = ƒ (Ht-1. 159-160). The survey was the first of its kind as it collected data on Jamaican’s Political Culture. Pmc.338 Jamaicans (Powell. the price of other inputs Po.. and good personal health behaviours (including exercise – Go).). ARj . The Review of Global Medicine and Healthcare Research . PPIj.[3] Method The current study uses a sample of 723 women. Department of Government. Eqn. Po. ESj . Yj. Go. Rt. [2] 1).33yrs ±13. The initial model (i. education of each family member (ED). 14). Eq. Rj . RAj . stock of health (Ht-1) in previous period. 1 No. all sources of household income (Et). Go) …. Tj . 1 (2010) 68 . family background or genetic endowments (Go).of six years.4 yrs. (2) expresses current health status Ht as a function of stock of health (Htprice of medical care Pmc. 2007). Theoretical Framework The overarching theoretical framework that will be adopted in this study is an econometric model that was developed by Grossman (1972).. ED. Ci . ‘…subjective wellbeing and ill being’. At. WSj εi)……. education of each family member (ED). MCt. Ej .1 for men…” (Wooden and Headey 2003. Grossman’s model further expanded upon by Smith and Kington to include socioeconomic variables (Eqn. the discourse is inconclusive and we will not add to the literature in this regard but will examine quality of life of women as this is the first of its kind in Jamaica and in the wider Caribbean literature.2).Vol. The University of the West Indies between July and August 2006 of some 1. Based on the nature of the study. Eqn. with a mean age of 34. lnAj . the reported wellbeing (measure by life satisfaction) of women is higher than that for men but that males have a higher financial wellbeing than females (Headey and Wooden 2003.e.000 household members who were 12 years and older. The information was taken form 20. the current study will test this general hypothesis in seeking to establish a quality of life model for Jamaican Women (Eqn. Oj . [3]): QoLj = ƒ(Gj. Xj . A research carried out by a group of economists (Headey and Wooden) revealed that “…women are slightly more likely to report higher levels of life satisfaction than men (mean=78. et al. Bt – smoking and excessive drinking. ED) …………… [1] where Ht – current health in time period t. retirement related income (Rt).…Eqn. All the interviewers employed by the CLG’s team were either data collectors by STATIN or SDC. Data were collected and stored using the Statistical Packages for the Social Sciences (SPSS). Modifications were made at a training symposium based on the comments of the different interviewers and remarks of trained researchers. Although the interviewers are trained data collectors. The survey was a stratified random sample of the fourteen parishes of Jamaica. where Li i=1…5 denotes each Need Item of Abraham Maslow’s 5Need Hierarchy i=1 (Each is a 10-point Likert Scale: Health status. where from 1 to 3. the Harvard/Washington Post Leadership survey.e. Basic Necessities. researchers as well as by interviewers within the data divisions of the Statistical Institution of Jamaica (STATIN) and Social Development Commission (SDC). using the descriptive research design. Measures: 5 QoLj = 1/10∑Lij .survey uses a questionnaire of some 166 items The themes ranged from democracy. After the vetting phase. 4 to 6. they were trained by the CLG team for a one-day period. perception of wellbeing using Abraham Maslow 5 Needs Item. Review of Global Medicine and Healthcare Research . The instrument consisted of 166 items that were taken from Latino barometer and Euro barometer cross-cultural survey. SelfEsteem. the New Zealand Election Surveys and the Cross-cultural Variations in Distributive Justice Perception survey and Carl Stone surveys. tests were done for Cronbach alpha to examine the validity of the construct – i. Reliability analysis of the 5-Need Likert Scale Item is 0. preference for private or public sector solving problems in the economy. and. 1 No. leadership.748 (or 75%).Vol. the questionnaire was pretested in a number of communities across the 14 parishes of Jamaica as well as among UWI faculty and student population. Social Needs. and this was in keeping with the gender and age distribution of the population. The sample size was proportionate to the population. Descriptive statistics were done to provide background information on the sample. wellbeing and political participation.9 are moderate and with high being from 7 to 10. Face-to-face interviews were used to collect the data on an instrument which took about 90 minutes. the American National Election Studies series. and electoral preferences. political participation and civic engagement. 1 (2010) 69 . The proportion of Jamaicans residing in each parish was calculated as well as gender and age composition. Quality of Life Index ranges from: 1≤Quality of Life Index≥10. The instrument was vetted by senior scholars. trust and confidence. Multiple regressions were used to build a model for quality of life of Jamaican Women. Self-Actualization). party. civic culture. The steps involved in computing the sample size is explained in the next sentences.9 are low. 1=St. tradesmen. and so low trust is a proxy for distrust. Portland. This is the summation of 22 Likert scale questions. The variable was then dummied. the confidence index is interpreted as from 0 to 34 represents very little confidence. Mary. vendor. the more people have confidence in sociopolitical institutions within the society. Hanover. Age is a continuous variable. office workers and so on. Ann. 1 No. This means the geographic location of one’s place of abode It is a dummy variable. Kingston and St. which is recorded in years. or that most people are not essentially good and cannot be trusted. Those categories which are classified within this are – teachers. Confidence index = summation of 22 items. Thomas. James. managers and/or supervisors whereas in the low category the following were includes – farmers. 1 if in high occupation. Trelawny.Vol. (3) some confidence. based on social stratification.896. socialcl1 socialcl2 1=Middle class 1=Upper class Referent group is lower class. Interpersonal Trust. 0=Other1 Subjective Social Class. shopkeeper. unskilled worker. Confidence in sociopolitical institutions. 0 if otherwise. doctors. 35 to 61 is low confidence. Age. Catherine. lawyers. (2) a little confidence. Westmoreland. St. This is people’s perception of their social and economic position in life. 1 if most people essential good and can be trusted. The heading that precedes the question reads: I am going to read to you a list of major groups and institutions in our society. with each question being weighted equally. haggler. For each. Elizabeth. St. Manchester. Thus. with a Cronbach α for the 22-item scale being 0.Area of residence. Trust is on a continuum. to (1) no confidence. 1 (2010) 70 . St. 0 if otherwise. businessmen. 62 to 78 is moderate confidence and 79 to 88 is most confidence. with each question on a scale of (4) a lot of confidence. and 0≤confidence index≤88. and Clarendon. Andrew. 1 Others constitute St. tell me how much CONFIDENCE you have in that group or institution. The higher the scores. Review of Global Medicine and Healthcare Research . Occupation is a dummy variable. St. The survey instrument asked the question ‘Generally speaking would you say that most people are essentially good and can be trusted. Mixed . Income is an ordinary variable with twenty-categories. such as voting. the right to vote. The demographic characteristics of the sample also reveal that approximately 7 out of every 10 women indicate that they are employed (i.e. Munroe.e. On an average the quality of life of the sample was high (i. Employment status.000 and above..828. it will be treated as a continuous variable.8 ±1. G. such as the right to protest. 1 (2010) 71 . which is used to constitute this Index. none to several times per year) Income.1) indicate that political participation for Jamaican Women is Review of Global Medicine and Healthcare Research .the extent to which citizens use their rights. ranging from (1) under $5.3 years ± 13. (3) christenings.4 years. church attendance once per week or fortnightly) Referent group is low religiosity (i.(14%). The Cronbach alpha for the 22-item scale. 1 No. ‘political participation’ “.Vol. where 1=employed and 0 is otherwise Extent of the Welfare System of governance: Results: Sociodemographic Characteristics of Sampled Population The findings of the current research has a sampled population of 723 women ages 16 to 85 years with a mean age of 34.e. church attendances more than once per week) Religiosity2 1=Moderate religiosity (i. is defined as people’s perception of administration of the society by the elected officials. 1999:33). the right of free speech. Approximately 6 out of 10 women indicate that they are in the lower class. (2) weddings.7: Range 10: 10– 0). temporarily. with 0≤PPI≤19. and bi represents each response to a question on political behaviour. Political Participation Index. 2002:4. Furthermore.e. Governance of the country..Religiosity. (4) funerals. part-time. 6. where 1 denotes in favour of a few powerful interest groups or the affluent. fulltime. Based on Trevor Munroe’s work. This variable was recorded as: Religiosity1 1=High religiosity (i. to influence or to get involved in political activity” (Munroe. the findings (Table 1. bi ≥ 0. Most of the respondents report that they are Blacks (78%) with some indicates Browns – i. This is a dummy variable.e. w use that construct to formulate a PPI = Σbi. E. involvement in protest.e. seasonally and self-employed). The frequency with which people attend religious services. 0 is otherwise. is 0. Caucasians (6%).000 to (20) $250. which does not include attending functions such as (1) graduations. Based on the nature of this variable. 1 (2010) 72 . RAj .e.…………….893. SSj .5% (Adjusted R-squared) of some 6 variables.[3] where QoLj Gj nation of person j.203) and lastly by interpersonal trust (Beta = 0.413. On the contrary.152.8: Range 79:86 – 7). Findings: Multivariate Analysis Using econometric analysis (i.2). p value = 0. Examination of the sociodemographic determinants in Eqn.…Eqn.198. b=0. ESj .high religiosity . b=0. Oj . 95%CI:-0.001]. RAj . Oj . Xj . 95%CI:0. ARj . 95%CI:0.1.2). PPIj.Vol.676) (Table 1.6 ±3. Yj.5: Range 17: 17– 0).…Eqn. with a sample report a high ‘welfare system of governance’ of the Jamaican state. b=-0. 0.058. 410] = 7. Rj .3±10.Tj . 0. WSj . Xj . lnAj .155. SSj QoLij εj)…………………………………….[4] .low (i. j the quality of life of person j.e.594. Tj . b=0. ESj . 95%CI:0. b=0. 1 No.214.020. -0. QoLj = ƒ(Gj. [4] revealed that subjective social class – middle class with referent to lower class . 95%CI:0. Tj .167. 3. income (Beta = 0.e. the population has moderate confidence in the various socio-political institutions in Jamaica (56.εj)…………. lnAj .094. Review of Global Medicine and Healthcare Research .348. Ej . (Table 1.380. WSj .. The model is a good fit (F statistic [15. 1.548.(Beta = 0. b=0. 0.725.101). 0. ARj .070) is the most influential factor followed by employment status (Beta = 0. self-reported administration of the governance of the political participation index of person j income of person j religiosity of person j logged age of person j occupation of person j interpersonal trust of person j subjective social class of person j area of residence (i.304.(Beta = 0. multiple regressions) – of the surveyed research data of some 723 Jamaican women – we found that the final model (Eqn. the administration of the governance of the nation (Beta = 0.139. SSj . PPIj Yj. ESj . [3]) explains 18. 95%CI:0.015.691. Ej . religiosity.974). parish of residence) of person j gender of respondent of person j educational level of person j employment status of person j ethnicity of person j extent of welfare state of a nation as reported by person = ƒ(Yj. Rj . Rj .077). Gj. 000 for males). The examples here are prostate cancer (affect only men) and cervical cancer (plague only women). cerebrovascular disease. 1 (2010) 73 . Concomitantly. Phillip Rice. Another limitation for the non-collection of some critical variables such as living arrangement and marital status which may aid in explain quality of life of females. Discussion The physiological composition of the sexes explains the rationale of some typologies of diseases affecting a particular sex (WHO 2005). In Jamaica the health conditions disparity between the sexes include malignant neoplasms (rates are 39% higher for males than females). life styles and ‘preventative health practices’ (Rice 1998). political administration) benefits mostly equally with referent to those who indicated that it favours the rich have a lower quality of life. A similar result was observed for employment status as an employed woman has greater quality of life compared to those who are unemployed. church attendance at least twice per week) with referent to low religiosity (i. An individual who is in the self-reported middle class with referent to lower class contributes the most to quality of life of Jamaican Women. argued that differences in death and illnesses are the result of differential risks acquired from functions. the 5 leading cause of mortality for males 5 years and older in descending order were external causes. those who cited being in moderate religiosity had a greater quality of life compared to those with had a low religiosity. 2005). 1 No. Those who reported that the governance of the nation (i. diabetes mellitus (females have a 64% greater mortality rates than males in diabetes) (Ward and Grant.e. and is more so a platform for future studies than a conclusion on the matter of quality of life of women in Jamaica. diabetes mellitus. Some statisticians argue that a cross-sectional study that is less than 30% and over is not a good predictor of the phenomenon. in concurring with WHO. The religiosity with which we speak is high church attendance (i. those in the upper class with referent to lower class contribution are marginally more than interpersonal trust that influence is the least. ischaemic heart disease and malignant neoplasm of prostate. However. a woman’s quality increases with greater church attendance. [4]). Eqn. Limitation of the Model Although the current model used data from a cross-sectional study by way of stratified probability sampling technique. and the greater the income of a person the higher is the quality of life of that individual. Thus. it has an adjusted R-square of less than 20%. For males. stress.1 per 100.e. One health psychologist.000 for females and 66.Vol.e.Further examination of the findings will now be forwarded to provide a more in-depth understanding of determinants in model (i. A woman who trusts other people has a greater quality of life compared to another who reported that she does not trust other people.2 per 100. from no church attendance to once per year). heart disease (71. in Review of Global Medicine and Healthcare Research . Religiosity is the fourth most significant factor of quality of life of sampled population. cerebrovascular diseases (rates are 14% higher for females than males). Biomedical studies showed that there are gender specific diseases. The current research is the first of its kind.e. In addition to what has been reported so far. we will maintain these traditions in the current work. Rodin and Ickovics (1990) this can be explained by epidemiological shifts. 1 No. Lifestyle practices may justify the advantages that women enjoy compared in men concerning health status. Ardelt 2003. Traditionally income was used to proxy wellbeing (i. the death rates are higher for men and boys in all age cohorts compared to women and girls. and more retired benefits compared to women ages 65 years and older. cerebrovascular disease. and many theologians continue to argue that there are reality benefits to have from this practice. We go further to say that the quality of life Jamaican Woman is the highest when she has the greatest degree of church attendance followed by moderate religiosity and lastly by the lowest religiosity. The current study has concurred with the literature that religiosity is positively associated with quality of life. hypertensive disease. medicinal care. but that income does not buy unlimited happiness. According to Rice (1998). However. and that is goes beyond the theologians’ views (Krause 2006. proper sanitation. church attendance is substantially a woman issue. and even diet. Among the fundamental characteristics of research are that adding something new to the discourse. 1 (2010) 74 . She noted that financial inadequacy prevents an individual from accessing – food and good nutrition.S. and that Richard Easterlin (2001a. adequate housing. In contemporary Jamaica. the 5 leading cause of death of same age cohort as males were diabetes mellitus. but provides new information on factors that explain variability in quality of life of females (or women) in Jamaica. potable water. and this is the fourth most influential predictor of quality of life of a Jamaican Woman. Graham et al. modifying what exists and so in keeping with these epistemological traditions.and attendance at particular Review of Global Medicine and Healthcare Research .descending order. Moody 2006: Jurkovic and Walker 2006. The current research does not expand on past literature. Religion is gender bias. Embedded within this theorizing are the differences in fatal diseases that are explained by gender constitution (Seltzer and Hendricks 1989. In a paper titled Poverty and Health.Vol. to which Courtenay (2003) explained are due to behavioural practices of the sexes and goes to explain the fact that men are dying 6 years earlier than females (U. and having a more durable possession than women. preventative care. 1978). Rice believed that this health difference between the sexes is due to social support. economic) than men (Rudkin 1993 222). their material wellbeing is higher is later life. drinking of alcohol. Thus with men receiving more than women. a survey done by Rudkin found that women have lower levels of wellbeing (i.e. ischaemic heart disease and external causes (Statistical Institute of Jamaica. religious guidelines aid wellbeing in that through restrictive behavioural habits which are health risk such as smoking.e. According to Kart (1990). and this dates back to nation’s slavery past. 1996). 2008). because men usually received had more material resources. 2001b) showed that income is important to happiness. 7). Murray (2006) argued that there is a clear interrelation between poverty and health. This finding is further sanctioned by Haveman et al (2003) whose study reveal that retired men’s wellbeing was higher than that of their female counterparts. economic wellbeing). It is well accepted that religiosity is positively associated with wellbeing. Preventive Services Task Force. knowledge of health practices . The issue extends beyond those two types of chronic illnesses as Courtenay (2003) noted from research conducted by the Department of Health and Human Services (2000) and Centers for Disease Control (1997) that from the 15 leading causes of death except Alzheimer’s disease. the positive psychological attributes that this freedom gives as well as the self-advancement that it is likely to provide why this variable is of that importance in determining the quality of life of Women. Arendt. employment. The quality of life of a Jamaican Women is primarily determined by her social class. with middle class women having the greatest quality of life and working class female experiencing the least quality of life. This contradicts the work of Edward Diener. the choices. found that “it cannot be rejected that the income effects are causal” and this proceeded the finding that “[a] robust relations exist between income and some measures of wellbeing of [the] elderly” (Ardent 2005. The issue of resource insufficiency affects the ability and capacity of the poor from accessing the quality of goods and services comparable to the rich that are better able to add value to wellbeing. Diener (1984). income and religiosity. with social class being the most influential of all the variables. Hambleton et al. Sen 1999). Bourne. choices and freedom and power of independency in this regard. Review of Global Medicine and Healthcare Research . modified and refute as these are pillows upon which research is based. states that the correlation between income and subjective wellbeing was small in most countries. opportunities. 327). which contravenes the finding of many studies (Diener 1984. other environmental factors. Although the current work counter the findings of Edward Diener’s work (1984). 2007). Hambleton et al. the factors of quality of life of Jamaican women are social class. on the other hand. Murray 2006.e. but it is about the independence. Conclusion In summary. and that income’s contribution to the quality of life of a Jamaican Woman is highly important as the current study reveals that it (income) is the third most influential factor in determining quality of life of the sampled population. 11).educational institutions among other things. The current work does not provide all the answers. and it shows that income is the third most valued predictor of quality of life of a Jamaican woman. found that the statistical relation was a weak one. 923) Michael Grossman’s work had established the direct link between income and health (Smith and Kington 1997. The current research was subjective wellbeing (i. “….Vol. Grossman. 2005. there is a mixed pattern of evidence regarding the effects of income on SWB [subjective wellbeing]”. Employment does not merely about the income. disproportionately affect poor families (Murray 2006.’s work. In this study education was not related to quality of life. 1 No. the sense of freedom. This is succinctly forwarded by Murray in her monograph that: Poverty also leads to increased dangers to health: working environments of poorer people often hold more environmental risks for illness and disability. self-reported quality of life using Abraham Maslow’s 5 Need Item scale). but it is a catalyst upon which we are able to build. 1 (2010) 75 . 1972. what contributes the most to quality of life of a Jamaican woman? The answer is social class followed by employment status (ie employed women). using ordered logistic models. Employment’s contribution to the quality of life of woman is highly important because of significant of employment in socio-economic independent. such as lack of access to clean water. According to Diener (1984. R.. 2740.spc. Chevannes. D. M.Socio-demographic determinants of Health care-seeking behaviour. International Journal of Collaborative Research on Internal Medicine & Public Health 1 (4):101-130. & Soares. 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Happiness and Economics. 1990-2007. Sen.. (2003).S.edu/papers/standard_of_living. Baltimore: Williams & Wilkins. ed. Washington.. S. Gender differences in economic wellbeing among the elderly of Java. Kingston. Health and economic status of older women ed. Retrieved on August 31. Kingston: Health Promotion and Protection Division. A.ch/papers/2003-07. & Murphy. In: Hendricks JA. (STATIN). J. L. (2008). Rudkin. Journal of Mental Health 15:289–300... Preventive Services Task Force. (2006). (1993).. Health psychology. M.S. 74 38.58 55.0: Expectation of Life at Birth by Sex. 2007.Vol.73 58.04 41. 1880-1991.4 8 116 246 127 195 222 494 1.30 39.7: Range 10: 10– 0.4 yrs.37 69. 1 (2010) 79 .02 39. Statistical Yearbook of Jamaica. Quality of Life Political Participation Index Extent of Welfare System of governance Confidence in sociopolitical institution index Percent 409 259 29 46 562 104 9 58.7:10 – 1.07 1880-1882 1890-1892 1910-1912 1920-1922 1945-1947 1950-1952 1959-1961 1969-1970 1979-1981 1989-1991 1999-2001 2002-2004 Sources: Demographic Statistics (1972-2006).1 31 69 34.5: Range 17: 17– 0.64 70.Table 1.89 38. Review of Global Medicine and Healthcare Research . 56.20 51.3±10.1: Demographic Characteristics of Sampled Population. Jamaicans Period Average Expected Years of Life at Birth Male Female e0 e0 37.4 77.2 16.94* 75.63 66. 1999 and * Economic and Social Survey.2 Educational Level No formal Education Primary/Preparatory and All Age school Secondary Post-secondary Tertiary Employment Status Unemployed Employed Age yrs.25 54. 150) Note e0 is life expectancy at birth Table 1. Jamaica 2005 (Quoted in Bourne.8 ±1.: Range 69: 85 – 16 6. N=723 Number Subjective Social Class Working (lower) class Middle class Upper class Ethnicity Caucasian Blacks Browns Other 1.80 36. 6.97 72.4 28.5: Range 8.8 ± 1.9 14.5 18.03 72.7 37. 1 No.70 70.2 6.6 ±3.2 4.65 66.89 62. 3.58* 71.8 35. p.33yrs ±13.20 69.8: Range 79:86 – 7.2.26 77.41 35. 413.362 0.031 0.401 0.348 -0.155 0. Reference group † Review of Global Medicine and Healthcare Research .096 0.974 0.044 2.001< 0.277 0.406 -0.293 0.000 0.Table 1.213 Adjusted R-squared = 0.058 0.064 0.581 0.236 4.085 -0.002 0.008 0.598.134 2.594 0.641 0.548 0.204 0.874 0.380 0.189 0.139 0.042 0.466 -0.071 -0.175 0.152 0.197 0.070 1.060 0.432 -0.222 0.139 0.094 -0.341 -0.387 95% CI Beta t 4.867 0. Coefficient Error 4.000 0.152 0.203 0.007 0.214 0.167 0.820 0.721 R = 0.461 1.015 0.086 -3.193 0.691 0.122 3.053 0.725 0.693 0.002 0.167 0.370 0.Vol.022 0.514 0.810 0.522 0. 1 (2010) 80 .198 0.676 -0.038 0.072 1.233 -0.035 2.225 0.077 0.013 0.670 3.002 0.254 0.317 1.086 -0.034 0.813 0.050 0.194 0. 1 No.176 0.383 0.2: Quality of Life of Jamaican Women by Some Explanatory Variables Unstandardized Std.893 0. P = 0.879 0.801 -1.124 2.424 0.073 2.209 0.000 0.462 R-squared = 0.101 1.060 6.063 0.017 0.036 -0.116 -0.022 0.020 -0.263 0.252 0.05 Standard error of the estimate 1.304 -0.088 0.185 N=425 F-test [15. 410] = 7.235 -0.121 P Lower Bound -Upper Bound Variable Constant Secondary or tertiary High religiosity Moderate religiosity Kingston/St Catherine Extent of Welfare System of Governance Lower Occupation Middle class Upper class †Lower class Interpersonal trust Governance of country (Benefits most equally) Income Employed Race: Black or brown Index of Political Participation Logged Age 0.847 0.028 0. and anthocyanins. Some of the common examples of phenolic compounds found in food are phenolics. vegetables. The phenolic contents of these selected samples were determined. Total phenolic content was determined by using Folin–Ciocalteu reagent.31mg GAE/L) and tomato (19.A. Malaysia. papaya (Carica papaya) and star fruit (Averrhoa carambola). Faculty of Health & Life Sciences Management & Science University. Phenolic compounds appears to contain multifunctional antioxidants properties and one of the studies conducted on extractable polyphenols present in grapes and wines plays a positive role in human nutrition. Aims & Objectives: The aim of this study is to evaluate the amount of phenolic contents on selected local fruits and vegetables.52mg GAE/L) and green spinach (170. T.Y. Banana (36. green spinach (Amaranthus spp.67±6. Methods/Study Design: Local fruits and vegetables were purchased from a local wet market in Chow Kit Central Market. Review of Global Medicine and Healthcare Research . Whereas selected local vegetables are such as beetroot (Beta vulgaris).28±0. Z. Faculty of Allied Health Sciences Universiti Kebangsaan Malaysia. Faculty of Health & Life Sciences Management & Science University.Vol.my Abstract Background: Polyphenol compound is an antioxidant types that can be commonly found in phytonutrient-bearing food such as fruits. M. The selected local fruits are banana (Musa sapientum). Six different samples of each of the fruits and vegetables were randomly selected.89±0.Total Phenolic Contents of Selected Fruits and Vegetables Commonly Found Locally in Malaysia Jamaludin. dragon fruit (Hylocereus undatus).00mg GAE/L) have the highest phenolic content among the selected local fruits and vegetables. Seedless guava (130. water spinach (Ipomoea aquatica) as well as tomato (Lycopersicum esculentum).05).com Chou. Results/findings: This study has found that the total phenolic contents were different in various types of selected local fruits and vegetables (P<0. Malaysia Email: [email protected]±2. flavonoids.edu. Malaysia Email: azrina@msu. 1 No.).00mg GAE/L) exhibits the lowest total phenolic content among selected local fruits and vegetables. carrot (Daucua carota). and grains. seedless guava (Psidium guajava).com Azrina. Kuala Lumpur. Malaysia Email: klona_8@hotmail. 1 (2010) 81 . legumes. They may play an important role in reducing chronic disease risk (AlMamary 2002. The aim of this present study is to determine the total phenolic contents of selected fruits and vegetables grown locally in Malaysia. Phenolic compounds appears to contain multifunctional antioxidants and one of the studies conducted on extractable polyphenols were present in grapes and wines plays a positive role in human nutrition (Larrauri et al. Tropical fruits are widely grown either in mixed or single fruit orchards. 1996). 2005). and anthocyanins. carotenoids. Temperate vegetables and flowers are grown in the highlands whereas tropical vegetables and flowers are grown in the lowlands (Alias 2005). and stroke (Grajek et al. All aspects of horticulture are readily available in Malaysia including fruit growing.Conclusion: Green spinach contains the highest phenolic content among the selected local fruits and vegetables in this study. 1996).2005). vitamins as well as antioxidant properties which may have beneficial effects. Example of phytochemicals in fruits and vegetables are phenolics. Grajek et al.Vol. 1 (2010) 82 . Review of Global Medicine and Healthcare Research . 1996) are playing an important role in preventing the free radicals from damaging the human body cells. gallic acid equivalent (GAE). Liu 2003). Introduction Several epidemiological studies have shown that a high intake of food rich in natural antioxidants such as fruits and vegetables can increase the antioxidant capacity of the plasma and reduces the risk of some cancers. flavonoids. antioxidants are compounds that are capable in reducing the harmful oxidation of other molecules by inhibiting the initiation or propagation of oxidizing chain reactions (Al-Mamary 2002). vegetable production in the open and protected structures (fertigation) as well as ornamental cultivation. The studies suggested that the antioxidant compounds are characterized in variety of components such as vitamin C. They are usually freshly-eaten among the members of various communities in Malaysia. Studies also explain that cancer patients have low level of antioxidants in their bloods (Larrauri et al. 1 No. Therefore. vitamin E. Folin-Ciocalteu reagent. heart diseases. Most polyphenol compounds are commonly found in fruits and vegetables. The examples of phenolic compounds that can be found in food are phenolic. 2002). and polyphenolic antioxidants (Wang et al. The fruit and vegetable industry in Malaysia is small and fragmental. Phenolic antioxidant is an antioxidant that found in phytonutrient-containing food including fruits and vegetables (Sellapan et al. flavonoids and carotenoids. Most of these fruits and vegetables contain minerals. Total phenolic content (TPC). Generally. many studies have demonstrated that the antioxidants activities present in fruits and vegetables may decrease the risk of chronic diseases (Amin & Cheah 2003. Keywords: Polyphenolic. and timer.Vol. This clear solution is used for further tests. 50g of the edible portions from each of the samples were cut into small pieces and homogenised by using a blender (MX-291N National) for approximately two minutes to a paste form. and beetroot (Beta vulgaris). 1 No. Review of Global Medicine and Healthcare Research . The extracts were filtered through a filter paper (Whatman No. absolute ethanol. UV-1601 UV-Visible spectrophotometer. 10ml measuring cylinder. Schwabach. aluminium foil. Schwabach. 2N). freezer. orbital shaker (HeidolphUnimax 1010. gallic acid. Germany). Malaysia. and sodium bicarbonate (Na2CO3) were purchased from Sigma Chemical Co. Samples extraction The 10% of sample extraction was prepared by mixing 10g of samples with 100ml of distilled water in a conical flask. filter paper (Whatman No. Equipments are required for this study such as sharp knife. green spinach (Amaranthus spp. All procedures were carried out carefully without much exposure to light (Amin & Cheah 2003). 1 (2010) 83 . The fresh and healthy of fruits and vegetables were then weighed. The samples of fruits are papaya (Carica papaya). MO. USA). The mixture was shaken at 200rpm for 2 hours at room temperature (28ºC) by using an orbital shaker (Heidolph Unimax 1010. vortex mixer (Stuart Scientific SA8). 1) using filter funnel to obtain a clear solution. spatula.). carrot (Daucus carota). blender (MX-291N National). (St. water spinach (Ipomoea aquatica). 50ml volumetric flask. All samples were extracted in triplicates.Materials and Methods Samples All fruits and vegetables were purchased from a local wet market at Chow Kit Central Market. conical flask. Chemicals and equipments In this study. star fruit (Averrhoa carambola). Folin-Ciocalteu reagent (Fluka. 1). Samples preparation The fruits and vegetables were washed under tap water and excessive water were dripped off. Germany). banana (Musa sapientum). chemicals are prepared including distilled water.Louis. air-tight container. and seedless guava (Psidium guajava) while the samples of vegetables are tomato (Solanum lycopersicum). Kuala Lumpur. beaker. cuvette. The homogenised sample was transferred into an air-tight container and kept at -20oC for further studies. dragon fruit (Hylocereus undatus). Guava and star fruit were blended without peeling the skin whereas the other three fruits were homogenised after the skin was removed. filter funnel. 05. and tomato (19.5ml of 6% sodium bicarbonate solution (Na2CO3) was added to the mixture in the same test tube for 90 minutes. All statistical analyses were performed with SPSS. The studies show that the ethanol extraction has the potential to bind the active antioxidant compounds compared to the water extraction (Soong & Barlow 2004) but it could not be used for further in vivo studies. Al-Mamary (2002) reported that coriander. Statistical Analysis All analyses were run in triplicates. MO.Determination of Total Phenolic Content The method used to investigate antioxidant capacity in fruits and vegetables is Folin– Ciocalteu method. The reason spinaches have higher in phenolic content among selected fruits and vegetables are due to the flavonoids present in the spinach leaves (Pandjaitan et al. parsley.050mg/ml gallic acid in distilled water was plotted. Green spinach and water spinach has no significant differences (P>0. 2006). and chilli contain higher phenolic contents compared to other vegetables including spinach.71±2.08±2. Gallic acid (St.89±0.05) in mean.81mg GAE/L). Amin et al. Amin et al. Results and Discussion The water extraction was used rather than ethanol extraction in the present study as the water mimics the human environment. An aliquot (200µl) of clear extract was mixed with 1. the absorbance was read at 725nm by using spectrophotometer (UV-1601 UV-Visible). After 5 minutes. This is to imply that human do not consume fruits and vegetables with presence of alcohol. 1. The comparison on total phenolic contents among selected local fruits and vegetables are shown in Table 1. 2005. 1 (2010) 84 . 1 No. MO. A standard calibration curve of 0. carrot (25.Louis. The previous studies have shown that phenolic contents in spinach are higher compared to other vegetables (Al-Mamary 2002. USA) was used as the standard reference for estimating the total phenolic content of the vegetable extracts. Total phenolic content was determined using Folin–Ciocalteu reagent (St.00mg GAE/L).63±2. Among the selected vegetables. After 90 minutes. beetroot (123. 1998). USA) with using gallic acid as a standard reference (Velioglu et al.010– 0. Data were analysed using one-way analysis of variance (ANOVA). and the differences were considered to be significant at P<0.71mg GAE/L). Green spinach and water spinach are similar spinach family Review of Global Medicine and Healthcare Research .76mg GAE/L).Vol.5ml Folin-Ciocalteu reagent (diluted 10 times with distilled water) in the test tube and allowed to be shaken using vortex mixer (Stuart Scientific SA8) at room temperature. The total phenolic content of the fruit and vegetable extracts were expressed as gallic acid equivalents (GAE) in mg per Litre (L).05) while carrot and tomato also shows no significant differences (P>0.Louis. 2006). green spinach has the highest phenolic content followed by water spinach (167. 52mg GAE/L) followed by star fruit (53.12mg GAE/L). The low level of phenolic contents is probably due to the action of sunlight (Mélo et al. the samples of the selected local fruits (starfruit. Star fruit. and banana were lesser when compared to seedless guava.05) in total phenolic content but has a show significant difference (P<0. Lim et al. papaya and banana has no significant differences and are considered to contain a low phenolic content in this study.05). Therefore. dragon fruit (47. papaya (45. The phenolic contents in star fruit. 1 No. This is due to the presence of ellagic acid found in skin guava that contains high phenolic contents (Koo & Mohamed 2001).31mg GAE/L).and inherited with flavonoid compounds in genotypes when it comes to breeding lines. and banana (36. water spinach and seedless guava has shown no significant differences (P>0. 2006).35mg GAE/L). the leafy vegetables including spinaches and beetroots contain a larger amount of phenolic contents when compared to non-leafy vegetables such as tomatoes and carrots in this study. the outer layer skin of fruits is less likely to be consumed by human. the previous study conducted has discovered that flavonol compounds are rich in the leafty vegetables (Herrmann 1976).62±1. It also show that there was significant difference of total phenolic contents between selected local fruits and vegetables (P<0. Moreover.Vol. 1 (2010) 85 . the studies have shown that the phenolic contents such as myricetin. apigenin. 2006). carrots Review of Global Medicine and Healthcare Research .00±0. Figure 1 shows that the amounts of total phenolic contents were different in various types of fruits and vegetables. and anthocyanins are also highly abundant in guava (Thaiponga et al. 2006). dragon fruit.89 to 170. However. The concentration of phytochemicals markedly drops from the outer to the inner leaves (Herrmann 1976). The comparison on total phenolic contents between selected local fruits and vegetables are shown in Table 1 as well as Figure 1. The seed and seedless guava has shown a higher phenolic content as well as antioxidant properties compared to other selected fruits in previous studies (Koo & Mohamed 2001. Furthermore. Therefore.83±2. The concentration of total phenolic contents in the samples of the selected local fruits and vegetables examined has a range between from 19. Beetroot belongs to the spinach family that has bred into different species and possess a slightly higher phenolic content in this present study. dragon fruit. 2005). papaya. Furthermore. By comparing total phenolic contents between fruits and vegetables whereby green spinach. the seedless guava has the highest phenolic content (130. The previous study has explained that the phytochemical contents such as flavonol compounds found on the outer leaves where it is more exposed to sunlight compared to inner leaves. ellagic acid. and banana) in this study were taken from inner tissues where it contains low phenolic contents compared to the outer skin layers.05) among other selected local fruits and vegetables in this study.28mg GAE/L. papaya. Betalain is an antioxidant commonly found in beetroot family has similar structure to anthocyanin (Pandjaitan et al.67±6.63±10. 2006). dragon fruit. Among the selected fruits.20mg GAE/L). One of the previous studies proves that the seed as well as seedless guava contain high phenolic contents as well as antioxidant properties when compared with other selected fruits (Lim et al. 89±0. season. 1 No. papaya & banana.31 170. d – carrot and tomato).00 ± 0.12 47. dragon fruit. soils.63 ± 2.71 ± 2.35 45. and maturity of plants. reliable rainfall. topography.62 ± 1.05 (a – green spinach & water spinach.(25.71mg GAE/L) and tomatoes (19.67 ± 6. c – starfruit.71 19.81 25. Al-Mamary (2002) reported that various amount in total phenolic contents might be due to the differences in structures of phenolic compounds in different fruits and vegetables. Bravo (1998) reported that the variation polyphenol contents in plant foods are greatly influenced by genetics.71±2. location.83 ± 2. Review of Global Medicine and Healthcare Research . Table 1: The Comparison of Total Phenolic Content among Selected Local Fruits and Vegetables Type of samples Fruits Samples Seedless guavab Starfruitc Dragon fruitc Papayac Bananac Green spinacha Water spinacha Beetrootb Carrotd Tomatod Concentration ± SD (mg GAE/L) 130.05 whereas same letters show that there are no significant different in amount of total phenolic content at p>0. Each fruit and vegetable studied has its own variety of polyphenol compounds that might influence their total phenolic contents. b – seedless guava & beetroot.89 ± 0.52 53. soil fertilization. 1 (2010) 86 .28 ± 0.20 36.Vol.76 123. In addition. sunlight.00 167.08 ± 2.63 ± 10.00mg GAE/L) has the lowest total phenolic content compared to other selected local fruits and vegetables.00 Vegetables Different letters indicate there are significant different in amount of total phenolic content among fruits and vegetables at p<0. Al-Mamary MA (2002). Fatimah MA & Zainalabidin M (2005).Figure 1: Comparison on Total Phenolic Contents between Selected Local Fruits and Vegetables. 94:47–52. Nutrition Reviews. Food Chemistry. 8:179-189. Amin I & Cheah SF (2003). metabolism and nutritional significance. dietary sources. Malaysian Journal of Nutrition. 1 No. Amin I. The Fruits Industry in Malaysia: Issues and Challenges. Acknowledgements The authors would like to acknowledge the research grant and technical assistance from Universiti Kebangsaan Malaysia. Malaysian Journal of Nutrition. β-carotene and riboflavin contents in five green vegetables organically and conventionally grown. Polyphenols: Chemistry. Antioxidant activity and phenolic content of spinach species (Amaranthus sp). Serdang: Universiti Putra Malaysia Press. References Alias R. Norazaidah Y & Emmy HKI (2006). Review of Global Medicine and Healthcare Research . 1 (2010) 87 . our study found that green spinach has high phenolic content among the selected local fruits and vegetables in this study. 56:317-333. 9:31-39. Determination of vitamin C. Bravo L (1998). Conclusion In conclusion. Antioxidant activity of commonly consumed vegetables in Yemen.Vol. The selected local fruits and vegetables have different in amount of phenolic contents. Edward PN. Cisneros-Zevallosc L & Byrnec DH (2006). DPPH. ascorbic acid and total carotenoid contents in common fruits and vegetables. Flavonol and flavones in food plants: a review. 1 No. Morelock T & Gil MI (2005). 19:669–675. 47:369-372. Journal of Food Composition and Analysis.Vol. Brazilian Journal of Food Technology. Koo MH & Mohamed S (2001). Health benefits of fruit and vegetables are from additive and synergistic combinations of phytochemicals. 53:8618-8623. Antioxidant capacity and phenolic content of spinach as affected by genetics and maturation. Journal of Food Technology. Cao G & Prior RL (1996). The American Journal of Clinical Nutrition. 9:89-94. Flavonoid (myricetin. Liu RH (2003). FRAP. Food Chemistry. Pandjaitan N. Biomarkers and Prevention. vegetables and grain products.Dietrich M. kaempferol. Carroll EC & Lester P (2002). luteolin and apigenin) content of edible tropical plants. 11:433-448. Mark H. Journal of Agricultural and Food Chemistry. 49:3106-3112. 11:7-13. Ruperez P & Calixto FS (1996). Phenolic compounds and antioxidant capacity of Georgia-grown blueberries and blackberries. 50:2432-2438. Polyphenol. Antioxidant supplementation decreases lipid peroxidation biomarkers F2-isoprostanes in plasma of smokers. Grajek W. 83:411-417. Thaiponga K. quercetin. Velioglu YS. Sunway Academic Journal. Akoh CC & Krewer G (2002). Probiotics. 1121:1-7. Gao L & Oomah BD (1998). Lim YY. prebiotics and antioxidants as functional foods. Lim TT & Tee JJ (2006). Herrmann K (1976). Cancer Epidemiology. Mélo EA. Journal of Agricultural and Food Chemistry.     Review of Global Medicine and Healthcare Research . 46:4113-4117. 44:701-705. Larrauri JA. Journal of Agricultural and Food Chemistry. Gladys B. Journal of Agricultural and Food Chemistry. American Journal of Enology and Viticulture. Antioxidant activity of wine pomace. Mazza G. Antioxidant activity and total phenolics in selected fruits. Lima VLAG & Maciel MIS (2006). Jason DM. Soong YY & Barlow PJ (2004). Antioxidant properties of guava fruit: Comparison with some local fruits. 3:9-20. Antioxidant activities of buckwheat extracts. 1 (2010) 88 . Sellappan S. Total antioxidant capacity of fruits. Crosbyb K. Maret GT. Acta Biochimica Polonica. Olejnik A & Sip A (2005). Comparison of ABTS. Boonprakoba U. 78:S517-S520. Journal of Agricultural and Food Chemistry. and ORAC assays for estimating antioxidant activity from guava fruit extracts. Wang H. Howard LR. 2005 Review of Global Medicine and Healthcare Research . a system in which a doctor enters a medication order directly into a software application designed to detect errors) and (2) bar coding medications to ensure that the right hospital patient gets the right dose of the right prescription at the right time3. and lives”.tfrisk. at http://www. hospitals each year as the result of lapses in patient safety. infrastructure and technology emphasizing the reporting. Healthcare is a professional setting which is established to restore. This definition can be applied to a Hospital. Bosnia and Herzegovina Abstract Patient safety is “the environment.S.asp 3 2 Saul Spigel. Public health institution or a Physician’s clinic.Vol. 1 No. USA Email: Sdey@ius. persevere and ensure physical and psychological health of patients. among other forms of establishments. American Medical Association reported as mentioned in a recent paper2 almost 200. Patient safety.The role of Information Technology in preventing Medical Errors Sukhen Dey Indiana University Southeast New Albany. Indiana. Managed Risk..000 people die in U. Specific objectives of healthcare include. Information Technology.com/knowledge/reducemederr. Information technology and medical error reduction. but not limited to: John Atkinson. 1 (2010) 89 . Healthcare Introduction The primary customer of the business of healthcare is the ‘patient’. informative and necessary for the medical community as well as medical scholars. Keywords: Medical error. 1) computerized physician order entry (CPOE. This article primarily deals with the application of Information Technology in preventing medical errors and preserving patient safety.. OLR Research Report. “Reducing Medical Errors: how state-of-the-art information technologies will save money . How technology can help? Two major ways we can immediately mention. Longterm care facility. We are certain that there are other nations where medical errors happen at a much more significant rate. analysis and prevention of medical error and adverse events that might cause a patient ‘harm’. Thilman Filippini.edu Mensura Kudumovic University of Sarajevo Sarajevo. In this paper we shall talk about several applications of Information Technology that have been developed to act against the epidemic. The topic is crucial. htm 5 Review of Global Medicine and Healthcare Research . treatment. While the scope of healthcare is vast and in many cases unknown.gov) “Most errors result from problems created by today's complex health care system. MD. Neglects during patient monitoring process by nurses and other medical staff. 1 No.Vol. Suggest preventive medications or treatment protocols to maintain ‘good health’.htm Medical Errors: The Scope of the Problem.gov/consumer/20tips. Patient fall. Prevent medical or treatment errors which may cause physical or psychological harm to the patient. 1 (2010) 90 . Rockville. the agency reports:5 4 Agency for healthcare research and quality (AHRQ) report at http://www. Wrong site surgery. Wrong equipment handling. But errors also happen when doctors and their patients have problems communicating. medication and technology to restore ‘good health’.• • • • • Diagnose the cause of discomfort or poor health condition. Preserve patient safety. this paper primarily concerns the role of Information Technology in preserving patient safety. AHRQ 00-P037. Following is a list from the literature:4 • • • • • • • • Medication error.S healthcare systems A good explanation is provided by AHRQ (Ahrq. Wrong Lab reports or test results. a recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor's choice of treatment and less likely to do what they need to do to make the treatment work.gov/qual/errback. Errors in Surgical procedures. For example.ahrq.ahrq. http://www. Agency for Healthcare Research and Quality. Publication No. Erroneous diagnosis. Organize and apply procedures.” By exploring further into AHRQ investigations. Typical cause and prevention methods for medical errors and patient safety violations: Observations in the U. There are various types of safety violations. Fact sheet. 6 percent were potentially preventable. CA. such as hand-held bedside computers. 1 (2010) 91 .One of the landmark studies on medical errors indicated 70 percent of adverse events found in a review of 1.000 medical records in Colorado and Utah. • • • • Information Technology in preserving patient safety Information Technology (IT) in U. Standardization of treatment policies and protocols to avoid confusion and reliance on memory. USA 6 Review of Global Medicine and Healthcare Research . found that 54 percent of surgical errors were preventable. based on a chart review of 15.133 medical records were preventable. 1 No. Knowledge sharing and standards development initiatives and their impact on medical error reduction. A study released last year. Up-to-date documentations and strategies for effectively implementing CPOE. The IT applications in healthcare came a long way establishing THE SUMMIT ON PATIENT SAFETY & INFORMATION TECHNOLOGY. 2002. Following are additional measures to preserve patient safety: • Computerized physician order entry (CPOE). San Diego.Vol. which is known to be fallible and responsible for many errors. smart IV pumps and other drug dispensing systems. healthcare started around 1960’s with mainframe computers mainly performing patient demographic record keeping and handling billing. September. The patient safety and productivity benefits of context management and single sign-on in presenting the patient record across multiple legacy systems. bar coding and systems to detect the frequency of adverse events. Avoidance of similar-sounding and look-alike names and packages of medication. • • Relevant incidences and statistics are well summarized in a Patient Safety Summit:6. Integrating CPOE technology into your organization’s existing clinical decision support / clinical computing system. Other potential system improvements include: • Use of information technology.S. and 24 percent were not preventable. to eliminate reliance on handwriting for ordering medications and other treatment needs. including strategies for securing physician buy-in and effective staff training. 7 This is true for physicians. Giangnguyen “Preventing Medical Errors: Use of Information Technology To Reduce Adverse Drug Events. by facilitating a more rapid response after an adverse event has occurred. Automatic order submission to pharmacies through electronic means or communication networks. It has been well established that CPOE systems. Read more: http://www. As stated earlier. 3. Clinical Decision Support Systems. pharmacy and other professionals who are authorized to administer drugs to patients.”9 Other benefits of CPOE systems are: 1.Number 25 9 Review of Global Medicine and Healthcare Research . “Improving Safety with Information Technology”.Vol. An alarming statistics was pointed out “Ward clerks or nurses make 80% of the errors in transcribing doctor’s handwriting.”8 Significant number of prescriptions is still administered through hand written orders. 1 No.000 patients die or experience severe complications due to prescription errors.000-140. An article in the New England Journal of Medicine stated “Information technology can reduce the rate of errors in three ways: by preventing errors and adverse events. and by tracking and providing feedback about adverse events. Along those lines.brighthub. 2. New England Journal of Medicine. ability to order drugs. nurses. Healthcare Informatics. June 19. A direct support component for Electronic Health Record Systems. we estimate in U. with or without a decision support tool appears to provide well documented electronic records and audit trails in reducing the chances of prescribing errors. Laboratory. Standardized and accurate documentation. David W. with logs. safety violations and benchmarking databases as tools of “Continuous Quality Measurement (CQM)” as well as “Evidence Based Medicine (EBM)”.S alone almost 130. Hanson C. 2006.aspx#ixzz0cbeHPh0N Bates. 4. 2003. lab tests and radiology reports in electronic format. et al. Output and display of legible orders. we also see sophisticated computing algorithms to predict potential medical errors. Drug management and Pharmacy systems and expanding ground with wireless communications using desktop and hand held devices. 7 8 William.powerful COPE systems. McGraw Hill. Volume 348:2526-2534.com/health/technology/articles/7297. Entering medication order directly into the computerized physician order entry system without going through the transcribing process can reduce errors by 40%60%. Computerized Physician Order entry (CPOE) CPOE appears to have a significant effect of preventing medical errors. In the following section we have discussed common Information Technology applications that are being used towards preserving patient safety. 1 (2010) 92 . wpd Review of Global Medicine and Healthcare Research . 2008. such as bar coding. such as clinical decision support systems and data mining. with the potential to reduce the number of medical errors by providing quick access to patient history and medical guidelines. Advanced Radiology workflow and integrate information systems working together with imaging systems to remove inefficiency at all points.11 • 10 The Institute of Electrical and Electronics Engineers. • Implementing the National Health Information Network (NHIN) and online Electronic Health Records (EHRs). Using advanced IT technologies. Improving patient identification through interoperable.com/au_en/products/healthcare_informatics/products/enterprise_imaging_ informatics/isite_pacs/closed_loop_imaging. Electronic prescriptions also offer immediate access to possible drug interactions. The Federal government. to assist in diagnosis and reduce errors and unintended consequences. 11 Phillips Healthcare Innovations. such as illegible handwriting. A number of recommendations from IEEE-USA10 IEEE-USA believes that increased use of information technology can play an important role in improving patient safety and the quality of health care.healthcare. secure and private lifetime EHRs. working collaboratively with health care providers and other interested parties should take proactive steps to enhance the utilization of information technology in health care delivery. Encouraging ePrescription systems. with closer monitoring of patient use of medications and/or duplicate prescriptions. Bard of Directors Position Statement. benchmark with national databases and regulatory agency audits. In-patient errors due to misidentification can be further reduced by using electronic data capture.philips.All of the above invariably decrease the probability of medication errors and potential to commit patient safety violation. RFID and biometric technology. Discussion at http://www. 1 No.Vol. 1 (2010) 93 . PATIENT SAFETY: THE ROLE OF INFORMATION TECHNOLOGY IN REDUCING MEDICAL ERRORS. • • • Some references to recent vendor based systems • Various types of “Medical Error Reporting Systems” have been proven effective in reducing errors by effectively educating caregivers and clinicians. which offer promising new alternatives to reducing errors. 2007. architecture consultancy. integration of partner solutions.com/amalga/products/microsoft-amalga-his/default.com/forum/53119-7-rfid-healthcare-system-error-prevention-rfid-wristband Review of Global Medicine and Healthcare Research . “Philips Xcelera provides access to multimodality cardiac imaging as well as powerful exam review.wpd 13 14 IBM-France: Press Release. 15 Closing the Loop in Medication Management. used for error prevention with RFID wrist band.16 • • • A few hurdles to overcome Information Technology has a very prominent role in Patient Privacy.”13 Microsoft seems to have stayed close to the theory “Close Loop Cycle”14 of prescribing information management in its Amalga Hospital Information System. 2009. May 13. Patty.” Healthcare IT News.tomshardware. Microsoft Whitepaper at http://www. electronic medical and health records.com/au_en/products/healthcare_informatics/products/cardiology_inform atics/xcelera/index. telematics and mobile applications.microsoft.”12 The integrated system is geared to electronically document patient records with multiple access points and audit trails so that medical errors can be prevented. and reporting tools from a single patient-centric workstation. Patient Safety as well as maintaining images. At http://www.• One access point to optimize cardiovascular care workflow called Xcelera. A recent news release covers the story “Focusing on healthcare analytics. 1 No. It will also provide prototyping across areas such as RFID. effect and symptoms where prevention of medical errors is an integral part. In addition to sophisticated healthcare systems.mspx 16 RFID healthcare system. business intelligence. analysis.philips. Discussion at http://www. complex solutions design.healthcare. IBM analytics and business intelligence engine are directed towards automation and predictive aspects of cause. Xcelera delivers vital patient information across the care continuum via enhanced connectivity with other hospital information systems and the patient’s electronic medical record. Enrado. regional and national health portals. quantification. In a white paper it claims “With a shared record that provides identical views of patient and medication information to everyone involved in a patient’s care.Vol. and.”15 There are numerous vendors implementing patient-safety technologies like bar coding and RFID which appear to be effective “bedside” measures. IBM took a different approach to issues relating medical error prevention. May 1. protect. the Centre will offer experiential demonstrations. “Key is closing the loop. and communicate medication information and features builtin safeguards for a high level of accuracy. telemedicine. the Amalga HIS medication management system helps capture. proof of concept and prototype demonstrations. identity management and unified communications. Tom’s Hardware Forum. documentations of patients in case such records are 12 Phillips Healthcare Innovations. 1 (2010) 94 . However.S is still not uniformly accepted and the practice of paper records will continue to contribute to medication and medical errors. Robert M. An effective Health IT system would cut costs by reducing the duration of hospital stays. 18 Adopted from Kelly Montgomery “Health Information Technology” .com editorial.20 While physicians in general support the notion of EMR and patient record automation. 2008. NO.Vol. patient privacy and confidentiality is a key concern.com”. December 24.S. which can often be ascertained by reviewing existing clinical or administrative records).000 survey respondents expressed concern about the potential for privacy breaches. Thus. Significant healthcare cost upraise requires rapid automation. Wacher writes “The difference lies in our continued reliance on provider self-reports to count most safety outcomes (versus quality performance. June. hospitals in U. California state officials recently fined 13 hospitals for medical errors that either killed or injured patients. the amount of time that nurses spend performing administrative tasks. Very recently.S medical community. “Studies show physicians still question EMR privacy” FierceEMR.required during later treatment of the patient. 2. according to a report that was made public. and drug and radiology usage. Dey. January. 20 David Mittleman. A recent study by the Rand Institute estimates that if 75-90% of all healthcare providers adopted Health IT potential savings could average $80-$100 billion per year. there remains to be some issues. “Patient Safety At Ten: Unmistakable Progress. “21. Sukhen. continue to make severe medical errors. 1 No. Troubling Gaps” HEALTH AFFAIRS 29. With more acceptances. As an example. A 63 percent of the respondents were less willing to include "highly confidential" patient information in an EMR than in a paper chart. “Role of Informatics in Patient Safety”. Neil. 2009. 4. The key is implementation of close loop integrated systems with good audit trails and easy user interface. 17 Review of Global Medicine and Healthcare Research . both medical and clinical are undertaken in pure hand written form. the use of Information Technology decreases the probability of medical errors and regarded to be a predominant measure. implementation. 2010.”19 Despite of all efforts in the past 10 years.. Quality Colloquium at Harvard University. EMR and EHR use in the U. About.18 Inadequate safety reporting standards from providers. “InjuryBoard. 3. 1 (2010). 1 (2010) 95 . Studies show “About 71 percent of the more than 1. 21 Versel. 1. supposedly well equipped with preventive technology. almost 80% of workflow documentation.17. better training of physicians and caregivers along with ‘easy to use systems’ we are hopeful that the error rates will continue to decrease. 19 Watcher. Looking at the global medical community. at least in the U. Thus. the challenge of automation is much widespread than what most think. 27% for hepatitis. For the protection against HIV/AIDS. the awareness regarding the HIV/AIDS still had some lacking and need to be aware as early as Review of Global Medicine and Healthcare Research . Most of the respondents were from higher middle class to upper class based on the monthly income status. among the 100 respondents 21. Bangladesh Email: whitetigeroby@yahoo. 22% for diarrhea. About 32% of the respondents thought there is 90% chance to develop AIDS from HIV. 27% about 70% probabilities and 18% thought about 50% probabilities. About 20% thought about 80% probabilities. The sample size is of 100.3% by ‘Prevent sharing needle’. Dhaka.4% by ‘Following religious values’. 83% of the respondents knew that there were no vaccine against AIDS as they thought it as a non curable.Most of the respondents were in the age group of 19 -20 years estimating 85% and their gender distribution was closely even distributed. About 60% respondents thought HIV positive means “presence of HIV antibody in blood” and about 37% thought HIV positive means “presence of HIV antigen in blood”. The survey ended up with 45% male and 52% female respondents. HIV/AIDS cases were detected in Bangladesh. More than half of the respondents (55%) thought that the prevalence of AIDS were increased. According to the respondents. 15% thought it was decreased. 29% thought normal.8% by ‘Avoiding multiple sex partner’. Respondent were clear that they could not be affected by shaking hands. Finally. Influenza (43%) is supposed to be resembled at the early stage of HIV.5% by ‘Awareness of AIDS’. hugging or sharing glass and they also thought there is a link between HIV and other Sexually transmitted disease( STD’s).Knowledge of First Year Medical Students on HIV/AIDS  Salahuddin Mohammad Bangladesh Medical College Dhaka University. A structured questionnaire was used for data collection and socio-demographic profile and information related to HIV. 2. 1.com Abstract A cross sectional descriptive study was carried out in Bangladesh Medial College to assess the depth of knowledge of 1st year medical students about HIV\AIDS.6% by ‘Safe sexual relation’. 1 No.5% by ‘Safe blood transfusion’. The religious distribution was also reflecting the Islamic dominancy in Bangladesh. 6. 8. Sexual transmission was responded as a predominant route for HIV/AIDS transmission beside parental transmission and perinatal transmission.Vol. 5. Respondents were not well aware. 15. They were also not aware fully about how many people were affected by the disease According to 63% of the respondents both developed and developing countries are mostly affected by the disease whereas 13% thought affection is in developed countries and rest 24% answered that affection is in the developing countries.65% knew about the age group of affected people and according to them the young people were affecting more and sex workers (88%) were in the realm of great danger of affecting HIV/AIDS. 1 (2010) 96 . They think Africa has the highest number of HIV patient followed by America. treatment less and life long virus.1 % thought ‘use of condom’ as a major protection method against AIDS. sexually transmitted infections.Vol. Bangladesh is highly vulnerable to an HIV/AIDS epidemic due to the prevalence. There is yet no established treatment. Introduction Bangladesh has a narrow window of opportunity to act decisively to prevent the spread of HIV/AIDS among vulnerable groups. with health organizations promoting safe sex and needle-exchange program in attempts to slow the spread of the virus. Although data derived from the different sources are being used by our planners. This study has been undertaken to fulfill this gap. The sole way to do this it to create awareness Review of Global Medicine and Healthcare Research . Another of IUDS in the country who sell their blood professionally Bangladesh relies on professional blood-sellers to meet most of the transfusion needs of its people.4% to 4% to 8. Antiretroviral treatment reduces both the mortality and morbidity of HIV infection. Risk factors include: Large commercial sex industry. HIV prevalence rates jumped from 1. Authentic information on transmission and prevention of HIV/AIDS in Bangladesh is scarce and deficient. AIDS is fatal once contracted. high risk groups sex workers and injecting drug users record much higher rates. Justification of the study HIV/AIDS is a burning issue in the modern world. although the study on transmission and prevention in developing countries is an important issue in pubic health programs. The HIV epidemic in Bangladesh is evolving rapidly. 1 No. There have been little change in high-risk behaviors and vigorous and prompt action is needed now to prevent the virus from taking hold. 1 (2010) 97 . Although overall HIV infection rates are low. needle sharing among injecting drug users. behavior patterns and risk factors that facilitate the rapid spread of the virus. While overall prevalence rates are still low.possible as these first year MBBS students will be the future pioneer for the rest of the generations. Thus prevention and early detection of HIV is essential. condom use. In a pocket of injecting drug users in one area in central Bangladesh.9% over a period of 3 years. but they are on the increase in some risk groups. HIV prevalence and the number of AIDS cases remain low in Bangladesh. There is currently no vaccine or cure. This level of infection among IUDS poses a significant risk as the infection can spread rapidly within the group then through their sexual partners and their clients into the general population. Prevention of HIV infection is a key aim in controlling the AIDS epidemic. findings based on actual study about the knowledge of HIV/AIDS in Bangladesh are a few. It’s being fatal untreatable and spread over the globe makes it imperative for the medical system to make the situation universally. Treatments of AIDS and HIV can slow the course of the disease. lack of knowledge etc. 000 .sectional type of descriptive study was conducted in Bangladesh Medical Collage. This particular private college was chosen because this is the institute where who are studying and it was very convenient for us to collect data side by side during our regular classes. We had closely even gender distribution in the sample and the Muslim dominancy was also found by their religious distribution as Bangladesh is an Islamic country by its origin. are adolescents and young adults. Methodology This cross. The data were analyzed by using computer software SPSS (Statistical Package for Social Sciences). each questionnaire was checked meticulously for any error. drug abuse. Dhaka on the topic of AIDS awareness among them. Results and Discussion I conducted my survey on the First year MBBS students of Bangladesh Medical College. Results were presented in tables and figures. It has been proved that the modern day teenagers are changing the patterns of sexual behavior and thus. Dhanmondi R/A. 1 No.Vol. sharing of needles and razors etc. Respondents were very reluctant to answer about some questions like monthly income of the family. increasing the risk of contracting HIV and ultimately AIDS. so as. The commonest mode of transmission of HIV infection is though sexual contact along with blood transfusion. Only 30% respondents respond positively about this question where as 70% refused to give this information as they thought financial information as confidential. Thus. 12% respondents were about 18 years old and rest of them was about 21 years old. 1 (2010) 98 . methods of prevention such as practicing of safe sex. One hundred (100) students of first year present in the class during the study period were included in the study. the test used for its diagnosis. screening of blood etc must order to reduce the mortality and morbidity due to AIDS. As they are in the realm of the learning medical studies they are supposed to be aware of the world’s most talked topics ‘AIDS’. Dhanmondi R/A. About 5% respondents had family income from 20. omission or ambiguity. Dhaka during June to November. Around 85% of the respondents were between the age limit of 19 to 20 years of old.000 taka and Review of Global Medicine and Healthcare Research . A thorough knowledge of the signs and symptoms of HIV. it is evident that the target group. avoiding promiscuity. After Collection of data. 2008. A structured pre-tested questionnaire was supplied to the respondents to obtain information. The only way to escape the disease is awareness and prevention. Approximately.especially amongst the young adults who are most exposed to the infection. the study result revealed quickly and cost-effectively. Thus our research targeted the 1st year student teenagers entering the world of science with only a layman’s idea of AIDS. In our survey we had selected 100 first year MBBS student by non-probability convenient sampling method to answer the questionnaire that was uniquely designed for them.40. prevent sharing needle. About 32% of the respondents thought there is 90% chance to develop AIDS from HIV. Their prior knowledge about the topic was poor to moderate. About 37% thought HIV positive means “presence of HIV antigen in blood”. Around 57% respondents thought that African countries had the highest number of affected patients and 25% thought in America and rests thought in Asian region like India. 1 (2010) 99 .000 taka monthly family income. But use of condom was supported at top against HIV protection.000 taka. 1 No.000-100. Not all the respondents knew exactly about the severity of the HIV/AIDS but 25% thought it’s very severe and fatal (by 9%). We found more than half of the respondents (55%) thought that the prevalence of AIDS was increased. 8% thought about the ‘lab technologist’ and rests thought about the ‘nurses’. non treatment and not curability. Above all. Almost 20% thought about 80% probabilities. 27% about 70% probabilities and 18% thought about 50% probabilities.0%) thought there is a link between HIV and STDs. More than 50% didn’t know the number of affected people by AIDS and their randomness in the consecutive question proved the status of their unknowns. safe blood transfusion. According to them the young generation is most likely to affect by HIV/AIDS and sex workers have the top risk (88%) for this. Almost half (43%) of the respondents thought ‘influenza’ as a disease at early age of HIV whereas 27% thought ‘hepatitis’ and 22% thought ‘diarrhea’. awareness of AIDS. Most of the respondents knew that there were no vaccine for HIV/AIDS and it’s a life long virus and it’s a fatal disease as it might ended up ones life with death. Respondents thought use of condom.20% had income ranges from 50. More than one-fifths (22%) said there is no connection and rests didn’t answer. They should be aware more and more. 92% of the respondents thought HIV/AIDS is a non curable disease. Most of the respondents (71. Very few of the respondents answered close to the original answer and most of them choose randomly for this question. Precisely 88% of the respondents didn’t think that one couldn’t get AIDS by shaking hands. hugging or sharing glass. 6% responded ‘parenteral transmission’ and 2% thought about ‘perinatal transmission’.Vol. avoiding multiple sex partner. Among the respondents. By this survey it can be said that the respondent had a very fuzzy idea about the HIV/AIDS. following religious values can protect one from having HIV/AIDS. destroying immune system. As high as 90% of the surveyed respondents considered ‘sexual transmission’ as predominant mode for HIV/AIDS transmission. Rest of the respondents had above 100. They did not know the first recognition of AIDS in Bangladesh. Review of Global Medicine and Healthcare Research . Most of the respondents thought that there are tests for detection of HIV/AIDS and according to them the HIV positive means “presence of HIV antibody in blood”. safe sexual relation. Though the percentage of students knew about the prevalence and transmission of HIV/AIDS is low. Hyder’s Textbook of community Medicine and public Health. Government should take proper steps to enlighten the peoples of all phase nationally. NGO’s should take different awareness programs at the grass root level of our country. Even though the minority of them are being awarded and motivating others to get awarded of HIV/AIDS.bd/WBSITE/EXTERNAl/COUNTRIES/SOUTHA SIAEXT/BA. Social awareness should be increased..org. the study showed that the students had poor to moderate knowledge about HIV/AIDS. 2007 Review of Global Medicine and Healthcare Research . Kabir. 4. Mass media should work for the awareness of uneducated people. 3. Reference 1.worldbank.. Self awareness and self willingness can be a good way to learning about HIV/AIDS. 2. Bangladesh AID Prevention.Vol. 1 No. Religious obligation should be imposed more strictly. Booklet published by the Ministry of Health and Family Welfare. June 2005. 2007: 285-300. 1 (2010) 100 . RHM publishers. Park’s Textbook of preventive and social Medicine. The overall level of awareness of students regarding knowledge of HIV/AIDS is not satisfactory. Students at the primary. M/S Banarsidas Bhanot publishers. Bangladesh and the National AIDS Committee. Recommendations • • • • • • • • The First year students should provide enough knowledge about HIV/AIDS at the very beginning of their entry. Rashid. 2008 : 353-362. http://www.Conclusion Reviewing findings of the data of this study it is concluded that some of the students knew about the disease HIV/AIDS. Jabalpur. secondary and higher secondary level should be introduced by the different phase of this fatal disease. They also knew about the causes of the disease and methods of prevention. Dhaka. India. Weekly Epidemiological Record AIDS Research and Therapy. Anton A. Regneny USA.5. New York USA. 1995:242-259 13. 1989:26-43 16. “AIDS Inc. Martin’s press. Mohammad Ali Al-Bayati. Jad Adam. The HIV myth” Macmillan London UK. Petu-Duesber. 1994:509-521 15. Scandal of the century” Human Energy press. 12. Inventing the AIDS virus. Niekenk and Loretta M. USA. 1996:760-792 Peter Duesbegr. volume 3. NO. 1 No. Deathly Deception.3. “AIDS : the failure of contemporary science” fouth Estate. Jon Pappoport. st. Eleni papadopulos Eleopulos et al. Neville Hodgkinso. 275 Medicine International 1999. 1993:312-324 Review of Global Medicine and Healthcare Research . London UK 1996:563-579 14. “Mother to child Transmission of HIV and its prevention with AZT and Neviropine” Riobay publishing western Australia. WHO (2005). USA.Vol. Robert willnes. “AIDS. 7. pettee publishing co. 6. “Infectious AIDS: Have we been misled? “North Atlantic Books USA.” Geualt the facts HIV does not cause AIDS” ToxiHeath International Dixon CA 1999:49-68 11. 8. 1 (2010) 101 . Kopelman Marvin kitzrous ‘The AIDS in dietment’ MRKCO publishing USA 2000:248- 9. 2001:671-688 10. 0 15. 1 (2010) 102 .0 80 60 40 20 Percent 0 Not curable No treatment Death is must Not answ ered Destroy the immune s Why fatal disease Figure 1: Why AIDS is fatal Review of Global Medicine and Healthcare Research .0 1.Table 1: Idea about prevalence of AIDS in Bangladesh Prevalence Normal Increased Decreased Not answered Total Frequency 29 55 15 1 100 Percent 29.0 25.0 57.Vol. 1 No.0 Table 2: Countries having the highest number of HIV/AIDS patient Name of Country India Africa America Wrongly answered Total Frequency 17 57 25 1 100 Percent 17.0 55.0 100.0 1.0 100. 1 No. 1 (2010) 103 .Vol.70 60 50 40 30 20 Percent 10 0 very severe severe fatal w rongly answ ered dont know How severe the problem is Figure 2: Severity of the problem Figure 3: Protection methods against AIDS frquency Figure 4: The frequeny of response to the the fact whether HIV/AIDS is curable or not Review of Global Medicine and Healthcare Research . Aim and Objective: The Aim is to study the value of pleural fluid adenosine deaminase (ADA) in the diagnosis of tuberculous pleural effusion. Positive Predictive value (PPV) was 96 % and Negative Predictive Value (NPV) was 83 %. Total of 187 patients were included. pleural fluid ZN staining and AFB culture were sent for diagnosis.56) years (range 12-85 years).Vol. The main test of this study. upper boundary 0. Results: There were (120) men and (67) Women with a mean age of (51.96(lower boundary 0.Diagnostic utility of ADA for tuberculous pleural effusion was evaluated using receiver operating characteristic (ROC) curve analysis. In each patient. UCSI University.0 ±17. The area under the curve (AUC) that represents the diagnostic accuracy was 0. However the bacillary population in TB effusion is small and the most likely pathogenic mechanism is essentially immunologic. Malaysia Soe Moe School of Medicine.com Wunna Hla Shwe School of Medicine. our main interest is pleural fluid chemical analysis of measuring the Adenosine Deaminase (ADA)activity to search for tuberculosis in pleural space.983). pleural fluid cytology. Yangon General Hospital.89 (89 %) respectively. positive and negative predictive values of ADA at that level. Myanmar. TB pleurisy accounted for 108 (58 %) of the effusions. Pleural fluid Adenosine Deaminase activities were determined by Giusti and Galanti method. Correcting this diagnostic deficiency. Study period from 2004 January to 2005 January. The best cut off points of ADA to diagnose tuberculous pleural effusion was 42. UCSI University. 1 (2010) 104 . Review of Global Medicine and Healthcare Research . Malaysia Email: zaysoe13@gmail. Methods: This study was a hospital based analytical cross sectional study performed at Chest Medical Ward.Value of pleural fluid Adenosine deaminase in Tuberculosis Zay Soe School of Medicine.936. Our objective is to find out the cut-off value of ADA for diagnosing tuberculous pleural effusion and to calculate the sensitivity. 73 with neoplastic effusions (39 %) . specificity. 1 No.5 U/L where sensitivity and specificity were 0.87 (87 %) and 0. Malaysia Abstract Background: A definitive diagnosis of TB pleural effusion requires the presence of granulomas in pleural tissue or a stained AFB or positive culture from the pleural tissue or pleural fluid. UCSI University. pleural biopsy. Although found in most tissue. The cut off values of high sensitivity and specificity are consistent with the value reported in other studies. which in turn activate macrophages for an enhanced bactericidal effect (Kataria YP.Vol. ADA activity is greatest in lymphoid tissue its activity being 10-20 times more active in T lymphocytes than in B lymphocytes and plays a part in the differentiation of lymphoid cells and the maturation of monocytes to macrophages (Barton RW and Goldshneider I 1979). and it’s most likely pathogenic mechanism is essentially immunologic and fluid collects as a result of delayed hypersensitivity reaction to tuberculoprotein. 2001). each with unique biochemical properties. This immunologic reaction causes the stimulation and differentiation of lymphocytes. Sometimes more invasive procedures such as bronchoscopy. Keywords: Tuberculosis. which released lymphokines. 1 No. It is present in the cytoplasmic fraction and a certain amount is located in the nucleus. Pleural effusion. Myanmar Introduction Tuberculosis is a worldwide killer whose occurrence is on the rise especially in developing countries. lymph node biopsy or percutaneous direct needle biopsy were performed to get the diagnosis. The ADA1 isoenzyme is found as a monomer (ADA1m) and as a dimer (ADA1c). 1 (2010) 105 . where two ADA1m molecules are combined with a combining protein . especially the activation of T lymphocytes Two isoenzymes of ADA coded by different gene loci exist. where as ADA2 isozyme gene products appear to be found only in monocytes. The enzyme is widely distributed in animal and human tissues. ADA is a polymorphic enzyme involved in purine metabolism. Review of Global Medicine and Healthcare Research . The bacillary population in TB effusion is small. namely ADA1 and ADA2. The diagnosis of Tuberculous Pleural Effusion (TPE) can be difficult to make because of the low positivity of the various diagnostic tests. our main interest is pleural fluid chemical analysis of measuring the Adenosine Deaminase (ADA) activity to search for tuberculosis in pleural space. UCSI University. Pleural biopsies using Abram’s biopsy needle often reveal chronic nonspecific pleuritis and need repetitions. Lymphocyte ADA levels can be considered a parameter of immune response. with the highest activity in lymphocytes and monocytes. pleural fluid ADA assay is highly sensitive and specific test suitable for rapid diagnosis of tuberculous pleural effusion. Our clinical experiences in Myanmar patients showed that the positivity of pleural fluid Ziehl Neelson stain or culture is quite low. Correcting this diagnostic deficiency. catalyses the deamination of ADA to inosine and ammonium. In pleural fluid it reflects the cellular immune responses in the pleural compartment. The ADA1 isoenzymes are found in all cells. Khurshid I. Adenosine Deaminase (ADA). Pleural effusion is one of the common complications of tuberculosis. Giusti and Galanti.Conclusion: In this study. E. resulting in a positive predictive value of 97. Valdes L et al (1998) studied 254 patients with tuberculous pleural effusions.0. The positive predictive value (PPV) was 82. Value of ADA in the diagnosis of TB pleural effusion in young patients in a region of high prevalence of TB was also studied (Valdes L et al. Another study of ADA in TPE was published in Portuguese (Chalhoub M et al. There was statistically significantly difference (p < 0. A pleural fluid ADA value < 16.1% and the negative predictive value (NPV) was 94. 1982).37. In addition. They concluded that in a country with a low tuberculosis incidence. In their study all TB cases had pleural fluid ADA level of > 47IU/L (mean (SD) 111. sensitivity of ADA activity at 40 U/L was 93. In their study 147 exudative were non tuberculous (non TB) and 63 were tuberculous (TB).8 I U/ L. 1 (2010) 106 . They have conducted a cross-sectional study of 221 patients with pleural effusion.5%.6) U/L). They concluded that pleural fluid total ADA assay is a sensitive and specific test suitable for rapid diagnosis of TB pleurisy.0001). Pleural fluids were analyzed by routine tests plus determination of ADA activity using Giusti’s method. A paper from Mexico including 218 patients revealed that the activity of adenosine deaminase in TPE had significantly higher ADA activity than patients with non tuberculous pleural effusions (p less than 0.5 – 94.0001) between the mean of pleural fluid ADA levels among the TB and non-TB populations.3 %) and specificity of 91. The value for diagnosing TB effusions was > 55. a high ADA activity in pleural effusion in neither sensitive nor specific enough to rely on the diagnosis of tuberculous pleurisy.05 U/l.963).81 U/ L). (1987) had measured ADA in pleural effusions of 95 patients.933 (S. A study of ADA estimations was performed on the pleural fluid from 368 effusions (Maritz FJ et al. some studies have shown that ADA levels are limited value.In their study the mean (+/SD) ADA concentration in TPE was 92. 1996). Review of Global Medicine and Healthcare Research . = 0.890.2% and a negative predictive value of 85. 2004) by using ROC curve.11 +/. 1 No. Although several studies have shown the diagnosis use of ADA in TB pleural effusion.3%. Van Keimpema AR et al.8% (95% CI: 86.Vol. They concluded that adenosine deaminase does not provide as valuable a diagnostic test of pleural tuberculosis as has been suggested. in this confirmed tuberculosis by histopathology or culture. They found that all but 1 effusion (99.ADA activity has been proposed as a diagnostic test for tuberculous pleurisy since 1978 (Piras & Gakis et al. 1991).3% (95% CI: 76. 1978).4%. with a sensitivity of 87. The diagnostic value in TB pleurisy was also determined (Chen ML et al.295. ( Banale JL et al. using a method optimalised for rapid determination on a Hitachi 705 analyzer. 95% CI: 0. 1995).6%) had adenosine deaminase (ADA) concentration higher than 47U/L.0230. the area under the ROC curve was 0.81 IU/ L suggests that a tuberculous effusion is highly unlikely (100% sensitive with 100% NPV and 0% negative likelihood ratio for a pleural fluid ADA level > / = 16.7%).1(36. According to a Receiver Operating Curve (ROC) analysis of the data. Their comment was high ADA concentration was a highly sensitive diagnostic test. Maartens G and Bateman ED et al (1991) determined the use of adenosine deaminase activity in pleural fluid as a diagnostic test for tuberculosis. Pleural fluid cytology and microbiological examinations are sometimes not informative. the individual was explained in an understandable language about the aims of the study. the extent of confidentiality. All patients with clinical features of pleural effusion confirmed by Chest X ray were included without age and sex limitation. Undiagnosed pleural effusion 5. benefits. which is relatively simple. foreseeable rights or discomfort. HIV serology positive Review of Global Medicine and Healthcare Research . Acute hepatitis and liver failure. Written informed consent was obtained from patient. provision of medical services. There is no document or published data on measurement of pleural fluid ADA in Myanmar and it may help to solve the diagnostic dilemma in many patients with undiagnosed pleural effusions. the methods of conduct. has a potential for use in area with limited resources and expertise. Myanmar from January 2004 through January 2005. Raised blood urea and creatinine Patients with renal insufficiency may present high values of ADA 3. the right to refuse to participate and withdraw from the study without affecting further medical care. Exclusion criteria 1. Rangoon General Hospital (RGH). expected duration of subject participation.In our experiences.Vol. Patients and methods This study was a hospital based analytical cross sectional study performed at the Department of Respiratory Medicine. 1 (2010) 107 . Patient having signs and symptoms of hepatitis or acute/chronic liver failure will be excluded for possible false positive results by hyper-amoniemia. Measurement of ADA. 4. positive and negative predictive values at that level. extent of investigators responsibility. Closed Pleural biopsies are frequently reported as chronic nonspecific pleuritis. 1 No. Our aim is to study the value of pleural fluid adenosine deaminase (ADA) in the diagnosis of TPE by finding out the best cut-off value of ADA and to calculate the sensitivity. specificity. 6. A total of 187 patients with various causes of pleural effusion were studied. Multiple pathology Patients with more than single cause of pleural effusion will be excluded. Transudative effusions ( using Light criteria) 2. clinicians frequently encounter the diagnostic problems of pleural effusion even with exhaustive investigations. Before requesting consent. ADA level significantly correlates with the number of CD4+ lymphocytes and HIV serology positive patients will be excluded. pleural fluid cytology. producing a deep blue indophenol.5 ml Standard A3 50µl 0. 1 (2010) 108 .5 ml Blank of reagents A4 550µl - b. The steps of the procedure are: a. After 60 minute incubation period.5 ml 1.5 ml 1. with sodium hypocholorite and phenol. pleural fluid ZN staining and AFB culture were performed on all patients. Solution Phosphate buffer Adenosine Standard solution Sample Sample A1 0. Pleural fluid ADA activities were measured by using Giusti and Galanti method.5 ml 1. Following solutions were transferred to four test tubes as mentioned below. Belgium was used (Figure 1). all test tubes were shook well again and incubated at room temperature for 30 minutes.5 ml 1.5 ml c. in alkaline solution. The ratio of pleural fluid: serum protein and LDH were calculated to exclude transudates according to Light criteria.Vol. Pleural biopsy. ADA is assayed by measuring the amount of ammonia formed during the 60 minutes of incubation at 37°C.5 ml 50 µl Blank of Sample A2 0. All test tubes were shook well and incubated for 60 minutes at 37°C. 1 No. Procedures Determination of pleural fluid protein and LDH concentration were done.5 ml 50 µl 1. HBO 25 in-vitro diagnostic test kit from Cypress diagnosis laboratory.5 ml 1.5 ml 1. Review of Global Medicine and Healthcare Research . Procedure of the Giusti and Galanti method The pleural fluid specimen was collected and the test was performed on the same day. Phenol catalyst Sample Alkaline hypochlorite 1. Ammonia reacts in presence of sodium nitrosylpentacyanoferrate as a catalyst. read photometrically with the aid of a tube reader at a wavelength of 630nm. Figure 1: Vials in HBO 25 in-vitro diagnostic test Diagnostic classification The diagnoses were made according to the predetermined operational definition. 1 No.Vol. 1 (2010) 109 . Review of Global Medicine and Healthcare Research . (b) Presence of granuloma in the biopsy tissue. (d) Caseation necrosis in biopsy tissue. TB pleurisy was diagnosed if one or more of the followings criteria were present. (a) Positive AFB in pleural fluid by ZN stain or AFB culture. Malignancy was diagnosed if histological features of malignancy is detected in pleural tissue and/or positive malignant cells in pleural fluid. Then.d. (c) Histiocyte and Langhans multinucleated giant cells. Interpretation of results as A1 − A2 × 50 ADA activity in U/L A3 − A4 One U/L of ADA activity corresponds to 3 nmoles of ammonia released into the reaction mixture per hour at 37 degree C. admixed with and surrounded by lymphoid cells in biopsy tissue. prevalence ) x specificity + prevalence x ( 1.specificity)] (1. Area under the curve (AUC) was also measured.Vol. SLE. The use of ADA as a diagnostic tool for tuberculosis was evaluated at various cutoff levels by calculating sensitivity. were classified as undiagnosed and were excluded. pulmonary pneumonic infiltrates.prevalence) x specificity] NPV = [( 1. Other aetiologies of exudative effusion were defined if definitive diagnosis were obtained such as pancreatitis. Results Review of Global Medicine and Healthcare Research . specificity. after exhausted investigations. purulent sputum and identification of organism in pleural fluid culture in the absence of any evidences of tuberculosis or malignancy. Patients having effusion of unknown origin. specificity and positive (PPV) and negative (NPV) predictive values which were compared by means of ROC curve. 1 (2010) 110 . pulmonary infarction etc.If one associated with acute febrile illness. and positive predictive value (PPV) and negative predictive value (NPV). (Prevalence x sensitivity) PPV = [(prevalence x sensitivity) + (1 – prevalence) (1. The values of ADA levels for the diagnosis of tuberculous pleurisy were evaluated in terms of its sensitivity. Dressler's Syndome. 1 No. In all cases there must be absence of malignancy and pulmonary infiltrates. Data Analysis A ROC curve was drawn to find out the best cutoff value of ADA activity to diagnose TPE. collagen vascular disease such or rheumatoid arthritis. he or she was diagnosed as parapneumonic effusion.sensitivity )] For the purpose of this study "prevalence" refers to the numbers of cases of a given kind of pleural effusion divided by the total number of pleural effusions studied. TB pleural effusion Malignant pleural effusion Others 73. (3%) Figure 2: Frequency of different etiologies of pleural effusion Table 1: Positivity of microbiological procedures for TPE Procedure 1 2 3 N % ZN Stain of pleural fluid Culture of pleural fluid in LJ medium Culture of biopsy tissue in LJ medium 1 6 2 0.86 Table 2: Positivity of pleural biopsy in patients with TPE Diagnostic positivity of pleural Number of biopsy to obtain definite tissue patients (%) diagnosis 1st biopsy 2nd biopsy 3rd biopsy Total 91 (84.65 1. 1 No.Vol. (58%) 6.93 5.8 %) 2 (1.3 %) 15 (13.9 %) 108 Table 3: Percentage positivity of pleural biopsy in patients with malignant pleural effusion Review of Global Medicine and Healthcare Research . (39%) 108. 1 (2010) 111 . 6% and 1. 187 patients with various causes of pleural effusion were studied.1 %) cytology of malignant cells Total 73 Within the study period.936 . only one patient (0.56) years (range 12-85 years). upper boundary 0. sixty five patients (88. In this ROC curve analysis.1%) were diagnosed by identification of malignant cells in the pleural fluid cytology because subsequent biopsies revealed chronic non specific pleuritis (Table 3).9%) had positive AFB smear in pleural fluid.87 (87 %) and 0. 1 No. If calculating a very small sample size in constructing ROC curve.96. 2 empyema patients and 1lymphoma patient (Figure 2).Diagnostic positivity of pleural biopsy to Number of patients (%) obtain definite tissue diagnosis 1st biopsy 2nd biopsy 3rd biopsy 48 (65. The area under the curve (AUC) that represents the diagnostic accuracy was 0. The positivity of microbiological and histological procedure is shown in table (1) and table (2) respectively. In the group of other exudates (6 patients) included 3 parapneumonic patients. Out of seventy three malignant effusions.5 U/L where sensitivity and specificity were 0. 1 (2010) 112 . data were calculated based on 181 patients (108 tuberculous pleural effusions and 73 malignant pleural effusions) excluding 6 other causes of pleural effusions.0 ±17.7 %) 14 (19. TB pleurisy was accounted for 108 (58 %) of the exudative effusions. According to the predetermined diagnostic criteria.9%) were diagnosed by identification of malignant pleural tissue. Eight patients (11. The rest were 73 with neoplastic effusions (39 %) and 6 patients with various other causes of exudates (3 %) as shown in Figure 2. The best cut off points of ADA to diagnose tuberculous pleural effusion was 42. culture of pleural effusion and pleural biopsy report was returned. Receiver operating characteristic (ROC) curve Diagnostic utility of ADA for tuberculous pleural effusion was evaluated using receiver operating characteristic (ROC) curve analysis. After one to two months later. Review of Global Medicine and Healthcare Research .983) Positive Predictive value (PPV) was 96 % and NPV was 83%.1 %) Negative Biopsy but positive pleural fluid 8 (11.9% respectively.1 %) 3 (4.89 (89 %) respectively. with positive result of 5. Among them. (lower boundary 0.Vol. statistic of larger sample sizes may be biased. There were (120) men and (67) Women with a mean age of (51. 25 0.960 . a Under the nonparametric assumption b Null hypothesis: true area = 0. Asymptoti Error(a) c Sig.00 0.ROC Curve ROC Curve 1.50 .000 .(b) .75 1.00 1 .25 .75 .983 The test result variable(s): ADA has at least one tie between the positive actual state group and the negative actual state group. Figure 3: Receiver operating characteristic (ROC) curve Area Under the Curve Test Result Variable(s): ADA Asymptotic 95% Confidence Interval Lower Bound Upper Bound Area Std.012 . 1 No.50 Sensitivity .Specificity Diagonal segments are produced by ties. Statistics may be biased.936 .00 .Vol. 1 (2010) 113 .5 Review of Global Medicine and Healthcare Research .00 . 806 0.959 0.898 0.5 38.5 45.7 % of malignant pleural effusion in this study. In this study commonest age group in malignancy was between 61 and 70 years which is significantly higher than patients with tuberculous effusion.87 0.5 49.945 0.918 0.843 0.959 0.Vol.877 0.5 0.907 0. There is a preponderance of male sex and highest incidence is in the productive age group reflecting a general state of pulmonary tuberculosis (Valdes L et al 1995).082 0.178 0.041 Discussion In this study.055 0.945 0.45 38.123 0. direct examination of pleural Review of Global Medicine and Healthcare Research .795 0.822 0.824 0.833 0.055 0.89 0.5 44.898 0.836 0.815 0.852 0. 1 (2010) 114 .11 0. In our study.5 40.87 0. Exudative pleural effusion due to other causes was uncommon in Myanmar.808 0.205 0.5 50. Some patients may not produce useful information even after third procedural session and were excluded.Coordinates of the Curve Test Result Variable(s): ADA Positive if Greater Than or Equal To (a) Sensitivity Specificity 1 .889 0. The positivity rate of first session of pleural biopsy was 84. Repeat performance of pleural biopsy is obviously an inconvenience to the patients.5 42.Specificity 37.89 0.3 % of TB pleural effusion and 65.041 0. 1 No.95 39.164 0.11 0. In this study second and third biopsy were needed in 29 patients and 10 patients respectively to confirm the diagnosis. 58 % of pleural effusions were caused by tuberculosis and 39 % were caused by malignancy.192 0.5 47 48. The nature of tuberculous pleural effusion was that of an exudate which is easily demonstrable by measuring protein and LDH in serum and pleural fluid.96) U/L and median value of 64. But the positivity rate was higher in the study by Valdes L et al (1998) which showed a positive smear of pleural fluid was 5. 2004). Smear examination of pleural fluid using Ziehl-Neelson stain had a very low positivity rate i. The activity of ADA was also determined in 79 pleural effusions in Spain (Perez de Oteyza et al. there is still a need for clarification of aetiology of effusion in many cases. sample size is important. 1972). Mycobacteria can be cultured from pleural tissue but the time required and the positivity rate was still unsatisfactory to be of value in routine clinical management. inexpensive and rapid test to support the diagnosis of TPE would be of great value in these areas. A simple.96). Pleuroscopy resolve this problem but the procedures require more material resources and expertise. pleural biopsy would be an inappropriate diagnostic procedure in very young patients in whom. pleural fluid AFB culture and pleural biopsy AFB culture were positive in 0 %. pleural fluid culture and pleural biopsy has proven to be insufficient for the aetiological diagnosis of pleural effusion. and are also relatively more invasive. Including very small sample in a larger study could cause bias in constructing ROC curve.9 % in the present study. 1999).91 Vs 33. Several studies have suggested that an elevated pleural fluid ADA level predict tuberculous pleural effusion with sensitivity of 90 to100 % and specificity of 89 to 100% when the Giusti method is used (Roth BJ.fluid.90 (33. Closed pleural biopsy is a fairly blind procedure rendering it into a diagnostic procedure with less than desired positivity rate. In deducting sensitivity and specificity from ROC curve. Pleural biopsy culture was positive in 1.6 % of patients. In their experience. Various cut-off level of ADA activity were tested from the ROC curve for the diagnosis of tuberculosis. 5 % and 2 % respectively (Mihmanli A et al. applying the Light criteria (Light RW et al.5 % and positive culture was 36.Vol. This may reflect the paucibacillary status of pleural fluid which results at least partly from immunologic mechanism.e 0.9 % of cases in this study and so was the positive culture of AFB from the fluid i.e TB and malignancy) were used for determining the sensitivity and specificity from ROC. 1 No. Mean (SD) ADA activity of tuberculous pleural effusion in the present study was 73. In our study the best cutoff level of ADA activity was tested at 42. 1 (2010) 115 .4 %.5 IU/L when sensitivity was 87% and specificity was 89%.0 U/L. The positivity rate of microbiological tests in this study was consistent with another study from 105 patients in which pleural fluid AFB staining. although age per se might exclude malignancy fairly well in majority of cases.6 % of patients. 1989). Pleural biopsy tissue culture also was high at 56. ADA determination had a sensitivity of 92% Review of Global Medicine and Healthcare Research . It would probably be impractical to recommend this procedure in place where incidence and prevalence of tuberculosis is high. Positive Predictive value (PPV) was 96 % and NPV was 83%. Further more.e 5. Mean ADA activity of TB group was significantly higher than malignant group (73. Thus two most commons causes of effusion (i. and specificity of 94%; with a predictive value of 89% and a negative predictive value of 96%. The activity of ADA in the pleural fluid of 218 consecutive patients was studied by Banales JL et al (1991) and reported that patients with pleural tuberculosis presented significantly higher ADA activity than patients with non tuberculous pleural effusion (p < 0.0001). This result indicated that in a population with a relatively high prevalence of tuberculosis, the analysis of ADA levels in pleural effusion constitutes a useful marker for diagnosis which, in addition, can be made quickly and cheaply. In a study measuring ADA activity in TB pleural effusion in young patients in a region of high prevalence of tuberculosis, the diagnostic threshold for tuberculosis was 47 U/ L with the sensitivity and specificity of 100 % and 87.5 % respectively for patients 35 years and younger ages. (Valdes L et al, 1995) Burgess LJ et al (1995) studied the ADA analysis of 462 pleural fluid samples. Various levels of ADA were tested as a cut-off level for the diagnosis of tuberculosis, 50 U/L was found to yield the best result, where sensitivity, specificity, PPV and NPV were 90 %, 89 %, 81 %, 94 % receptivity. Valdes L et al (1998) studied the 254 patients with tuberculous pleural effusion. All but 1 effusion (99.6 %) had an ADA concentration higher than 47 U/L. They concluded that ADA activity remains a useful test in the evaluation of pleural effusions as it is higher than any other diagnostic group and at a level of 50 U/L the sensitivity and specificity for the identification of TB was 90% and 89% respectively. Conclusion The Gold standard for diagnosis of tuberculosis is demonstration of mycobacteria in ZN stain or AFB culture. Although it is highly specific, sensitivity of microbiological examinations on pleural fluid does not reach the degree required for a single diagnostic investigation for tuberculosis. Pleural biopsy will be useful as an ultimate procedure in cases with diagnostic problem as it is a procedure which can give a definitive tissue diagnosis. In this study, pleural fluid ADA assay is highly sensitive and specific test suitable for rapid diagnosis of TPE. The sensitivity and specificity of the ADA depend on the prevalence of tuberculosis in the population. With the decline in the prevalence of TPE, the PPV of pleural fluid ADA also declines, but the NPV value remains high. So this test is still useful even in area with low prevalence to exclude tuberculosis. At the ADA level of 42.5 IU/L, sensitivity of ADA in diagnosing TPE is higher (87%) compared to first time pleural biopsy (84.3%). In areas where facilities and expertise for proper conduct of histological and microbiological examinations are lacking, ADA measurement of pleural fluid would be an alternative, cheap and affordable for the patients. However the test should be performed only by trained medical technologist to get accurate results. It is also important that all reagent bottles must be kept in 0°C to 4°C which requires continuous electricity and laboratory refrigerator. The electricity in certain parts of Myanmar is cut off frequently. A spectrophotometer which can read Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 116 the test tube at a wavelength of 630 nm is essential equipment for the test which is not available in some township and district hospitals. As we already mentioned, the gold standard for diagnosis of tuberculosis is demonstration of mycobacteria in ZN stain or AFB culture or pleural biopsy. As such, It will be very useful that the use of combining ADA measurement in pleural fluid and these gold standard procedures for the diagnosis of tuberculous pleural effusion. References Banales JL, Pineda PR, Fitzgerald JM, Rubio H, Selman M. (1991). Adenosine deaminase in the diagnosis of tuberculous pleural effusions. A report of 218 patients and review of the literature. Chest, 99(2), 355-7 Barton RW, Goldshneider I.(1979). Nucleoside metabolizing enzymes and lynphocytic differentiation. Mol Cell Biochem , 28, 135-47. Burgees JL, Maritz JF, Roux LI, Taljaard JF1. (1995). Use of adenosine deaminase as a diagnostic tool for tuberculous pleurisy. Thorax , 50, 672-674 Burgess LJ, Maritz FJ, Rouh IL, Taljaard JJ. (1996). Combined use of pleural adenosine deaminase with lymphocyte/ neutrophil ratio: Increased specificity for the diagnosis of tuberculous pleuritis. Chest , 109(2), 414-9 Chalhoub M, Cruz AA, Marcilio C, Netto MB. (1996). Value of determining of the activity of adenosine deaminase (ADA) in the differential diagnosis of pleural effusions. Rev Assoc Med Bras , 42(3), 139-46 Chen ML,Yu WC, Lam CW, Au KM, Kong FY. (2004). Diagnostic value of pleural fluid adenosine deaminase activity in tuberculous pleurisy. Clin Chin Acta , 341 (12),101-7 Giusti, G, Galanti B (1974) Adenosine Deaminase, in: H. U. Bergmeyer (ed.), Methods of Enzymatic Analysis, 2nd edition, Verlag Chemie, Weinheim, and Academic Press, New York , 1092-1096. Kataria YP, Khurshid I (2001). Adenosine deaminase in the diagnosis of tuberculous pleural effusion. Chest, 120, 334-335 Light RW, MacGregor MI, Luchsinger PC (1972). Pleural effusions: The diagnostic separation of transudates and exudates. Ann Interm Med , 77,507. Maartens G, Bateman ED (1991). Tuberculous pleural effusion: increase culture yield with bedside inoculation of pleural fluid and poor diagnostic value of adenosine deaminase. Throax , 96-99. Maritz FJ, Malan C, Roux I (1982). Adenosine deaminase estimation in the differentiation of pleural effusions. S Afr Med J, 62(16), 556-8 Mihmanli A, Ozseker F (2004). Evaluation of 105 cases with tuberculous pleurisy. Tuberk Toraks , 52 (2), 137 - 44. Ocana I, Martinez - Vazquez JM, Segura RM, Fernandez De Sevilla T, Capdevila JA, adenosine deaminase in pleural fluid. Test for diagnosis of tuberculous pleural effusion. Chest 1983; 84:51-3. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 117 Perez de Oteyza C, Chantres MT, Rebollar JL, Munoz Yenez MC, Garcia MF.(1989). Adenosine deaminase in pleural effusions: Its usefulness in the diagnosis of tuberculous pleurisy. An Med Intera , 6(5), 244-8 Piras MA, Gakis C, Budroni M, Andreoni G.(1978). Adenosine deaminase activity in pleural effusions: an aid to differential diagnosis. BMJ , ii, 1751-2. Riantawan P, Chaowalit P, Wongsangien M, Rojanaraweewong P (1999). Diagnostic value of pleural fluid adenosine deaminase in tuberculous pleuritis with reference to HIV co infection and a Bayesian Analysis. Chest , 166, 97-103 Querol JM, Minguez J, Garcia-Sanchez C, Farga MA, Gimeno C (1995). Rapid diagnosis of pleural tuberculosis by polymerase chain reaction. Am J Resp Crit Care Med , 152, 1977-1981. Ribera E, Martinez, Vazquez JM, Ocana I, Ruiz I, Segura RM (1990). Gamma interferon and adenosine deaminase in pleuritis. Med Clin (Brac), 94 (10), 364-7 Roth BJ (1999). Searching for tuberculosis in the pleural space. Chest , 116, 3 -5. Sharma SK, Suresh V, Mohan A, Kaur P, Saha P (2001). A prospective study of sensitivity and specificity of adenosine deaminase estimation in the diagnosis of tuberculosis pleural effusion, Indian J Chest Dis Allied Sci , 43(3), 149-55. Valdes L, San Jose E, Alvarez D, Sarandeses A, Pose A, Shomon B (1993). Diagnosis of tuberculous pleurisy using the biologic parameters: adenosine deaminase, lysozyme and interferon γ. Chest, 103, 458-465. Valdes L, Alvarez D, San Jose E, Juanatey RG J, Pose A, Valle JM, Salgueiro M Suarez RRJ (1995). Value of adenosine deaminase in the diagnosis of tuberculous pleural effusion in young patients in a region of high prevalence of tugberculosis. Thorax, 50, 600-603. Valdes L; Alvarez D, San Jose E, Penela P, Valle JM, Garcia Pazos JM (1998). Tuberculous pleurisy: a study of 254 patients. Arch Inter Med, 158, 2017-21 Van Keimpema ARJ, Slaats EH, Wagenaar JMP (1987). Adenosine deaminase, not diagnostic for tuberculous pleurisy. Eur J Respir Dis , 71, 15-18. Villena V, Lopaz Encuentra A, Echave-Sustacta J (1996). Interferon gamma in 388 immunocompromise and immunocompetent patients for diagnosing pleural tuberculosis. Eur Respiir J , 9, 2635-2539. Yagi S (1990). Clinical evaluation of pleural effusion- carcinoembryonic antigen (CEA) and adenosine deaminase (ADA) activities in pleural fluids. Kekkaku , 65(12), 775-783. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 118 Hip resurfacing arthroplasty for severe osteoarthritis secondary to Legg-Calvé-Perthes disease - A case report and current literature review ZC Liang Yong Loo Lin School of Medicine National University of Singapore, Singapore Email: [email protected] SY Tan Yong Loo Lin School of Medicine National University of Singapore, Singapore EJ Wang Yong Loo Lin School of Medicine National University of Singapore, Singapore Introduction In recent times, hip resurfacing has emerged as a viable alternative to the traditional hip replacement arthroplasty in cases of hip osteoarthritis secondary to childhood orthopaedic disorders1. This is especially so given the younger profile of paediatric orthopaedic patients, who will benefit from the various advantages hip resurfacing have over traditional hip arthroplasty 2. For example, hip revisions with less complications3 and better post-operative results with higher Harris Hip scores3,4. Hip resurfacing has been done in centers in the United States with encouraging results1,5 , however resurfacing has not taken off as rapidly in the Singapore, with no published cases till date. This case report aims to highlight the positive experience of the National University Hospital (NUH) in performing hip resurfacing in a patient with Perthes disease complicated by secondary osteoarthritis. We propose resurfacing as a viable alternative to the traditional hip arthroplasty in the Asian setting as well. The patient was informed that data concerning the case would be submitted for publication, and he consented. Case study A 26-year-old Chinese male with a past history of Perthes’ Disease presented to our Orthopaedic clinic with a 2 month history of left hip pain. This was associated with a left hip deformity and significant functional impairment—he was unable to sit crosslegged and had difficulty ambulating up and down the stairs. He first presented to the Orthopaedic Department 14 years ago in 1995 with persistent left hip pain, which was Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 119 eventually diagnosed as avascular necrosis of the left hip ( Perthes disease). He was subsequently treated conservatively with lower limb skin traction, and was on crutches for 2.5 years before seeking traditional Chinese treatment in Beijing, China. Subsequently, he developed back pain associated with a left lower limb shortening, and investigations revealed a collapse of the left femoral head of about 3 cm. He underwent a left lower limb lengthening procedure in 2004, which involved the insertion of a fit bone. Subsequent removal of fitbone antenna revealed an intact antenna. The patient underwent a course of physiotherapy for hamstring stretching, as a result of relative hamstring shortening. Three months post-operatively, the patient returned with the complaint of progressive left hip pain persisting even at rest, associated with weakness and muscle wasting, precipitating frequent falls at home. Investigations revealed a loosened distal locking screw, which was subsequently reinserted. On physical examination, our patient was alert and comfortable. His vital signs were stable and he was afebrile. Multiple well-healed surgical scars and slight muscle wasting was noted on the left hip. Range of motion of the left hip was limited, with internal rotation at 15 degrees, and external rotation at 30 degrees. A limb length discrepancy of 1 cm ( left lower limb 95cm, right lower limb 94cm) . There was no fixed flexion deformity. Neurological examination was unremarkable. Investigations revealed an elevated white cell count at 9.81 x 10^9/L (normal 3.309.96), slightly elevated neutrophil count at 7.48 x 10^9/L (normal 1.41 - 6.83). Culture was negative for MRSA and infection. X- Ray pelvis revealed flattening and deformity of the left femoral head with underlying osteoarthritic changes involving the left hip joint (Figure 1.1). Sclerosis and cortical thickening along the left femoral shaft was also noted. This was concurred by the CT scan, which showed a similar flattening and deformity of the left femoral head. Irregularity of the surface of the left femoral head was noted with subchondral cystic changes.The left acetabulum was noted to be deformed. No obvious left hip joint effusion was noted. This was in keeping with the diagnosis of hip osteoarthritis secondary to Perthes disease. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 120 Fig. 1.1 Note deformity and flattening of the left femoral head. Subchondral scleorosis suggests an underlying left hip osteoarthritis. The left hip joint space is noted to be slightly widened. Taking into account his relatively young age, a decision was made for him to undergo a hip resurfacing as opposed to the traditional hip arthroplasty (Figure 1.2). Postoperative recovery was uneventful and no complications were noted. DVT scan postop was normal. At this time of writing (10 months post-operatively), the patient remains well and pain free. He is currently avidly involved in sports especially baseball, and does not experience difficulty or pain walking or climbing stairs. Harris Hip score 8 months post-operatively was excellent at > 95. Radiographic investigations done 8 months post-operatively were also normal with no evidence of prosthetic loosening, or peri-prosthetic lucency (Figure 1.3) Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 121 Figure 1.2 X-Ray pelvis done 1 day post-operatively. Note the well alignment of prosthetic implant. No peri-prosthetic fractures seen. Figure 1.3 X-Ray left hip taken 7 months post-operatively. No evidence of prosthetic loosening, or peri-prosthetic lucency. Patient remains well, ambulant and pain-free. Discussion Childhood hip disorders, in particular Legg-Calve-Perthes and acetabular dysplasia are well-established risk factors for the development of early osteoarthritis of the hip, with patients at an increased risk of a total hip arthroplasty later on in life6. A higher Stulberg classification was associated with an increasing incidence of secondary Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 122 osteoarthritis. The prevalence of secondary osteoarthritis in Stulberg Class II stands at 37% and 70% in Stulberg Class IV7 . The prognosis of Perthes disease is also known to be related to age of diagnosis. Diagnosis after the age of 9 is associated with a poorer prognosis, with most patients ending up in Classes III, IV or V7. Given that our patient was diagnosed at 12 years of age with a Stulberg Class IV/V, this is associated with a poor prognosis and increased risk of development of secondary osteoarthritis, which he presented with 14 years later at the young age of 26. We advocated the usage of hip resurfacing over the traditional hip arthroplasty in our patient after taking into consideration his young age and activity needs. The 5-year results of the Birmingham Hip Resurfacing Arthroplasty in Oxford reported that young patients with osteoarthritis treated with resurfacing exhibited the most excellent post-operative results.8 A huge factor in our decision to opt for a hip resurfacing in our patient was due to our patient’s young age. At 26 years old, our patient would be looking at a further 3-4 hip revisions in his lifetime. Due to the retention of less bone stock in total hip arthoplasty, this would make each subsequent hip revision more difficult and technically challenging, and more complications might ensue9. There was also no concomitant hip infection which would otherwise have been an important contraindication to surgery9. Our patient was of normal weight with a BMI of 23kg/m2.. This is another favourable factor in our choice of resurfacing as obesity (BMI of 30kg/m2 or higher) is associated with a higher incidence of femoral neck fractures10. It should also be of note that the Surface Arthroplasty Risk Index (SARI) of our patient was low at 2 points ( for a cyst greater than 1cm in femoral head). A 12-fold increased risk in early implant failure is reported to be associated with a high SARI score11 of more than 3. We also considered possible disadvantages for the patient. One is the complications associated with resurfacing such as femoral neck fracture, acetabular component loosening and metal hypersensitivity. However, such complications have been shown to be rare12, with clinical outcomes of resurfacing comparable to that of total hip arthroplasties. The technical difficulties associated with hip resurfacing have to be taken into consideration as well. Such technicial difficulties include a head-cup size mismatch amongst others, which might have impeded post-operative recovery and function. Post-operatively, the patient was followed up and we noted excellent Harris hip scores of >95 8 months post-operatively. The patient is currently being followed up to monitor the development of any future complications. Conclusion Hip resurfacing is a viable alternative to total hip arthroplasty with statistically similar or even better post-operative outcomes. However, to fully benefit from the advantages of hip resurfacing, discriminate choice of patients need to be exercised to prevent associated complications.With the good results that we’ve achieved with our patient, we advocate the use of resurfacing in patients with osteoarthritis secondary to Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 123 36(2):223-30. Tudisco. Beaule PE.67(2):142-5. Palan J. J Bone Joint Surg Br.90:436-41. 2008 Dec. Alkire MR.JBJS (Br) 2 March 1987 243. Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders Amstutz HC. Farsetti. 2008. 1009:67(2):113-115. Acta Orthop. Steffen RT. Minimally invasive hip resurfacing compared to minimally invasive total hip arthroplasty. Shimmin A. Thillemann TM. et al. Ippolito. Le Duff MJ 2. The five-year results of the Birmingham hip resurfacing arthroplasty. Delanois RE. Steffen RT. Johnsen SP. Clin Orthop Relat Res. Barrack RL. Hip resurfacing. 2007 Dec.Vol.(418):87-93. 2008:90.465:80. 10. Su EP. Mont MA. 2009. 1987 . 1 No. Bull NYU Hosp Jt Dis.childhood hip disorders. Lai LP. Boyd HS.keys to success. 11. Pandit HP.   Review of Global Medicine and Healthcare Research . Lai LP. 2005 Apr. Søballe K. Maguire CM. Is patient selection important for hip resurfacing? Clin Orthop Relat Res. 12. Metal-on-metal hip resurfacing arthroplasty J Bone Joint Surg Am.79(6):769-76. Pedersen AB. Della Valle CJ. 7. Swank ML. where preservation of bone stock might be required for future hip revisions. Jinnah RH et al. Bull NYU Hosp Jt Dis. Seyler TM. C. British Volume. Marulanda GA. et al. Campbell P. 2008. Hip resurfacing. 3. Bull NYU Hosp Jt Dis. Dorey FJ. Jinnah RH et al. Ulrich SD. Implant survival after primary total hip arthroplasty due to childhood hip disorders: results from the Danish Hip Arthroplasty Registry. Beaule PE. 2004.(467):56-65. 2009. Delanois RE. E. Palan J. The five-year results of the Birmingham hip resurfacing arthroplasty. Boyd HS. 4.keys to success. The Long term prognosis of unilateral Perthes Disease Journal of Bone & Joint Surgery. 6. This is especially more so for younger patients. Nunley RM. Resurfacing for Perthes disease: an alternative to standard hip arthroplasty.67(2):142-5. Risk factors affecting outcome of metalon-metal surface arthroplasty of the hip. . References 1. 5. Seyler TM. P. Boyd HS. Clin Orthop Relat Res. Orthop Clin North Am.637-654. Maguire CM. Le Duff M. et al. 1 (2010) 124 . 9. J Bone Joint Surg Br. Pandit HP. 2009.90:436-41. Seyler TM. 8. Pure tone thresholds improved by an average 18 dB in the partial reconstruction group and 25 dB in the total reconstruction group. No other complication was noted. low rate of complications and superior hearing outcomes. Email: ghoshsayantani@rediffmail. Methods: It is a prospective study on 87 patients. 1 No.Vol. In our study. Conclusion: Titanium is an ideal material for ossicular chain reconstruction due to its biocompatible nature. but it is also very costly and needs an expert to handle. while hearing had improved in 100% cases. Hearing results were better for primary versus revision cases. Aim: To prospectively assess the results of titanium partial and total ossicular replacement prostheses in chronic ear disease. we have dealt with the use of titanium prosthesis for ossiculoplasty.com Sayantani Ghosh Bankura Sammilani Medical College. for intact canal wall procedures versus canal wall-down procedures and also for lower preoperative MERI. Preoperative and 3 months post-operative averages of pure tone audiograms.Role of titanium prosthesis in ossiculoplasty Rajdeep Guha Senior Resident Surgeon Bankura Sammilani Medical College. India. India.com Abstract Background: Ossicular chain damage from chronic middle ear diseases is a significant problem in India. The ideal ossicular chain reconstruction procedure is yet to be defined. 36 titanium partial and 51 total ossicular replacement prostheses were performed in either primary or revision surgery by a single surgeon (Dr. 1 (2010) 125 . Hence it Review of Global Medicine and Healthcare Research . carried in 2 different tertiary hospitals in India in 2 spells from September 2005 to December 2008 and February 2009 to June 2009. ease of insertion. done over a frequency range as per American Academy of Otolaryngology Head and Neck Surgery criteria (0. Results: Successful rehabilitation of conductive hearing loss (less than or equal to 20 dB air-bone gap) was obtained in 29 out of 36 patients with titanium partial ossicular replacement prostheses (80. with mean follow up being 5. Baseline demographic and surgical characteristics including middle ear risk index (MERI) and postoperative complications were also noted.7%).6 months.5–3 kHz). India Saugat Dey Bankura Sammilani Medical College. Overall Extrusion Rate was 8% (7 cases). Guha) and with a single microscope. were compared.5%) as compared to 32 out of 51 patients with total ossicular replacement prostheses (62. All patients were followed for at least 3 month. Email: dey_saugat@rediffmail. & Karja. 1985) reported that incus and malleus grafts show less evidence of erosion. To reduce the high rate of Review of Global Medicine and Healthcare Research . In the last three decades. as most patients cease to come for regular check ups once their hearing gets improved. It provides the impedance matching which transmits sound energy from the tympanic membrane to the inner ear. In the late 1970s nonreactive. 1990). 1971). The earliest recorded attempts to reestablish connection between the tympanic membrane and the oval window in cases of missing or damaged ossicles dates to Matte’s myringostapediopexy in 1901 (Matte.Vol. Teflon. In 1985. 1 No. Middle ear is the key apparatus in the mechanism of hearing. Nevertheless. ossiculoplasty continues to be a process in evolution (Janssen de Varebeke . ossiculoplasty. 1901). 1 (2010) 126 . Somers & Offeciers. Govaerts . 2004). biocompatible solid polymeric materials were being introduced for ossicular reconstruction which included ultra high molecular weight polyethylene. Schuknecht and Shi (Schuknecht & Shi. Ossicular repositioning was first performed by Hall and Rytzner in 1957 (Hall & Rytzner. TORP. 1996). various ossiculoplasty methods have evolved and good results were achieved. Chronic middle ear diseases such as chronic suppurative otitis media.6 months).should be prescribed judiciously and operated with proper precautions by an experienced hand. The purpose of middle ear surgery is to provide improved hearing to the patient. Shea was the first to use a length of polyethylene 90 tubing to reconstruct sound conducting mechanism in the middle ear in a tympanoplasty ( Shea JJ. causing damage to the ossicular chain is very common in India (WHO. It also provides protection from loud sound and minimizes internal effects of vocalization. PORP. and metallic implants. foreign body reactions and penetration into inner ear. 77% of the affected persons in India suffer significant hearing loss (WHO. extrusion. 1958). Ossiculoplasty is a surgical procedure for restoring the ossicular chain as near to normal as possible or to achieve continuity and transmission in an entirely different way after abandonment of the natural system. hence were abandoned. 1963) and Palva used metallic implants (Palva T. Also the follow up period is quite less (mean 5. high density polythene sponge known as “plastipores” and “polycels” were used. Study limitations: Less number of cases is covered as fewer titanium prosthesis ossiculoplasties are done in India due to the higher price of titanium. Keywords: titanium. Later Austin used Teflon tubing (Austin. 1957). thus alloplastic materials are considered as an option. Palva A. ABG Introduction The sense of hearing has been one of the most useful assets to human life. prosthesis. they had the additional advantage of being easy to sculpt but they too had higher extrusion rate (Mangham & Lindeman. The results were very poor with migration. Autologous ossicles often cannot be used due to underlying disease and homologous ossicles may transmit infections. In 1960s. 2004) and causes severe jeopardy in the mechanism of hearing. Humans owe their civilization to the fact that we can communicate with our fellow beings through hearing. In this study we have prospectively assessed the use of titanium as partial and total ossicular replacement prostheses and have tried to discover its relevance as a successful prosthesis material in India. initial complaints. Audiometries were done using Elkon 3N3 Multi audiometer. 1993). All the surgeries were performed by a single surgeon (Dr. Middle Ear Risk Index (MERI). The partial implant was used in the presence of an intact and mobile stapes and the total prosthesis was used when the stapes superstructure was absent. & Grun.6 months. Statistical Analysis Review of Global Medicine and Healthcare Research . Stupp HF. In 1992. A written consent was taken from every patient and the study was approved by the ethical committee of the institution. 1 (2010) 127 . which were either a primary or a revision surgery. 1967). The study was conducted in 2 spells from September 2005 to December 2008 in one of the hospitals and from February 2009 to June 2009 in the other hospital. the preoperative and the postoperative air-bone gap (ABG) and the postoperative complications. were also compared. done over a frequency range 0. A proforma was made for every patient. All patients were followed for at least 3 months. 1990). Patients and Methods It is a prospective study on 87 adult patients requiring ossiculoplasties and admitted to 2 different tertiary hospitals in India. Since then it is been extensively used by oto-surgeons in the developed countries. acoustic comparison of the various existing ossiculoplasty materials revealed that hydroxyapetite prosthesis has the best acoustic results (Nishihara & Goode.Vol. Guha) and with a single microscope to avoid manual (individual) and instrumental bias.5–3 kHz (0. Bioinert materials like Aluminum oxide ceramic (Al2O3) and bioactive glass and bioceramics were popular in the 1970s but had higher erosion (Mangham & Lindeman. The improvement in air-bone gap in the two different groups of were analyzed and compared with their preoperative determinants. 1996). with mean follow up being 5. 36 titanium partial (PORP) and 51 total ossicular replacement prostheses (TORP) were performed. but then it was found to be heavy (Gjurić & Rukavina. which documented the baseline demographic characteristics.5/1/2/3 kHz). Use of titanium for ossicular reconstruction began in Germany in 1993.extrusion. Sliced cartilage was used as a standard to cover all prostheses and reconstruction of the tympanic membrane was carried out with temporalis fascia. as per American Academy of Otolaryngology Head and Neck Surgery criteria. Coyle Shea had proposed cartilage interposition (Shea MC & Glasscock . which were produced by the German company Kurz GmbH (Stupp CH. Preoperative and 3 months postoperative averages of pure tone audiograms. 2007). 1 No. Since late 1980s gold prosthesis was gaining popularity. MERI was found to have a crucial role in the improvement of hearing results.05 was considered statistically significant. 1995).1. 2000. The MERI was calculated (Table 2) for each patient based on several pre and intra operative findings.7%) [Table 4].0001). Battista. The demographic and preoperative details of the patients are given in Table 1. as per American Academy of Otolaryngology–Head and Neck Surgery guidelines ( Monsell et al. version 9. Martin & Harner. 2003. which was obtained in 29 out of 36 patients with titanium PORP (80. Song. Siddiq & Raut. as would be expected in the presence of an intact stapes superstructure. The mean improvement of ABG in TORP is 19. subjective sensation of hearing ability improved in 100% cases and not much difference was found between the hearing outcome in TORP group and PORP group. 33 were male and 54 were female.1 dB compared to 14. 2007).All data were analyzed using SAS software. in the rest 8 were only ossicular reconstructions and 34 required additional graft placement (Figure2).073). The success of bone-anchored hearing aid devices testifies the affinity of Review of Global Medicine and Healthcare Research .64 %) surgeries were done by canal wall down procedure. i. 3 months post surgery. Krueger et al. while the rest had intact canal wall. Pure tone thresholds improved by an average of 25 dB.28 %) had MERI ≥ 7 (indicating severely diseased ear) [Figure 1] while 31 (35.5%) as compared to 32 out of 51 patients with TORP (62. 1 (2010) 128 .026). Hearing results were not found to be significantly better for primary versus revision cases (p = 0. Chi-square test and Fisher’s exact test was used to compare the proportions. in TORP compared to an improvement of 18 dB in PORP (p < 0. A both sided p value of < 0.Vol. 1999. 45 ossiculoplasties were accompanied with mastoid surgery. however the difference in the results were not found to be statistically significant (p = 0.14 %) were revision surgeries. 22 patients (25. 11 (12. 1 No. Discussion Titanium prostheses have been successfully used for ossicular reconstruction with favorable results (Wang. although the degree of improvement was much higher in TORP group (Table 3). & Wiet. Overall Extrusion Rate was 8% (7 cases). Ho.4 dB in PORP (p = 0.798). Post surgery.63 %) patients had preoperative air-bone gap > 30 (indicating poor prognosis). Results with PORP for ABG closure are marginally better than TORP.042). postoperative ABG (p = 0. 2004. & Wang. 66 cases (75.86 %) were primary surgeries and 21 (24.e. 2002.001) [Table 5]. all of them on revision surgeries revealed improper placement of cartilage sandwich as a reason behind the extrusion.ranging in age from 18 years to 54 years. Begall & Zimmermann. Less than or equal to 20 dB postoperative ABG is defined as a successful rehabilitation of the conductive hearing loss. No other complication was noted. Results Among the 87 patients studied. but were better in intact canal wall procedures versus canal wall-down procedures (p = 0. References 1. 1754 – 1758. Results of a multicenter study. it is inert and no foreign body or macrophage reaction has been noted in titanium prostheses obtained from revision surgery (Schwager. Austin. Dumas.F. & Zimmermann. Lehner. Trans Am Acad Ophthalmol Otolaryngol . Moreover. Its thin shaft and perforated head allow visualization of the stapes head or footplate during placement. more so when the rates of CSOM are exceedingly high in the poorer communities (Okafor. 2004. Titanium has better acoustic properties and showed improved results at particularly 2–3 kHz maintained over 24 months (Zenner. was found slightly more in the PORP group than the TORP one. this supports the popular belief that middle ear status has a major role in the hearing outcome post ossiculoplasty. Austin. 79. ease of insertion. Begall. 2. Earlier there has been controversy regarding the efficacies of the procedures certain studies have found that patients undergoing TORP procedures did better (Zenner. 2004. The effect of MERI on hearing outcomes have been studied for the first time in this study and has been found to play a vital role. hearing outcomes in canal wall down procedures were found less successful compared with that of intact canal wall procedures. D. D. 83. Lavieille. The low prosthesis weight and good coupling allows good sound transfer which is lost with heavier prostheses. although the degree of improvement of both postoperative ABG and pure tone thresholds were more for the TORP group. Graphical comparison of the preoperative and postoperative ABG for PORP and TORP are given in Figure 3 and Figure 4. Am J Otology. Reporting results in tympanoplasty. the partial titanium prosthesis gave marginally better hearing results than the total prosthesis. Troussier. In our study. (1985). & Stupp. Laryngoscope. 4. Baumann. 2001). H. Bellucci. whereas some others found that PORP patients did better (Dalchow. 2001). Also the extrusion cases illustrate that it needs an expert to handle. 6. Baumann.198–208. although the degree of improvement was higher in the total one. K. 3. 2000). Hence it should be prescribed judiciously and operated with proper precautions by an experienced surgeon. Gardner. Jackson. 85 – 88. low rate of complications and superior hearing outcomes. Lehner. In line with other studies (Martin & Harner. & Nguyen. Also this study revealed that hearing outcome doesn’t considerably differ in a revision surgery. postoperative ABG < 20dB. 1 No. (2000). & Zimmermann. Martin & Harner. successful restoration of hearing.Vol. Reconstruction of the ossicular chain with titanium implants. Stegmaier. & Kaylie. 1 (2010) 129 . (1973). In our study. 2004. i. 67. (1963). Grun. & Zimmermann. 1984).e. 2004).. Review of Global Medicine and Healthcare Research . as long as the surgical expertise isn’t compromised. 2006). Vein graft tympanoplasty: Two-year report. Laryngorhinootologie. Schmerber. Stegmaier. Dual classification of tympanoplasty. Our results indicate that titanium is an ideal material for ossicular chain reconstruction prostheses because of its biocompatible nature. R. But it is also very expensive in an economy like ours.139– 45.titanium to bone – termed osseointegration. . & Shi. Laryngoscope. D. L. Goode. (1958). September 1. Otol Neurotol. Early results of titanium ossiculoplasty using the Kurz titanium prosthesis: a UK perspective. 113-119.J. C. The chronic discharging ear in Nigeria. (1971).. 12. Balkany. Results with 2.836–9. E. 106(4).. 18.. R. (2000).A.F. Ho.. (1967).Vol.P. 16. S. 507 – 10.. Laryngo-Rhino-Otologie. Arch Ohrenheilkd. 21. 539–544. 14. 61–4. Stapedectomy and autotransplantation of ossicles.C. & House. Otol. Okafor. Ossicular reconstruction with titanium prosthesis. 1 (2010) 130 . Schwager. V.F. Tragal Cartilage as an Ossicular Substitute. 10. G. G. 7. H.. Govaerts. Lavieille.. 263. Stupp. Otolaryngol HeadNeck Surg. Monsell.308-317. J. Jackson.V. Otolaryngol Head Neck Surg . C.. (2004). M.or 3-legged wire columellization in chronic ear surgery. (1993): An experimental study of acoustic properties of incus replacement prosthesis in a human temporal bone model. P. Feghali. & Wiet. Goldenberg. & Kaylie. V. & Harner. Dalchow. Krueger. (1957). Palva. (2007).R. 318-324. Laryngorhinootologie. A. Results with titanium ossicular reconstruction prostheses. (2006).. J. T. (2004). D. R. Laryngoscope. Dumas. & Raut. F. & Wilson. Nishihara.F. 22.174-8. 17. Grun . S. Hall.W.K.628–30... (1990). Ceravital versus plastipore in tympanoplasty: a randomized prospective trial. 98. C. J.762–6..W.. A. Laryngol. 114. Preliminary ossiculoplasty results using the Kurz titanium prostheses. 79. Janssen de Varebeke. Green. 125... Shea.The two – hole ossiculoplasty technique. Tympanoplasty in chronic right otitis media: a case report. Review of Global Medicine and Healthcare Research . Meyerhoff. Gates.. Somers.C. & Rukavina. 65.A. (2001). 75. M. Adv Otorhinolaryngol.G. Ann Otol Rhinol Laryngol. Acta Otolaryngologica . C. Mangham. Laryngoscope.. J. Shelton. U. (1996).W. 25. 24. C. Arch Otolaryngol. Schmerber..W. Reconstruction of the ossicular chain with titanium implants. Siddiq.. Martin. 6.. (2003)...53. E. & Lindeman. III.. B. 23. S.Y. A. 1 No. (1984).Q. U ¨ eber Versuche mit Anheilung des Trommelfells an das Ko¨pfchen des Steigbu¨gels nach operativer Behandlung chronischer Mittelohreiterungen. & Offeciers.. J.65–70. 121. Troussier. T. Scanning electron microscopy findings in titanium middle ear prostheses. & Karja. 80. J.M.F. Battista. & Grun. Ann Otol.760–5.G. S.112–6. 33. 11.G. A. Geho¨ rkno¨ chelchenersatzmit Titan-Prothesen. 24..A. Gardner.. J.5.. 23.271–5. C.. Stupp. L. J. D. 47. Schuknecht. J.D. 347–54. R. The Journal of Laryngology & Otology. Beatty.149–52. (1901). & R.A. & Stupp.96–9 15.. T.. 8. Gjurić. (1995). Laryngoscope.249–58.H. (2007). & Rytzner.J. K. C. & Nguyen.L. R.. 19. S. Hearing results with the titanium ossicular replacement prostheses. H. (1996). et al (2002). H. 95. Shea. 99. 20.D. Evolution of stapedectomy prostheses over time.A. (1985). M. Palva.. 9. 114. & Glasscock. M.D. 13. Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss. Eur Arch Otorhinolaryngol. W. Am J Otology.C. Otol Neurotol.. M. Early results with titanium ossicular implants. 86(3).335–7. D.. S. Memphis Med. Surgical pathology of middle ear implants.186–7. Matte. 113..E. Open Tubingen titanium prostheses for ossiculoplasty: a prospective clinical trial. Stegmaier.4% 35. TABLES TABLE 1: Demographic and preoperative details of the patients Details SEX Male Female TYPE OF SURGERY Primary Secondary MERI ≤3 4-6 7-12 PREOPERATIVE ABG 0-10 dB 10-20dB 20-30dB ≥ 30dB Number Percent 33 54 66 21 17 48 22 37. 1973] Dry Occasionally wet Persistently wet Wet.1% 75. 22. Lehner. J. Baumann...26. R. R. Results of tympanoplasty with titanium prostheses. I.6% 26..4% 33. WHO (2004).9% 24.1% 19.. Otolaryngol Head Neck Surg. Otol Neurotol.int/child-adolescent health/New_Publications/CHILD_HEALTH/ISBN_92_4_159158_7.582–9. 28.Vol. (1999).P. Zenner.5% 55. & Zimmermann.606–9..2% 25. 1 (2010) Risk Value 0 1 2 3 0 1 0 1 131 . H. X. A. 27. Burden of illness and management options. 1 No.9% 62. (2001).pdf (last accessed 8 November 2005). Song. cleft palate Perforation Absent Present Cholesteatoma Absent Present Review of Global Medicine and Healthcare Research . 121. Wang. http://www.who.6% 4 23 29 31 TABLE-2: Calculation of MERI for each patient Risk Factor Otorrhea (Bellucci classification)[Bellucci. H. Wang. Chronic suppurative otitis media.3% 4.. 1 (2010) 132 .5% 19. 1985] 0: M+I+S+ A: M+S+ B: M+SC: M-S+ D: M-SE: Ossicle head fixation F: Stapes fixation Middle ear: Granulation or Effusion No Yes Previous surgery None Staged Revision 0 1 2 3 4 2 3 0 1 0 1 2 TABLE 3: Postoperative improvement of ABG and PTA TEST Mean Improvement in ABG Mean Improvement in PTA TORP PORP p value 19.Vol.7% 37.026 < 0. 1 No.001 TABLE 4: Postoperative ABG closure for PORP and TORP PORP Postoperative ABG Number Percent TORP Number Percent ≤ 20 dB >20 dB 29 07 80.1 dB 25 dB 14.5% 32 19 62.Ossicular status (Austin/ Kartush classification) [Austin.4 dB 18 dB 0.3% TABLE 5: Hearing results as per MERI (Middle ear risk index) MERI Postoperative ABG < 20 Postoperative ABG > 20 1-3 4-6 7-12 17 34 10 0 14 12 Review of Global Medicine and Healthcare Research . Figures: Figure 1: Distribution of the patients according to their MERI Figure 2: Pie chart showing different surgical procedures done in the patients Review of Global Medicine and Healthcare Research .Vol. 1 (2010) 133 . 1 No. Vol. 1 No.Figure 3: Pre and postoperative comparison of air-bone gaps in PORP cases Figure 4: Pre and postoperative comparison of air-bone gaps in TORP cases Review of Global Medicine and Healthcare Research . 1 (2010) 134 . showed a significantly (p<0. T. Budin. Malaysia * Corresponding Author. STZ injected rat was confirmed diabetic with measurement of blood glucose level. M. This study was to see the effect of homeopathy remedy Syzygium jambolanum on glucose level.71%). Biochemical analysis of glucose.05. lipid profile and pancreas histology of streptozotocin (STZ) induced rats. lipid profile and the histology of pancreas was carried out. Two groups of rat were injected with single dose of STZ with the dose of 45mg/kg intravenously. jambolanum was administrated through force feeding for 28days. triglyceride (70. Email: jamal3024@yahoo. *. Department of Biomedical Science Faculty of Allied Health Sciences Universiti Kebangsaan Malaysia. the rats were sacrificed and the blood sample and the pancreas was collected. Homeopathy remedy S.Effects of homeopathy remedy Syzygium jambolanum on glucose level.05) reduced mean level of plasma total cholesterol (61.84%) and LDL-cholesterol (79. Methods 32 male rats of Sprague-dawley with body weight 250-300g divided randomly into four groups.14) compared to Review of Global Medicine and Healthcare Research .. lipid profile and histology of pancreas of Streptozotocin induced diabetes rat Jamaludin.71%) compared to non treated diabetes group rats. Then. Ketharin. S.05) reduced (61. The treated diabetes group rats showed significantly (p<0.com Abstract Background: Polyphenol compound is an antioxidant types that can be commonly found in phytonutrient-bearing Background The hyperglycemic condition can cause various complication in diabetes mellitus patients and various new treatments with promising therapeutic results and minimized side effects were being researched. Results Mean plasma glucose level of treated diabetes group rats.Vol. 1 (2010) 135 .B. the data obtained is analysed using One-way Anova with significance value of p<0. 1 No. On the third day. However the effectiveness of S. the antidiabetic potential of the fruit and seed extracts of S. jambolanum can be used as a treatment to diabetes patients. 2003). and in addition have a number of side effects (Holman and Turner.Vol. Sharma et al. insulin injection and management through diet and physical exercise (Vats et al. Therefore. jambolanum have been shown by several studies (Sridhar et al. In spite of the presence of number of oral synthetic oral antidiabetic drugs in the market. Therefore. Jambolanum seeds (William Boericke 2002). Mean plasma HDL-cholesterol level was significantly (p<0. 2009). in this study. The HDL carries the cholesterol and triglyceride to liver to be metabolised and excreted (Briones et al. its concluded that the homeopathy remedy S. LDL and HDL plays important role in transportation of cholesterol and triglyceride. researchers are now diverted their attention to different herbs and medicinal plants in order to find out new active principal with less side effects and better antidiabetic activity (Beigh et al. 1 (2010) 136 . Conclusion From the result of this study (glucose. jambolanum is a well known Indian folk medicine for the treatment of diabetes mellitus and prickly heat (Samba-Murthy & Subrahmanyam 1989). 1 No. Jambolanum used in this research is a comercially available homeopathy remedy in the dosage of mother tincture and used for diabetes patients by homeopathy practitioners. jambolanum on glucose level. The commonly practised treatments of diabetes include oral antidiabetic drugs. 1991). H&E and Maldono staining was used to stain the pancreas. 2002) Syzygium jambolanum from the family of Myrtaceae. Unfortunately. 2002).the non treated diabetes group rats. jambolanum as a homeopathy remedy has not been studied yet. effect of homeopathy remedy S. 1984). Background Diabetes is a group of metabolic disorders that result in hyperglycemia due to decreased insulin production (Type 1) or insufficient insulin utilization (Type 2) (Marshal & Bangert 2004). 1983). it has become necessary to look for an economical as well as therapeutically effective treatment without side effects (Grover et al. Mother tincture of S. Pakistan Southern Asia and Brazil (Grover et al. 2002). ‘jamun’ or ‘rose apple’ in English. Cholesterol and triglyceride carried by LDL from liver into the blood circulation (West et al.jambolanum is prepared from the ethanol extract of powdered S. lipid profie and histology result). STZ. S. lipid profile and pancreas histology of STZ induced rats was tested. S.86%) in treated diabetes group rats compared to the non treated diabetes group rats. an antibiotic produced by Review of Global Medicine and Healthcare Research . evergreen tree found primarily in India. 2005.05) increased (364. is also commonly known as ‘jambol fruit’. Dyslipidemia is a secondary complication of diabetes (Shamim et al. 2002). The histology examination showed the presence of denser beta cell distribution and larger islet of Langerhans of treated diabetes group rats compared to the non treated diabetes group rats. none of the oral hypoglycaemic agents have been successful in maintaining euglycaemia. Its a large. Streptomyces achromogenes, is a common used agent in experimental diabetes (Rakieten et al. 1963) Methods 32 male Sprague-Dawley rats, body weight range of 210-250g from Unit Haiwan UKM was used in this study (UKMAEC approval number: FSKB/BIOMED/2008/HAWA/12-AUGUST/230-SEPT-2008-FEB-2009). The rats were divided into four groups randomly. After a week of adaptation period, two groups were induced diabetes by injecting STZ via intravena and the other two groups were the nondiabetic rats. The dose used was 45mg/kg. The volume of STZ injected was 1ml/kg (Fonteles et al. 1996). The four groups were the non diabetes mellitus rats without treatment (NDMNoTX), non diabetes mellitus rats with treatment (NDMTx), diabetes mellitus rats without treatment (DMNoTx) and the diabetes mellitus rats with treatment (DMTx). STZ was freshly prepared. After three days, the blood glucose level was measured using the Advantage II glucometer (Roche Diagnostics, New Zealand) via tail prick. Blood glucose level higher than 13.8mmol/L was considered diabetes condition. Then the treatment of homeopathy remedy S. jambolanum was carried out for 28days daily via force feeding the NDMTx and DMTx group rats. The S. Jambolanum mother tincture was mixed with water and the volume force feeded was 1ml/kg. The mixing of remedy was done according to the local homeopathy practitioner. The NDMNoTx and DMNoTx group rats were force feed with distilled water. After 28 days, the rats were weighted. Cardiac puncture was done to collect blood sample for the biochemical tests and the tail of pancreas was collected for histology purpose. Blood sample was collected in litium heparin tube for the lipid analysis and the sodium oxalate tube was used for glucose analysis. Blood sample was centrifuged at 3500rpm, 4ºC for 15 minutes. The plasma was kept at -45ºC. The pancreas sample was washed with normal saline and divided into two equal pieces. One part was fixed with 10% formal saline for 24hours and the the other part was fixed in Bouin solution for 12 hours. The plasma glucose level was determined using glucose oxidase kit from Thermo electron corporation (USA). The plasma total cholesterol (TC) level was measured using the Loeffler et al. (1963) method. The plasma trigliseride (TG) level was measured using Trigliseride kit from Randox laboratories (UK). The plasma high density lipoprotein (HDL) level was measured using modified Lape-Virella and Feris (Wooton 1974). The plasma low density lipoprotein (LDL) level was calculated using Friedawald formula (Genst & Cohn 1998). The pancreas samples were fixed and processed. The sliced tissues fixed on slaid were stained. The Bouin solution fixed samples were stainned using Maldono (Luna 1968) staining and the 10% formal saline fixed samples were stainned using Hematoxylin & Eosin (Clayden 1971) staining. Results were recorded and expresed as mean ± SD. The data were analyzed by ANOVA test. Differences were considered as statistically significant when p<0.05. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 137 Results Figure 1: Plasma glucose concentration according to groups a – significant compared to NDMNoTx. b – significant compared to NDMTx. c – significant compared to DMNoTx. Figure 1 shows plasma glucose level according to groups after 4 weeks of study. Mean plasma glucose of NDMTx group (109.62 ± 11.48) shows no significant difference compared with NDMNoTx group (90.61 ± 13.64). Mean plasma glucose of DMNoTx group (313.89 ± 45.07) was higher sifgnificantly compared to NDMTx group and NDMNoTx group. DMTx group (132.41 ± 17.59) shows mean plasma glucose significantly lower compared with DMNoTx group, no significant difference compared with NDMTx group and significantly higher compared to NDMNoTx group. Plasma total cholesterol analysis Figure 2: Plasma total cholesterol concentration according to groups a – significant compared to NDMNoTx. b – significant compared to NDMTx. c – significant compared to DMNoTx. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 138 Figure 2 shows mean plasma total cholesterol according to groups after 4 weeks of study. Mean plasma total cholesterol of NDMTx group (67.49 ± 7.09) was significantly higher compared to NDMNoTx group (39.58 ± 5.79). DMNoTx group (117.85 ± 21.87) shows mean total cholesterol significantly higher compared with NDMTx group and NDMNoTx group. Mean plasma total cholesterol of DMTx group (45.10 ± 8.39) was significantly lower compared with DMNoTx group and NDMTx group and no significant difference compared to NDMNoTx group. Plasma Triglyceride analysis Figure 3: Plasma triglyceride concentration according to groups a – significant compared to NDMNoTx. b – significant compared to NDMTx. c – significant compared to DMNoTx. Figure 3 shows mean plasma triglyceride according to groups after 4 weeks of study. Mean plasma triglyceride of NDMTx group (59.98 ± 5.12) was significantly higher compared to NDMNoTx group (39.48 ± 7.36). DMNoTx group (101.73 ± 19.71) shows mean plasma triglyceride significantly higher compared to NDMTx group and NDMNoTx group. Mean plasma triglyceride of DMTx group (29.66 ± 9.64) was significantly lower compared with DMNoTx group and NDMTx group and no significant difference compared to NDMNoTx group. Plasma HDL analysis Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 139 Figure 4: Plasma HDL concentration according to groups a – significant compared to NDMNoTx. b – significant compared to NDMTx. c – significant compared to DMNoTx. Figure 4 shows mean plasma HDL according to groups after 4 weeks of study. Mean plasma HDL of NDMTx group (10.18 ± 1.88) shows no significant difference compared to NDMNoTx group (11.46 ± 2.40). DMNoTx group (4.24 ± 2.22) shows a significantly lower mean plasma HDL compared with NDMTx group and NDMNoTx group. Mean plasma HDL of DMTx group (19.71 ± 5.78) was significantly higher compared with DMNoTx group, NDMTx group and NDMNoTx group. Plasma LDL analysis Figure 5: Plasma LDL concentration according to groups a – significant compared to NDMNoTx. b – significant compared to NDMTx. c – significant compared to DMNoTx. Figure 5 shows mean plasma LDL according to groups after 4 weeks of study. Mean plasma LDL of NDMTx group (45.31 ± 6.53) was significantly higher compared to NDMNoTx group (20.22 ± 3.75). DMNoTx group (93.26 ± 21.57) shows mean plasma LDL significantly higher compared with NDMTx group and NDMNoTx Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 140 group. Mean plasma LDL of DMTx group (19.45 ± 4.42) was significantly lower than DMNoTx group and NDMTx group and no significant difference compared to NDMNoTx group. Analysis of pancreas histology a) H&E staining Figure 6: Histology of pancreas of DMNoTx group. H&E staining. Magnification 400x. Light microscope. Figure 7: Histology of pancreas of DMTx group. H&E staining. Magnification 400x. Light microscope. H&E staining revealed the presence of necrosis and the islets of Langerhans can be differentiated from the exocrine region. however the β cells cannot be differentiated with α cells. DMTx group shows islets larger in size and less necrosis compared to DMNoTx group. b) Maldono staining Figure 8: Histology of pancreas of DMNoTx group. Maldono staining. Magnification 400x. Light microscope. Figure 9: Histology of pancreas of DMTx group. Maldono staining. Magnification 400x. Light microscope. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 141 Maldono staining revealed the presence of necrosis and islets of Langerhans can be differentiated from the exocrine region. The β cells can be differentiated with α cells. DMTx group shows islets larger in size, less necrosis and more β cells compared to DMNoTx group. Discussion Destruction of β cells causes lower production of insulin and this disturbs carbohydrate metabolism (Chatterjee & Shinde 2000). Glucose in blood circulation could not be taken up by body cells and the body stays in fasting state. Impuls would be send to produce more glucose via the glucagon action. This causes the hiperglycemia and dyslipidemia state as found in DMNoTx group rats (Pansy et al 1989). Homeopathy remedy S. jambolanum shows antidiabetic activity and indicated by the significant (p<0.05) decrease in glucose level, total cholesterol, triglyceride, LDL and an increase in HDL in DMTx group rats compared to DMNoTx group rats. This result supports the usage of S. jambolanum seed tradisionally as antidiabetic agent (Anonymous 1985). The possible mechanism of action of homeopathy remedy S. jambolanum was by increasing the insulin level either by increasing the release of insulin hormone from β cell or by increasing the insulin from its bound form (Kumar et al 2008). Homeopathy remedy S. jambolanum could also increased insulin level via increasing the cathepsin B activity. Cathepsin B plays role in formation of insulin from proinsulin (Bansal et al. 1981). An increase in insulin level increases the uptake of glucose by cells and stops the glucagon activity and improves the hyperglycemia and dyslipidemia condition. Earlier study of Ravi et al. (2004) indicates S. jambolanum posses antioxidant activity. This study also suggests the homeopathy remedy S. jambolanum posses the antioxidant activity which destroys the free radicals and complication of hyperglycemia and dyslipidemia could be avoided. STZ destroys the β cells in Islets of Langerhans via the free radical production. The antioxidant property protects the β cells from destruction and this to increase the insulin level in body (Ravi et al. 2004). The histology observation indicates the denser β cell distribution in Islets of Langerhans in DMTx group rats compared to DMNoTx group rats. This supports the suggestion of protective effect of homeopathy remedy S. jambolanum on β cells. Glycemic control is the major factor that influences the level of VLDL and triglyceride (Markku 1995). It is suggested that homeopathy remedy S. jambolanum have effect on glycemic control and lowers the triglyceride level in DMTx group rats. Study have shown diabetes condition and lack of insulin action leads to high levels of triglyceride and total cholesterol compared to normal individual as insulin stimulates synthesis of adipose tissue by lipoprotein lipase (Matshushita 1982). This study also suggests the homeopathy remedy S. jambolanum causes increased production of HDL as in DMTx group rats which transports the cholesterol and triglyceride to liver to be metabolised and excreted and thus causing the decreased level of cholesterol and triglyceride as in DMTx group rats (Sharma et al. 2003). A decreased production of LDL also leads to lack of transportaion for cholesterol and triglyceride to be carried to blood circulation and leads to lower level of cholesterol and triglyceride in DMTx group rats. The presence of diatery fibers in S. jambolanum seed decreases the Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 142 absorption of cholesterol in intestine (Lansky 1993). A decreased absorption of cholesterol decreases the blood cholesterol level in blood and could be another mechanism of action of homeopathy remedy S. jambolanum in DMTx group rats (Kar et al. 1999). NDMTx group rats showed a nonsignificantly increased glucose level, significantly (p<0.05) increased total cholesterol, triglyceride and LDL and nonsignificantly decreased HDL level. These results might be caused by the destructive effect of the remedy on the islets of Langerhans in NDMTx group rats. However more study should be done. These result indicates homeopathy remedy S. jambolanum is not suitable to be used as supplement and should only be used in diabetes patients. Conclusion The present study demonstrates the homeopathy remedy S. jambolanum can be used as a treatment for diabetes patient. this study shows the homeopathy remedy S. jambolanum has hypoglycemia and hypolipidemia activity. the homeopathy remedy S.jambolanum decreases plasma glucose, total cholesterol, triglyceride and LDL and increases the plasma HDL level of DMTx group. From the histology observation, homeopathy remedy S. jambolanum protects β cell from free radical destruction and repairs the hyperglycemia and dyslipidemia condition in DMTx group. The homeopathy remedy S. jambolanum is not recommended to be used in nonpathological condition. References Marshall, J.W. & Bangert, S.K. 2004. In: Clinical Chemistry: Disorders of carbohydrates metabolism. 5th Edition. Amsterdam: Elsevier Limited. Shamim A. Qureshi, Warda Asad & Viqar Sultana. 2009. The Effect of Phyllantus emblica Linn on Type II Diabetes, Triglycerides and Liver – Specific Enzyme. Pakistan Journal of Nutrition 8(2): 125-128. West, K.M.M.M., Ahuja, S., Bennett, P.H., Czyzyk, A., Mateo de Acosta, O., Fuller, J.H., Grab, B., Grabauskas, V., Jarrett, R.J., Kosaka, K., Keen, H., Krolewski, A.S., Miki, E., Schliack, V., Teuscher, A., Watkins, P.J. & Stober. J.A. 1983. The role of circulating glucose and triglyceride concentrations and their interactions with other “risk factors” as determinants of arterial disease in nine diabetic population samples from the WHO Multinational Study. Diabetes Care. 6: 361-371. Briones, E.R., Mao, S.J.T., Palumbo, P.J., OFallon, W.M., Chenoweth, W. & Kottke. B.A. 1984. Analysis of plasma lipids and apolipoproteins in insulindependent and noninsulin-dependent diabetics. Metabolism. 33(1): 42-9. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 143 Vats, A., Tolley, N.S., Polak, J.M. & Gough, J.E. 2003. Scaffolds and biomaterials for tissue engineering: a review of clinical applications. Clinical Otolaryngology & Allied Sciences 28(3): 165-172. Holman, R.R. & Turner, R.C. 1991. Oral agents and insulin in the treatment of noninsulin-dependent diabetes mellitus. In Textbook of Diabetes. 48th Edition. Oxford: Blackwell Scientific Publications, Oxford. Beigh, S.Y., Nawchoo, I.A. & Iqbal, M. 2002. Herbal Drugs in India: Past and Present Uses. Journal of Tropical Medicinal Plants 3: 197-204. Grover, J.K., Yadav, S. & Vats, V. 2002. Medicinal plants of India with anti-diabetic potential. Journal of Ethnopharmacology 81(1): 81-100. Samba-Murthy, A.V.S.S. & Subrahmanyam, N.S. 1989. Fruits. In a text book of economic botany. Wiley: New Delhi. Sridhar, S.B., Sheetal, U.D., Pai, M.R.S.M. & Shastri M.S. 2005. Preclinical evaluation of the antidiabetic effect of Eugenia jambolana seed powder in streptozotocin-diabetic rats. Brazillian Journal of Medical and Biological Research 38(3): 463-468. Sharma, S.B., Nasir, A., Prabhu, K.M., Murthy, P.S. & Dev, G. 2003. Hypoglycemic and hypolipidemic effect of ethanolic extract of seeds of Eugenia jambolana in alloxan-induced diabetic rabbits. Journal of Ethnopharmacology 85: 201-206. William Boericke. 2002. New Manual of Homeopathic Materia Medica and Repertory. New Delhi: B. Jain Peublishers. Rakieten, N. Rakieten, M.L. & Nadkarni, M.V. 1963. Studies on the diabetogenic action of streptozotocin. Cancer Chemotheraphy Reports 29: 91–98. Fonteles, M.C., Huang, L.C. & Larner, J. 1996. Infusion of pH 2.0 d-chiro-inositol glycan insulin putative mediator normalizes plasma glucose in streptozotocin diabetic rats at a dose equivalent to insulin without inducing hypoglycaemia. Diabetologia 39: 731-734. Luna, L.G. 1968. Manual of histologic staining method of the armed forces institutes of pathology. 3rd Edition. New York : Mc Graw Hill. Chatterjee, M.N. & Shinde, R. 2000. Textbook of medical biochemistry. Metabolism of Carbohydrates. Delhi: JayPee Medical Publisher. Anonymous. 1985. The Wealth of India. New Delhi: CSIR, I. A. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 144 Kumar, A., Ilavarasan, R., Jayachandran, T., Deecaraman, M., Aravindan, P., Padmanabhan, N. & Krishan, M.R.V. 2008. Anti-diabetic activity of Syzygium cumini and its isolated compound against streptozotocin-induced diabetic rats. Journal of Medicinal Plants Research 2(9): 246-249. Bansal, R., Ahmad, N. & Kidwai, J.R. 1981. Effects of oral Administration of Eugenia jambolana Seeds and chloropropamide on blood glucose level and pancreatin cathepsin B in Rat. Indian Journal of Biochemistry and Biophysics 18: 377. Ravi, K., Ramchandran, B. & Subramanian, S. 2004. Effect of Eugenia jambolana seed kernel on antioxidant defence system in streptozotocin induced diabetes in rats. Life sciences 75: 2717-2731. Ravi, K., Sekar, D.S. & Subramanian, S.A. 2004. Hypoglycemic activity of inorganic constituents in Eugenia jambolana seeds on streptozotocin induced diabetic rats. Biological Trace Element Research 99(1-3): 145-55. Markku, L. 1995. Epidemiology of diabetic dyslipidemia. Diabetes Review 3: 408422. Matshushita, K., Saito, N. & Ostuji, F. 1982. Factors influencing serum lipid level in patients with diabetes mellitus. Journal of Nutrition 40: 79-90. Sharma, S.B., Nasir, A., Prabhu, K.M., Murthy, P.S. & Dev, G. 2003. Hypoglycemic and hypolipidemic effect of ethanolic extract of seeds of Eugenia jambolana in alloxan-induced diabetic rabbits. Journal of Ethnopharmacology 85: 201-206. Lansky, P.S. 1993. Plants and cholesterol. Acta Horticulture 332: 131-36. Kar, A., Choudhary, B.K. & Bandyopadhyay, N.G. 1999. Preliminary studies on the inorganic constituents of some Indigenous hypoglycemic herbs on oral glucose tolerance test. Journal of Ethanopharmacology 64: 179-184.     Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 145 Changing demographics of rheumatic heart disease in western world: A case report of mitral stenosis and brief review of literature Mukesh Singh, Jeen-Soo Chang, Evyan Jawad, Sandeep Khosla Chicago Medical School / Rosalind Franklin University of Medicine & Sciences, North Chicago, Illinois, USA Email: [email protected] Abstract Rheumatic heart disease related mitral stenosis in United States is a rarely seen entity. Classically, valve problems develop 5 - 10 years after the rheumatic fever. In North America and Europe, this classic history of MS has now been replaced by an even milder delayed course with the decline in incidence of rheumatic fever. We report an interesting case of untreated rheumatic mitral stenosis (MS) with atrial fibrillation and fatal multi-organ thromboembolism demonstrating the altered natural course of this entity in developed world. This case provides an excellent educational opportunity for both new and old generation of physicians. It illustrates a typical scenario of altered natural history of rarely seen severe MS in the developed world and emphasises the importance of timely intervention including adequate anticoagulation to prevent thromboembolism, as these can and have proven to be fatal. Keywords: Rheumatic heart disease, Mitral stenosis, Thromboembolism Background Rheumatic heart disease related mitral stenosis in United States is a rarely seen entity. Mitral stenosis (MS), resulting from thickening and immobility of the mitral valve leaflets, causes an obstruction in blood flow from the left atrium to left ventricle. As a result, there is an increase in pressure within the left atrium, pulmonary vasculature, and right side of the heart, while the left ventricle is unaffected in isolated MS. However, MS often coexists with mitral regurgitation and occasionally with aortic valve dysfunction, which may cause left ventricular dysfunction [1]. Mitral valve disease is associated with atrial fibrillation (AF), which may lead to serious and fatal thromboembolic complications. We report an interesting case of untreated rheumatic MS with AF and fatal multi-organ thromboembolism. This case provides an excellent educational opportunity for both new and old generation of physicians. It illustrates a typical scenario of altered natural history of rarely seen severe MS in the developed world and emphasises the importance of timely intervention including adequate anticoagulation to prevent thromboembolism, as these can and have proven to be fatal. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 146 Case Report A 56 year old female presented with nausea, vomiting, headache, abdominal pain, and sudden onset of bilateral leg pain. Her past medical history was significant for two previous strokes with residual left hemiparesis, a heart condition (unknown diagnosis at the time of admission), and atrial fibrillation on warfarin therapy. Patient denied any similar presentation in the past. On examination, patient was found to be in atrial fibrillation with absent distal pulses in lower extremities bilaterally, diffuse abdominal tenderness and diminished bowel sounds. Rest of the physical examination was unremarkable. Laboratory investigations revealed normal blood count and metabolic panel with subtherapeutic INR of 1.3 at the time of admission. Chest Xray showed cardiomegaly with prominent aorto-pulmonary window suggestive of pulmonary hypertension typical of mitral stenosis [Figure 1]. The trans-thoracic echocardiogram revealed severe MS, thickened mitral valve cusps without any vegetations, and an enlarged left atrium without any clots [Figure 2]. CT scan of brain confirmed a large subacute infarct in right parietal region [Figure 3]. Computerised tomography (CT) of the abdomen revealed multiple infarcts in the spleen and kidneys, mesenteric ischemia and acute bilateral iliac artery occlusions [Figure 4]. Abdominal aortic angiogram was performed together with an emergent intra-arterial thrombolysis of the occlusive thrombi in iliac arteries. Post-procedure, she recieved systemic heparin and alteplase infusion for 24 hours. A trans-esophageal echocardiogram was scheduled, but the patient expired before its completion due to cardiac arrest with pulseless electrical activity that did not respond to advanced life support. Discussion: Rheumatic fever is the predominant cause of MS. Isolated MS occurs in 40% of all patients presenting with rheumatic heart disease [2,3], although only 50 to 70 percent of patients report a history of rheumatic fever [2,3]. Isolated MS is twice as more common in women than in men [2-4]. Other causes of MS, though rare, include left atrial myxoma, ball valve thrombus, mucopolysaccharidosis, and severe annular calcification. In patients with MS due to rheumatic fever, the pathological processes include leaflet thickening and calcification, commissural fusion, chordal fusion, alone and / or in combination [5,6]. These ultimately result in a funnel-shaped mitral apparatus with reduced size of mitral valve orifice. Interchordal fusion obliterates the secondary orifices, and commissural fusion narrows the principal orifice [5,6]. Classically, valve problems develop 5 - 10 years after the rheumatic fever. Rheumatic fever is becoming rare in the United States, so MS is also very rarely seen. In North America and Europe, this classic history of MS has now been replaced by a milder delayed course with the decline in incidence of rheumatic fever [7]. The mean age of presentation is now in the fifth to sixth decade [7] and more than one third of patients undergoing valvotomy are older than 65 years [8]. Our patient was 58 years old and this exemplifies the changing demographics of this condition. In developed countries, there is a long latent period of 20 to 40 years from the occurrence of rheumatic fever Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 147 to the onset of symptoms. Once symptoms develop, there is another period of almost a decade before symptoms become disabling [2]. The symptoms induced by MS are primarily related to the severity of the valvular stenosis as reflected by the left atrial pressure, pulmonary pressures, pulmonary vascular resistance, and cardiac output. However, many patients with severe MS deny symptoms because slow progression of disease is "matched" by a gradual reduction in activity. As a result, a careful history is often required to document a slow decline in exercise tolerance. Any situation that increases the cardiac output, thus raising transmitral flow, or causes tachycardia, which reduces diastolic filling time, can markedly increase the transmitral pressure gradient and precipitate symptoms such as dyspnea or hemoptysis, even in patients with mild MS. In some patients, the diagnosis of MS is first made when the patient is exposed to such stresses. Others present only with a secondary complication, such as AF or an embolic event. Atrial fibrillation (AF) is common in patients with MS due to the elevation of left atrial pressure and consequent left atrial enlargement. The prevalence of AF is higher with more severe disease, increasing age, and the presence of other valvular abnormalities. Munoz et al in their study of 854 patients with MS, reported incidence of AF as 47 percent overall; the rate was higher in those with other valvular abnormalities [9]. The 2006 ACC/AHA valvular disease guidelines and 2008 Eighth ACCP consensus conference recommended long-term oral anticoagulation (target INR 2.5, range 2.0 to 3.0) in patients with MS who have a prior embolic event, left atrial thrombus, or paroxysmal, persistent, or permanent AF, since all forms of AF carry a similar risk for thromboembolism [10-12]. The 2006 American College of Cardiology/American Heart Association (ACC/AHA) and the 2007 European Society of Cardiology (ESC) guidelines on the management of valvular heart disease concluded that the primary indications for intervention were moderate to severe MS and the presence of symptoms [10,13]. The main indication for intervention in asymptomatic patients was moderate to severe MS and pulmonary hypertension (pulmonary artery systolic pressure >50 mmHg at rest or >60 mmHg with exercise). Overall, the 10-year survival of untreated patients presenting with MS is 50% to 60%, depending on symptoms at presentation [3,4]. In the asymptomatic or minimally symptomatic patient, survival is greater than 80% at 10 years, with 60% of patients having no progression of symptoms [3,4]. However, once significant limiting symptoms occur, there is a dismal 0% to 15% 10-year survival rate [2-4,14]. Once there is severe pulmonary hypertension, mean survival drops to less than 3 years [15]. The mortality of untreated patients with MS is due to progressive pulmonary and systemic congestion in 60% to 70%, systemic embolism in 20% to 30%, pulmonary embolism in 10% and infection in 1% to 5% [4,5]. Conclusion This case provides an excellent educational opportunity for both new and old generation of physicians. It illustrates a typical scenario of altered natural history of rarely seen severe MS in the developed world and emphasises the importance of timely intervention including adequate anticoagulation to prevent thromboembolism, as these can and have proven to be fatal. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 148 References 1. Marcus RH; Sareli P; Pocock WA; Barlow JB. The spectrum of severe rheumatic mitral valve disease in a developing country. Correlations among clinical presentation, surgical pathologic findings, and hemodynamic sequelae. Ann Intern Med 1994 Feb 1;120(3):177-83. 2. Wood P. An appreciation of mitral stenosis, I: clinical features. Br Med J 1954;4870:1051– 63. 3. Rowe JC, Bland EF, Sprague HB, White PD. The course of mitral stenosis without surgery: ten- and twenty-year perspectives. Ann Intern Med 1960;52:741–9. 4. Olesen KH. The natural history of 271 patients with mitral stenosis under medical treatment. Br Heart J 1962;24:349 –57. 5. Roberts WC, Perloff JK. Mitral valvular disease: a clinicopathologic survey of the conditions causing the mitral valve to function abnormally. Ann Intern Med 1972;77:939 –75. 6. Rusted IE, Scheifley CH, Edwards JE. Studies of the mitral valve, II: certain anatomic features of the mitral valve and associated structures in mitral stenosis. Circulation 1956;14:398–406. 7. Carroll JD, Feldman T. Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. JAMA 1993;270:1731– 6. 8. Tuzcu EM, Block PC, Griffin BP, Newell JB, Palacios IF. Immediate and long-term outcome of percutaneous mitral valvotomy in patients 65 years and older. Circulation 1992;85:963–71. 9. Diker E; Aydogdu S; Ozdemir M; Kural T; Polat K; Cehreli S; Erdogan A; Goksel S. Prevalence and predictors of atrial fibrillation in rheumatic valvular heart disease. Am J Cardiol 1996 Jan 1;77(1):96-8. 10. Bonow, RO, Carabello, BA, Chatterjee, K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523. 11. Salem, DN, O'Gara, PT, Madias, C, Pauker, SG. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:593S. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 149 12. Singer, DE, Albers, GW, Dalen, JE, et al. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:546S. 13. Vahanian, A, Baumgartner, H, Bax, J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007; 28:230. 14. Munoz S, Gallardo J, Diaz-Gorrin JR., Medina O. Influence of surgery on the natural history of rheumatic mitral and aortic valve disease. Am J Cardiol 1975;35:234–42. 15. Ward C, Hancock BW. Extreme pulmonary hypertension caused by mitral valve disease: natural history and results of surgery. Br Heart J 1975;37:74–8. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 150 1 No.Figure 1: Chest Xray demonstrating cardiomegaly with prominent aorto-pulmonary window suggestive of pulmonary hypertension typical of mitral stenosis Review of Global Medicine and Healthcare Research . 1 (2010) 151 .Vol. 1 No. 1 (2010) 152 .Figure 2: Transthoracic echocardiogram showing severe mitral stenosis Review of Global Medicine and Healthcare Research .Vol. Figure 3: Computerised tomography of brain showing right middle cerebral artery territory ischemic infarct Review of Global Medicine and Healthcare Research . 1 No. 1 (2010) 153 .Vol. Figure 4: Computerised tomography of abdomen showing bilateral multiple kidney infarcts and persistent delayed nephrogram compatible with decreased transit of contrast through renal parenchyma indicative of diffuse renal parenchymal injury Review of Global Medicine and Healthcare Research .Vol. 1 No. 1 (2010) 154 . Nutritional Compliance Review of Global Medicine and Healthcare Research . Monash University Sunway Campus. Malaysia * Corresponding author: amudha. Common reasons behind lack of compliance amongst HD patients were lack of family support. personal and medical characteristics and self-reported compliance. misinformed calorie intake and unwillingness to change lifestyle. Keywords: Hemodialysis. Amudha Kadirvelu * Tan Sri Jeffrey Cheah School of Medicine. Objective: To assess the level of nutritional (dietary and fluid) compliance among patients in a dialysis centre of National Kidney Foundation (NKF) and to identify the common reasons behind the lack of compliance. Methods: An interview was conducted on 52 randomly recruited patients to obtain their knowledge of dietary and fluid restrictions related to dialysis. Conclusion: Health care providers should be aware of the common factors behind noncompliance in HD patients. Goh Gim Ling. By improving the nutritional status of dialysis patients. financial constraints. co-existing morbidities.my Abstract Background: Nutritional compliance is known to play a pivotal role in enhancing the quality of life for end-stage renal failure patients. Grace Tay Hui Ling.monash. 1 (2010) 155 . 1 No. Patient education with family involvement and concentrated effort towards life style intervention should be part of health care provision to HD patients. nutritional compliance has been reported to be significantly low among haemodialysis (HD) patients. Results: Self-reported nutritional compliance among HD patients was 94% when compared to actual compliance of 48%.Vol. Nutritional compliance of the patients was derived from comparing the resting energy expenditure (REE) with the total calories consumed by a patient in a typical day.edu. Patients at-risk of noncompliance should be identified early to institute appropriate interventional practices. However.kadirvelu@med. Jarret Lim Ian Yeng. the rate of morbidity and mortality associated with nutritional impairment in dialysis patients can be reduced.Nutritional Assessment of Dialysis Patients at a Malaysian National Kidney Foundation Center Lee Chiang Sheng. End-Stage Renal Failure. Seventy five percent of patients from National Kidney Foundation (NKF) were uncertain of their dietary requirement and sought advice to enhance their nutritional status. .. 2007). Dietary compliance has been reported to be significantly poor in dialysis patients (Denhaerynck K.Introduction Nutritional status plays an essential role in enhancing the quality of life for ESRD patients (Locatelli F. The inclusion criteria were patients aged above 21 years. ESRD patients are required to consume a high protein diet (1-1. Patients undergoing dialysis are advised to practice salt free diet. 2003). Counseling sessions on the right diet have been given in the dialysis center by the nurses. et al. renal osteodystrophy as well as coronary artery disease (Block GA et al. et al.. Nutritional compliance of the patients was derived from comparing the resting energy expenditure (REE) with the total calories consumed as reported by the patient in a typical day. data were collected from the study participants. Though protein adds up to uremia. nonadherence to dietary recommendation can result in elevated serum phosphate levels which play an important role in the development of secondary hyperparathyroidism. et al. Materials and Methods In this cross-sectional study. The study population consisted of patients undergoing hemodialysis at the NKF Dialysis Center situated in Klang Valley. The objectives of this study are to assess whether the dialysis patients fulfill the recommended dietary requirement and if not. Nonadherence to fluid restriction can lead to fluid overload and complications such as hypertension and pulmonary congestion. 2004). several surveys have reported protein-calorie malnutrition in up to 40% of this patient population (Mehrotra R. Likewise. Balanced intake of protein is also vital to HD patients.Vol. to investigate the common factors behind it. Treating underlying issues that prevent adequate intake can improve nutrition status.2 g/kg/day) so as to meet the extra demands for body repair functions and immunity (Jones M et al. personal characteristics and self-reported compliance regarding prescribed diet and fluid regimen. However. 2007). 2008). However.. it is not known if the patients adhere to the advice given or whether the advice was adequate. 2001). 2002). Review of Global Medicine and Healthcare Research . 2003). of sound mind and had provided informed consent. about 75% of patients are uncertain of their dietary requirement and seek advice to enhance their nutritional status (Annual General Meeting Report by National Kidney Foundation. Reports indicate that frequently observed gastrointestinal complaints in this patient population are likely to contribute to decreased protein intake and malnutrition (Strid H. and improved nutrition along with compliance to the prescribed regimen has the potential to reduce morbidity for those with ESRD. 1 (2010) 156 . According to the Annual General Report of the Malaysian NKF.. Structured interviews with questionnaires were used to collect information about patients’ knowledge of dietary and fluid restrictions related to dialysis. 1 No. low potassium containing foods and limited fluid intake as it delays the deterioration of glomerular filtration rate thus restricting the progression to ESRD (Luis DD. dietary prescriptions for HD. 1 (2010) 157 . The questions were based on the content of an information booklet that was developed by the Malaysian NKF which is routinely given to HD patients. marital status. The study protocol was approved by the Monash University Standing Committee on Ethics in Research.7 X age) The total calories consumed by each patient on a typical day were calculated by adding up the respected caloric value of each food mentioned by the patient. gender. Results Demographic Distribution 22 Amount of calories required for a 24-hour period by the body during a non-active period. 1 No. Review of Global Medicine and Healthcare Research . Measure of self reported compliance Study participants were asked to rate the level of dietary compliance with based on caloric value during the past week on a 7-point rating scale. fluid allowance and the consequences of noncompliance.8 X age) = (665.5 + 13. 1998).8 X height) . occupation. As REE tends to overstate calorie needs by 5% (Frankenfield DC. REE was calculated as explained by the Harris-Benedict principle. Patient demographic data that were collected included age. number of family members. Patients were classified as compliant if the rating was above ‘4’. comorbidities and duration of HD. religion. recognition of restricted/nonrestricted food.Vol.8 X weight) + (5. The responses were in yes/no format. where responses ranged from ‘0’ (poor) to ‘7’ (excellent).6 X weight) + (1.(4. level of education. family income. and the number of correct responses was totaled to obtain the patients’ knowledge score. REEmale REEfemale = (66. Measure of actual dietary compliance Dietary compliance for each patient was determined by comparing the Resting Energy Expenditure (REE)22 with the total calories consumed by a patient in a typical day.Measure of patients’ knowledge A questionnaire was developed together with an experienced dietician to assess patients’ knowledge of diet and fluid regimens. The questionnaire included items on general knowledge about the ESRD.(6.1 + 9. patients with a caloric intake within 5% of the lower range of REE were accepted as compliant.0 X height) . actual compliance to the dietary advice was found only in 48% of the patients based on the REE by gender. Of these. Forty eight percent of the subjects had coexistent diabetes mellitus and hypertension and 33% had hypertension alone. only 52 patients were eligible and consented to participate. However. Patients’ knowledge The maximum score for the knowledge scale was 100. Self reported and actual nutritional compliance Self reported compliance is defined as the patients’ perception of the appropriate calorie intake whereas actual compliance reflects the true calorie intake acquired from the calculation of the calorie value of food consumed per day. Review of Global Medicine and Healthcare Research . (c) coexisting morbidities. Based on the data collected from HD patients. 71% scored between 70 and 90 and 14% of HD patients obtained a score of <70. 7 were employed and 9 were housewives. 1 (2010) 158 . 1 No. common reasons behind lack of compliance were: (a) insufficient family support. No correlation was observed between the score of dietary knowledge and the measure of actual compliance. Eighteen (35%) patients admitted to be active smokers and alcoholics. unwillingness of the dialysis patients to change their habits and lifestyle was found to be main reason for the lack of compliance (87%). Ninety percent of the patients in the study population indicated that a dedicated dietician may help in the maintenance of nutritional compliance by reinforcing appropriate dietary habits on the subsequent visits.Sixty patients undergoing dialysis in NKF were recruited to participate in the study. age group and co-morbidity.Vol. Thirty six subjects were retirees. Although 94% of the study participants self–reported to be compliant. 35 patients were males and 17 were females. (d) misinterpretation of dietary intake and (e) unwillingness to change lifestyle (Table 1). Of the study population. Eight subjects (15%) had a score of >90. (b) financial constraints. Financial constraints (42%. n=45) Discussion The main finding of this study is the lack of nutritional compliance in 52% of patients undergoing haemodialysis although.Figure 1: Actual and self reported dietary compliance among haemodialysis patients Table 1: Common Reasons to Patients’ Non-compliance in Dietary Intake 1. Such difference in the prevalence rate might be attributed to the different criteria used for measuring compliance and different confounding factor such as culture and type of food consumption. effects of Review of Global Medicine and Healthcare Research . Unwillingness to change lifestyle (87%. 1993). n=38) 5. 1982). possibly due to the depressed appetite. 1 (2010) 159 . The patients in our study were observed to be consuming lesser calories as compared to the recommended caloric intake as stated by the REE. Co-existing morbidities (19%. This is significantly less compared to previous studies of reported compliance ranging from 50-85% (Cummings et al. Misinformed of dietary intake (73%.Vol. n=31) 2.. 1 No. n= 22) 3. n=10) 4. Lack of family support (60%. 96% of participants self-reported to be compliant with the prescribed dietary regimen. Several studies have also stated that dialysis patients’ nutrient intake is lower than recommended (Hakim RM. 1 No. However. 2003). Review of Global Medicine and Healthcare Research . Previous studies have reported contradictory results on the role of family support on compliance level (Christensen et al. Identifying the underlying issues early and implementing appropriate interventional strategies can improve nutrition status. The health care professional should evaluate the perception of the patient towards the illness and assess carefully the role of the family in the patient’s treatment program.Vol. In addition. lack of family support and dietary knowledge are the common factors behind lack of dietary compliance in our patients. and has the potential to reduce morbidity for those on chronic haemodialysis. it should be admitted that these factors are common pitfalls of inadequate control of any chronic illness and an uphill challenge for health care community. Our results also indicate that patients’ awareness do not correlate with compliance. Cameron. 1999). 1992. This suggests that more communication and explanations on the interpretation of compliance behavior as well as dietary advice are required to assist the patients in achieving the desired level of compliance. before attempting to steer the patients towards better compliance. Patient’s denial of their condition may also contribute to higher self reported compliance rate (Yanagida EH et al.. This suggests that knowledge alone may not be sufficient in enhancing the level of compliance among dialysis patients.uremia (Bergstrom J. As reported earlier. Recent studeies have reported that patient councelling centered on dialysis compliance. Patient’s self reported compliance rate was significantly higher than the measured actual compliance in our study population. Inadequate dietary awareness may also lead to false sense of satisfaction that they are consuming enough food to fulfill their energy requirement. This study has a few limitations. the usage of predictive equation for REE as well as the calculation of the typical dietary intake for each patient provides only estimates but not true figures.. It is also vital that these strategies are reinforced and monitored at regular intervals by the health care team working towards the patients’ empowerment of self management. Unwillingness to change lifestyle. it may be due to patients’ fear of embarrassment or lack of knowledge of their recommended food source (Hudson et al. 1996). 1994).. 2009). 1995). These issues could be overcome by increasing awareness among the health care providers and the family members of the importance of working together in the management of HD patients. 1994.. diet and medications are effective strategies to improve the quality of liffe and awareness in ESRD (Thomas D. 1981). This is supported by other studies that indicate no relationship exists between knowledge and compliance (Chan & Molassiotis. 1 (2010) 160 . 1994) along with loss of albumin and amino acids during dialysis (Ikizler TA. Positive patient staff relationship is known to increase self reported compliance efforts and behaviours of patients and also enhanced self-efficacy capacities (Zrinyi M et al. Conclusion Dietary management is an essential component for patients with EDSR. The sample size was relatively small (n = 52). J Am Soc Nephrol. P. Rich. Lazarus JM. Block GA.C. (1992). Ikizler TA. Mamoun H. Becker. (1999).M. Levin N. Gregory. Levin. Amino acid and albumin losses during hemodialysis.. 15: 313–3.. 7. 16: 222-235. M. Malaysia (2007). (1994)..C. Porcelli..References 1. Kirscht. Turner.J. Lowrie EG. J Am Soc Nephrol. Anderstram B. Patient compliance: recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. (1996). Parker Ha. Annual General Meeting Report by National Kidney Foundation. 6. Denhaerynck K (2007)..P. B. Prevalence and consequences of non-adherence to haemodialysis regimens. Holman.15:2208-2218. 21: 125-137.. C. 46: 830-837. Ofsthun N.W. Journal of Advanced Nursing 30. 3. 5: 488A. J Am Soc Nephrol. (1982). Bergstrom J. 6: 1386-1391. Patient education: renal osteodystrophy and adequacy of dialysis. 12. Hakim RM.M. Ikizler TA.A. Middle molecules (MM) isolated from uremic ultrafiltrate (UF) and normal urine induces dose-dependent inhibition of appetite in the rat [abstract]. Greene J. M. (1995). T. (1993). 415–417. 10. The relationship between diabetes knowledge and compliance among Chinese with non-insulin dependent diabetes mellitus in Hong Kong... A. J. 1 No. Hakim RM. 11. Chan.. Smith.24:244–250. Journal of Behavioral Medicine. Sodersten P. (1994). C. 9. Journal of Advanced Nursing. Family support. N. K. Malnutrition in hemodialysis patients.W. Spontaneous dietary protein intake during progression of chronic renal failure. Medical Care 20.Vol.. moratlity and morbidity in maintenace haemodialysis. Flakoll PJ. Parker RA. Am J Kidney.M. Chertow GM (2004). Cummings.. 5. 1 (2010) 161 . Hudson. Molassiotis. 8. 4. Am J Crit Care. Mineral metabolism. J. physical impairment. (1994). Cameron. Hakim RM. H. American Nephrology Nurses Association Journal 21. A. and adherence in hemodialysis: an investigation of main and buffering effects. 431–438.W. Wingard RL. Klassn PS.H. 567–580. Christensen. 2. Y. Review of Global Medicine and Healthcare Research . Kidney Int. Psychosocial factors affecting adherence to medical regimens in a group of hemodialysis patients. M. Brockstein. 1 No. Bustamante J (2008). 7(3):181-184. Parrish CR (2004). Thomas D. 18:1863-1873.Drueke B. Streltzer J. 15. 43(3): 271-280. 1 (2010) 162 . Heimburger O. Simren M. Dietary self-efficacy: determinant of compliance behaviors and biochemical outcomes in haemodialysis patients. Digestion. Psychosomatic Medicine. Nutritional status in dialysis patients: a European consensus Oxford Journals. 14.Vol. Review of Global Medicine and Healthcare Research . Nephrol Dial Transplant. Practical gastroenterology. Juhasz M. Siemsen A. Mehrotra R. Nutritional management of maintenance dialysis patients: why aren’t we doing better? Ann Rev Nutr. Cannata-Andia B. Denial in dialysis patients: relationship to compliance and other variables.Nutrition in Renal Failure: Myths and Management. Francis B and Mohanta GP (2009).13. (1981). Joseph J. Balla J. Patients with chronic renal failure have abnormal small intestinal motility and a high prevalence of small intestinal bacterial overgrowth. 67(3): 129-137. et al (2003). Stotzer P. 17. Locatelli F. Fouque D. 20. Strid H. Horl H. 16. Ritz (2002). Effect of patient counseling on quality of life of haemodialysis patients in India. Yanagida EH. 20:41-59. and 17(4):563-72. Luis DD. 21: 343. 19.379. 18. Nutritional aspects in renal failure: Nefrologia and 28(3):339-348. Zrinyi M. Kopple JD (2001). Pharmacy Practice. et al (2003). 0% students were anaemic. rich in green leafy vegetables and fruits as nutritional anemia is totally preventable. Hemoglobin estimation was performed by Sahli’s Haemoglobinometer and observations were interpreted as per the WHO criteria. Various socio-demographic characteristics like age. sex. India Email: drpiyushkalakoti@gmail. The data was analyzed by SPSS Statistical software and chi-square test of significance was applied to assess the significance level by calculation of p-value of the observations. Loni. 1 (2010) 163 . Body Mass Index Introduction Review of Global Medicine and Healthcare Research . India Abstract Background: Nutritional anemia is very much prevalent and largely undiagnosed among students in Professional Institutes. India Nadeem Ahmad Department of Community Medicine Rohilkhand Medical College & Hospital. 32. social class. out of which 44. 25.8%) of anaemic students were undernourished as per their Body Mass Index. 1 No. Conclusion: Hemoglobin estimation of students at the time of entrance to Medical Colleges should be done. Results: In the present study on 100 Medical students. Methods: The study was done on 100 MBBS students.Nutritional Anemia in Medical Students Piyush Kalakoti Rural Medical College Pravara Institute of Medical Sciences. and infections are the etiological factors for nutritional anaemia.com Rubeena Bano Department of Physiology Rohilkhand Medical College and Hospital. Majority (81.0% were girls and 20. Iron and folic acid tablets and deworming drugs in therapeutic doses should be provided to anemic students. Keywords: Nutritional Anemia. Objectives: To study nutritional anemia and its’ correlates among the Medical Students of Rural Medical College.0% students had mild anemia.Vol.0% boys. Hemoglobin level. dietary habits. The data was collected on a predesigned and pretested questionnaire. The students should be motivated and educated to take balanced diet. there are relatively few published studies on the prevalence of anaemia in medical students and probably none in boys. Exclusion criteria: 1. In a study by Kapoor and Aneja 7(from public and government schools in Delhi. lactating mothers. and none from the town of Loni. By far the most frequent cause of nutritional anemia is iron deficiency. anaemia among adolescent girls was as high as 50. It has been defined by WHO as "a condition in which the hemoglobin content of blood is lower than normal as a result of a deficiency of one or more essential nutrients. Materials and Methods Type of Study: Cross Sectional Study Participants: 100 Medical Students Inclusion criteria: 1.Nutritional anemia affects all age and sex groups in India. 1 No.Compared to the vast amount of work done in pregnant mothers and young children. Sampling technique: Purposive sampling Study Setting: Rural Medical College & Pravara Rural Hospital (PRH) Statistical analysis: SPSS Statistical software.8%. Anemia is particularly severe among pregnant women. 2. hypertension.) Those who did not volunteer to give blood for examination.Iron deficiency anemia is a major nutrition problem in India and many other developing countries4. . 3. 1 (2010) 164 . Review of Global Medicine and Healthcare Research . Nursing. The incidence of anemia is highest among women and young children. regardless of the cause of such deficiency"2.) Students from other allied health branches like Dental.) Those adolescents with chronic illness or receiving long-term drugs and needing hospitalization in the last two weeks before the study were excluded. Iron deficiency anemia is the most common micronutrient deficiency in the world affecting more than 700 million persons.) Students without any systemic disorders like diabetes. 2.Nutritional anemia is a disease syndrome caused by malnutrition in its widest sense2. adolescent girls and pre-school age children1. In addition. Statistical methods: Chi-square test of significance. varying between 60 to 70 percent6. Physiotherapy.Vol.) Students enrolled in MBBS from first year to final year. bleeding diathesis. and less frequently folate or vitamin B123. many subjects have iron deficiency without anaemia5. Anemia is established if the hemoglobin is below the cut-off points as recommended by WHO8.0078) on applying chi-square test of significance (table 1). Majority of students had mild grade of anemia (25. Finally 100 medical students were included in the study & their hemoglobin estimation was performed by Sahli’s hemoglobin meter and results interpreted as per the WHO criteria. Cut-off points for the diagnosis of anemia.Methodology The present study was conducted on 100 Medical students to study the magnitude of nutritional anemia in them. The relation between the dietary pattern of the students & anemic status was highly significant with p-value<0. Majority (81.0% students were anaemic.005432) (table 5). Category Adult males Adult Females (non-pregnant) Venous Blood (g/dl) 13. Almost all the non vegetarian student.0%).Most of students were vegetarians (94. Mean Corpuscular Volume (MCV).001 (p-value= 0.9. edema. The relation of anemia with under nutrition was highly significant since p-value < 0. with 44. except one was found to be anemic.Vol.0%).01 (p=0. The association between normal hemoglobin level and anaemic status was statistically highly significant p-value < 0.0% girls and 20. None had severe anemia (table 2). Results In the present cross sectional study on 100 Medical students.0 12. lymphadenopathy. which was more common in girls (36.01 (p=0. The anthropometric measurements (weight and height) were made by single observer eliminating inter observer variability and errors. Statistical analysis was done by chi-square test of significance by SPSS Statistical software. hyperpigmentation. non-vegetarian) was noted.0% boys.00064) (table 3).8%) of anaemic students were undernourished as per their Body Mass Index. 1 (2010) 165 .0%) though only 51.0% were taking green leafy vegetables and fruits Review of Global Medicine and Healthcare Research . bleeding spots and signs of vitamin deficiency and was noted on a predesigned proforma.0%) than boys (14.0 The students detected as anaemic were further investigated by laboratory tests like Packed Cell Volume (PCV). Physical examination was done to rule out any systemic abnormality. A detailed general physical examination was done to look for pallor. 32. Mean Corpuscular hemoglobin (MCH). 1 No. family structure and diet consumed (vegetarian. icterus. A social demographic profile including parents’ education. Mean Corpuscular hemoglobin Concentration (MCHC) to rule out non-nutritional causes of anemia. 0%) 9 (81.7%) 0 (0.0%) 0 (0.8%) 21 (41. highly significant association Review of Global Medicine and Healthcare Research .00064).0%) 15 (15. None of adolescents had icterus.0%) 100 (100.0%) 23 (23.0%) 7 (7. (%) Under nutrition (< 18.regularly.0% students were taking nutritional supplements.Vol.0.0%) Chi-Square test.0%) Chi-Square test. (table 5). 1 (2010) 166 . iron tablets. (%) 28 (56. (%) 68 (68.0 %) Total 50 (100. p< 0.0%) Girls No.2%) 2 (8. Associated micronutrient deficiencies included xeropthalmia in 18 and knuckle hyperpigmentation in two adolescents and all of them were anaemic.0) Girls No.0%) Total No. p< 0.0%) 50 (100.9 kg/m2) Obese (>= 30 kg/m2 ) Total 11 (11. (%) 28 (56.0%) 4 (8.9 kg/m2) Overweight (25.0 %) Hemoglobin Anemic 10 (20.0%) 51 (51.0%) 50 (100. of Students No.01 (p=0. highly significant association Table II: Sex wise grading of severity of Anemia (WHO Criteria) Grading Boys No.001 (p-value= 0. Only 7. lymphadenopathy.0%) 25 (25.29. Table I: Sex wise distribution of anemia among students Status of Boys Anemia No. edema or bleeding spots.0%) 0 (0.0%) 7 (14.0%) 100 (100. 1 No.5 – 24. multivitamins etc.0%) 3 (6.5 kg/m2) Normal (18. The possible role of infections and socio-economic status was not significant.0078).0%) 50 (100.0%) 32 (32. (%) 40 (80.0%) Normal Mild Moderate Severe Total Table III: Association of nutritional status with anemic status of students Body Mass Index (BMI) (kg/m2) Total no.0%) 18 (36. (%) Anemic Students No.0%) 0 (0. (%) Normal 40 (80.0%) 22 (44. 1% with severe anaemia (Hb <7 g/dL) in 7.Table IV: Association of dietary pattern with anemic status of students Dietary Pattern Vegetarians Non-Vegetarians Total Anemic No. the prevalence of anaemia in girls has been found to be around 2530%13. 10 g/dl high doses of iron or blood transfusion may be necessary. studies on prevalence of anaemia from different states of rural India.14 in a government school based study from middle socioeconomic group of North East Delhi reported a prevalence of anaemia as 45%.Iron deficiency can arise either due to inadequate intake or poor bioavailability of dietary iron or due to excessive losses of iron from the body. If hemoglobin is between 10-12 g/dl. Similarly. the other interventions are like Iron and folic acid supplementation and other strategies such as changing dietary habits.Vol. 94 06 63 46 51 % 94. et al. 1 (2010) 167 . Non.01 (p-value= 0. young children and during pregnancy and lactation.0 51. Total 27 5 32 67 1 68 94 6 100 Chi-Square test.0 63. Recent data from the District Nutrition Project (Indian Council of Medical Research) in 16 districts of 11 states.005432). In some of the less developed countries like Peru. 1 No.Aggarwal. reported a prevalence of anaemia from 46% to 98% 15-17.1%11. highly significant association Table V: Diet pattern of students. If the anemia is "Severe".0 07 7. Indonesia and Bangladesh. control of parasites and nutrition education9.0 6. on prevalence of anaemia in non pregnant adolescent girls (11-18 years) showed rates as high as 90. It is estimated to affect nearly two-thirds of pregnant and one-half of non pregnant women in developing countries10.0 46.0 Discussion Nutritional anemia is a worldwide problem with the highest prevalence in developing countries. the prevalence of anaemia in adolescent girls aged 11-18 years was found to be about 68. In a recent study conducted in semi urban Nepal. It is found especially among women of child-bearing age. (Multiple response table) Dietary pattern Vegetarians Non-vegetarians Only mess food Junk foods/snacks Fruits/Green leafy vegetables regularly Nutritional supplements / Iron tablets /Vitamins No. p< 0. An estimation of hemoglobin should be done to assess the degree of anemia.8%12. Although most habitual diets contain adequate Review of Global Medicine and Healthcare Research .Anemic No. 1 (2010) 168 . Nutritional disorders in adolescent girls. Ser. World Health Statisics Quarterly. WHO Statistics. 1982. No.0% students were anaemic. only Sahli’s Haemoglobinometer was used. No other methods were used to determine hemoglobin level of the blood. 22 (4) 235. WHO. Biennial report. 2. of Med. Review of Global Medicine and Healthcare Research . Students should be motivated and educated to take balanced diet. 1971. Techn. Sood SK and U. E. India. poor diet and under nutrition as compared to males. 1990. 1984. 7. Some of the other factors leading to anemia are malaria and hookworm infestations. Nutritional anemia especially iron deficiency anemia is more prevalent among females especially adolescent girls due to causes like menstrual blood loss. Women lose a considerable amount of iron especially during menstruation. 1984. WHO. No. 1968. 1986. Nutritional anemia is easily preventable as well as treatable and the available control measures are affordable. New Delhi. Rep. Ser. References 1. WHO. 29: 69-973.. 8. Study Limitation For Hemoglobin estimation. 405.Rusia. 9. Rep. Royston. Recommended dietary intake for Indians. 35:52. 1 No. Ann of Nat Acad. Also iron store estimation by detecting serum ferritin by ELISA was not done Conclusion In the present cross sectional study on 100 Medical students... 10. 477. Vol. Techn. Sci. 32. WHO. Aneja S. Ser. 4. Kapoor G. ICMR. 1982. rich in green leafy vegetables and fruits. WHO. WHO. This poor bioavailability is considered to be a major reason for the widespread iron deficiency19. Tech. Guidelines for drinking quality. 1 P 55 Geneva WHO. 14 35:52. 5.amounts of iron only a small amount (less than 5 per cent) is absorbed18. Indian Paediatric 1992. Iron and folic acid tablets and deworming drugs in therapeutic doses should be provided to the anaemic students. 3. Periodical and routine health check-up and Haemoglobin estimation of the students at the time of entrance to Medical Colleges should be done. The work of WHO. 6. 713. 1980-1981. 1982. Rep.Vol. Combating anemia in adolescentgirls: a report from India. 19. 13. Raghuvanshi RS.Anaemia prophylaxis in adolescent school girlsby weekly or daily iron-folate supplementation.Vol. Anemia in adolescent girls: A preliminary report from semi urban Nepal. WHO. Sixth Report World Health situation. Gupta P.Indian Pediatr 2003. Rajaratnam A. 40: 296-301. 8: 73-75. Arch Pediatr Adolsc Med 2002.13: 1-3. Prevalence of anaemia and hookworm infestation among adolescent girls in one rural block of Tamil Nadu. 1 No. Weekly vs daily iron and folic acid supplementation in adolescent Nepalese girls. vol.11. 16. 1 (2010) 169 . Indian J Pediatr 2003. p 131-140. 70: 299-301. Singh P. 2002. Techn. 1980. vitamin A and iodine deficiencies among adolescent pregnant mothers. 14. 503.Prevalence of iron. New Delhi: Indian Council Medical Research. Shah BK. Mothers Child 1994. Rep. Bisht H. Singh P. Teoteja GS. 156: 131-135. 1. Som M. 1972. Gupta P.. Kapil U. Sampath Kumar V. Shah BK. Ser. WHO. 15.Indian Pediatr 2002. 39: 1126-1130. Gomber S. . Indian J Matern Child Health 1997. Micronutrient profile in Indian population (Part-I). 18. Pathak P. 17. Kanani S. Agarwal KN.   Review of Global Medicine and Healthcare Research . 12. Aim of the study: To determine the risk factors of device-related infection in nurse practice performed invasive procedures: patients’ care with tracheostomy or intubation tube. More than 50% of device-related infections are due to the combined effect of the patient's own flora and invasive devices. 1 No.Vol. or urinary tract infection is significantly associated with device exposures. bloodstream infection. 1 (2010) 170 . Latvia Inga Millere Faculty of Nursing Riga Stradiņš University.platace@inbox. Review of Global Medicine and Healthcare Research . The spread of device-related infection cases in ICUs is influenced by the number of invasive procedures as well as the severity of the patients' condition and the environment of the ICU.The risk factors of device-related infection in nurse practice Diana Platace Faculty of Nursing Riga Stradiņš University.lv Juta Kroica Department of Biology and Microbiology Rigas Stradiņš University. Latvia Aigars Reinis Department of Biology and Microbiology Rigas Stradiņš University. Latvia Abstract Background: Healthcare associated infections (HAIs) concern 5-15% of hospitalized patients and lead to complications in 25 to 33% of those patients admitted to intensive care units (ICUs). Latvia E-mail: diana. In the NNIS (National Nosocomial Infections Surveillance System). Latvia Ilze Klava Faculty of Nursing Riga Stradiņš University. Latvia Valentina Kuznecova Department of Biology and Microbiology Rigas Stradiņš University. the risk of acquiring nosocomial pneumonia. peripheral venous catheter and urinary catheter insertion and care at the time. 2009). The most common device-related infection pathogens are Staphylococcus aureus. excessive workload and insufficient knowledge of the care-givers. tracheostoma care Introduction The risk of device-related infection. Serratia. The immune systems of critically ill patients are in a severity state which increases the probability of beneficial conditions for a colonization by pathogenic microorganisms due to invasive procedures (Graves et al. b) with a swab. Enterobacter. resulting in persistent infections that are difficult to treat (Donlan 2008. using the quantitative research method: questionnaire (n=288). has forced medicine to accept the necessity for infection control.Vol.Material and methods: The research was carried out in the ICUs and in the surgical units of Latvia's regional multi-profile hospitals (n=2). Conclusions: The main risk factors of device-related infection in nurse practice are: the lack of unified nursing protocols. device-related infection.3% of the observed cases and urinary catheters only in 27% of the cases. 1 (2010) 171 . aseptic and antiseptic mistakes. 2007). During the research it was discovered that many respondents (average 18%) hadn't been introduced to the hospital-developed guidelines. Microbiological tests showed a high level of bio-contamination during invasive procedures: the amount of microorganisms on the nurses' hands exceeded acceptable levels sixteen-fold. and medium to high levels of biocontamination were discovered on patient's changed bed linen as well as in nurses' hair and their work wear. tracheostoma or intubation tube) disrupts the natural defence mechanisms by itself. and c) with catheter sedimentation method. Weigel et al. intravascular catheters were changed in 83. peripheral venous catheter. Klebsiella. all embedded in a thick matrix of exoglycocalyx (Stoodley et al. peripheral venous catheter. Les than half of the observed nurses adhered to the principles of hand hygiene and appropriate visual appearance during invasive procedures. the action of inserting an invasive device (urinary catheter. Furthermore. and qualitative research methods: clinically structured empiric plan (n=85) and microbiological tests (n=92): a) with a Count-Tact applicator and a special culture medium. more than anything else. urinary catheter. as well as a high level of biocontamination in the units. More than 50% of invasive device-related infections are due to the combined effect of the patient's own flora and invasive devices (Madeo et al. 1 No. This tendency was especially pronounced in the case of insertion and handling of peripheral venous catheters. Scanning electron microscopy of an infected devices shows the surface covered by an amorphous biofilm containing numerous host proteins and microcolonies of the infecting organism. Results: A common problem in ICUs and in surgical units is the lack of unified nursing protocols on performing invasive procedures. bacterial cells evade the host immune response and survive antimicrobial chemotherapy. Within this matrix. Keywords: Invasive devices. Candida Review of Global Medicine and Healthcare Research . During 72 hours or less. 2002). 2008). Staphylococcus epidermidis. Escherichia coli (Wilson 2006. a clinically structured empiric plan was developed. tracheostomy (n=20) or intubation tube (n=20) as well as the nurses' work environment in the ICUs and in the surgical units (sufficient material and technical means. b) the swab method was used for determination the microbiological contamination of the equipment and the nurses hands. Citrobacter freudii. for insertion and patients’ care with urinary catheters in 77 cases (87. The research was performed in the intensive care units (ICUs) and in the surgical units of Latvia's regional multi-profile hospitals. the presence or lack of nursing protocols. The obtained data was analysed with the help of the following software: SPSS 16.0 for MS Windows. Interpretation of the Count-Tact method results was performed according to the risk level present and the colony forming unit (CFU) count on a 25 cm2 surface. To determine aseptic invasive procedures tehnique and patients’ care with peripheral venous catheter (n=30). χ2 test and MS Office Excel. Confidence Interval Analysis (CIA).5%.Vol. c) the catheter sedimentation method was used for determination the microbial contamination on the invasive devices. The results showed that a nurse from the surgical units takes care of 18 to 40 patients per day and 2 to 3 patients per day in the case of ICUs. urinary catheter (n=15). peripheral venous catheter and urinary catheter insertion and care at the time. There were not available hospital-developed guidelines for patients’ care with tracheostomy or intubation tube in the ICUs. the number of nursing staff in the units and the visual appearance of the nurses). nurses' work wear and patients' bed linen. Results In total were analysed 288 questionnaires. work surfaces. The quantitative research method: questionnaire (n=288). Aim. 1 No. The obtained results by clinically structured empiric plan showed that adherence of these guidelines in nurses’ daily work was limited. material and methods The purpose of the study to determine the risk factors of device-related infection in nurse practice performed invasive procedures: patients’ care with tracheostomy or intubation tube. 77/88). a structured questionnaire was developed. The obtained results by questionnaire showed that most of the nurses were informed about the hospital-developed guidelines for insertion and patients’ care with peripheral venous catheters in 77 cases (77%. Corynebacterium. To determine the nurses knowledge as well as practical skills performing patients care with invasive devices. The samples taken with the aim of identifying bacterial species present were put on selective culture mediums. 1 (2010) 172 . and qualitative research methods: clinically structured empiric plan (n=85) and microbiological investigations (n=92) were used. By means of microbiological investigation the contamination level of the ICUs and surgical units was determined during invasive procedures: a) Count-Tact applicator and a culture medium specially selected for this method was used for determination the bio-contamination level of the work environment. 77/100). Stamm 1998). MMWR 2002. Pseudomonas aeruginosa. Peripheral vein Review of Global Medicine and Healthcare Research .albicans. catheterization in 16 cases (53.3%; 16/30) and urinary catheterization in 5 cases (33.3%; 5/15) were recorded in the ordination list, the patient's care protocol or the manipulation journal. However patients’ care with tracheostomy or intubation tube were not recorded (40/40; 100%) in unified nursing protocols of ICUs. Les than half of the observed nurses adhered to the principles of hand hygiene performed invasive procedures: during the peripheral vein catheterization only 3 nurses (10%; 3/30) treated their hands before putting on gloves and 10 nurses (33.3%; 10/30) treated their hands after removing the gloves, but none of them used an adequate technique for treating their hands. By comparison, when dealing with insertion of urinary catheters, 3 nurses (13.3%; 3/15) treated their hands before putting on gloves and 6 nurses (40%; 6/15) treated their hands after removing the gloves, and 3 of them (13.3%; 3/15) used adequate hands treatment techniques. In case of patients’ care with tracheostomy or intubaction tube, 20 nurses (50%; 20/40) treated their hands before putting on gloves and 20 nurses (50%; 20/40) treated their hands after removing the gloves, and 14 of them (35%; 14/40) used adequate hand treating techniques (Figura 1). In 23 cases (77%; 23/30) of the observed peripheral vein catheterization and in 4 cases (27%; 4/15) of urinary catheterization, as well as in 14 cases (70%; 14/20) performed pacients’ care with tracheostomy or intubation tube, there was jewellery on the nurses' hands (Figura 2). Performed tracheobronchial suction the protective means such as disposable masks were used in 8 cases (40%; 8/20) of tracheostoma care and in 5 cases (25%; 5/20) in patients’ care with intubation tube, sterile gloves were used in 4 cases (20%; 4/20) of tracheostoma care and in 6 cases (30%; 6/20) in patients’ care with intubation tube, goggles used in 4 cases (20%; 4/20) of tracheostoma care as well as in 4 cases (20%; 4/20) in patients’ care with intubation tube, and protective apron used in 7 cases (35%; 7/20) of tracheostoma care and in 2 cases (10%; 2/20) in patients’ care with intubation tube. The results of tracheobronchial suction showed that disposable catheters were changed in 34 cases (85%; 34/40), but oral hygiene before tracheobronchial suction was provided in 28 cases (70%; 28/40). According to the questionnaire, 79% (79/100) of the respondents agreed that peripheral venous catheters have to be changed once in at most 72 hours but only 40.9% (36/88) of the nurses agreed that the urinary catheters has to be changed in similar intervals. The observation study results showed that change of the peripheral venous catheters no rarer than once in 72 hours was observed in 25 cases (83.3%; 25/30), the timely changing of urinary catheters - in 4 cases (27%; 4/15) (Figura 1). Microbiological investigation with the Count-Tact method of samples taken from the hands of ICU nurses carried out invasive procedures determined that the number of microorganism colonies exceeds the acceptable levels (the permissible level on 25cm2 ≤ 5 CFUs) as much as nine-fold to sixteen-fold (44 colony forming units (CFUs) and 83 CFUs; n=2). Similarly, the bio-contamination of the hands of surgical nurses also exceeded acceptable levels (permissible level on 25 cm2 ≤ 50 CFUs) as the 25cm2 surface produced more than 100 colony forming units (128 CFUs and 241 CFUs; n=2) (Table 1). There was different contamination between clinic A and B, which was confirmed by an analysis of statistics (χ2=36,349; p<0,01). Microbiological investigation of the patients' changed bed linen and nurses' work wear using the Count-Tact method revealed a medium to high level of bio-contamination in pacients’ care with tracheostomy or intubation tube and performed urinary catheterization (Table 1).The number of bacteria colonies on nurses’ work wear exceeded the norm in 44 of the investigated cases (78.5%; 44/56), Mucor fungi were found in 44 cases (78.5%; 44/56) and the bacteria colonies count in the nurses' hair exceeded Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 173 permissible levels in 48 cases (85.7%; 48/56). There was different contamination between clinic A and B, which was confirmed by an analysis of statistics (χ2=340,357; p<0,01). The microbiological results of the urinary catheters' connection with the collectors 72 h and 7 days after the insertion of the catheters showed that in 6 cases (50%; 6/12) pathogenic microorganisms like the E. coli, β haemolytic Streptococcus spp. and fungi, like the C. albicans were identified. The research performed with the swab method and by catheter sediment analysis 72 h and 96 h after the insertion of a peripheral venous catheters revealed the presence of such pathogens as Pseudomonas aeruginosa, Staphylococcus aureus in the sterile zone of the peripheral vein catheter in one out of four cases (25%). Likewise the analysis of the urinary catheters’ sediments showed presence of at least one and in some cases several of the following pathogens as S.aureus, P.aeruginosa, E.coli, β haemolytic Streptococcus spp. and fungi like C.albicans and C.tropicalis in 6 cases (100%; 6/6) both after 72 hours and 7 days of the insertion of the catheter. change of catheter following instruction appropriate gloves use adequate hands treatment technique hands tretment after gloves use hands tretment before gloves use nursing protocols use 0 20 40 60 80 100 patients care with tracheostomy or intubation tube urinary catheterization peripheral vein catheterization percent (%) Figure 1: Aseptic patients’ care with invasive devices (n=85). Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 174 accessible hands disinfectant changed footwear appropriate appearance of nails (short, without polish) absence of jewellery patients care with tracheostomy or intubation tube urinary catheterization peripheral vein catheterization appropriate work wear 0 20 40 60 80 100 percent (%) Figure 2: Appropriate visual appearance of nurses in patients’ care with invasive devices (n= 65). Table 1: Bio-contamination measurement with Count-Tact method in patients’ care with invasive devices (n=10) Object of microbiological investigation Surgical nurse’s hands in clinic A Surgical nurse’s hands in clinic B ICU nurse’s hands in clinic A ICU nurse’s hands in clinic B Patient’s bed sheets in clinic A Patient’s bed sheets in clinic B Nurse’s work wear in clinic A Nurse’s work wear in clinic B Sterile equipment in clinic A Sterile equipment in clinic B CFU on a 25 cm2 241 128 44 83 1000 15 100 69 0 0 Mean 65,3 34,7 34,6 65,3 98,5 1,4 59,1 40,8 0 0 95% CI limits 60,3- 70,0 30,0- 39,7 27,0- 43,2 56,7- 73,0 97,5- 99,1 0,9- 2,4 51,6- 66,3 33,7- 48,4 0 0 Discussion Every nurse can play a significant role in minimizing the risk of device- related infections. The identification of risk factors and prevention of device-related infections are the key procedures in quality of patients care (Wilson 2006). The study of the risk factors in patients’ care with invasive devices help to identify areas of clinical practice that could be improwed and to optimize the hospital work, the use of more efficient and financially advantageous methods for prevention of device-related infections. This is the first report on risk factors of device-related infection in Latvian Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 175 nurse practice. Obtained results reflect problem areas in patients’ care with invasive devices and necessity for guidelines creation and implementation in nurses’ practice, especially, guidelines based to visual appearance of nurses and development of unified nursing protocols for patients’ care with invasive devices. As shown by several studies, a significant role in limiting the risk of device- related infections are care guidelines and nursing protocols for the development and implementation in practice (Gotelli et al, 2008; Loeb et al, 2008; Morris & Hong Toy, 2008; Quattrin et al, 2004; Saint et al, 2009; Spencer & Clifford, 2009). Our results showed that a common problem in ICUs and in surgical units is the lack of unified nursing protocols on performing invasive procedures. Patients’ care with invasive devices were recorded in the ordination list, the patient's care protocol or the manipulation journal. Our study, like observational study by Hugonnet (2007), confirmed another important risk factor in the nurses' practice that is the excessive workload in nurses’ daily work, which significantly exceeded the limits of patients’ care (1-2 patients per nurse in ICU and 15 patients per nurse in surgical units). While the leading measure for quality of patients care is a hand hygiene that essential reduce device- related infections, more and more, the authors support the principle of adequate hand hygiene (Allegranzia et al, 2009; Farmer 2009; Kusachi 2006; Weinstein 1998). In our studies, less than half of the observed nurses adhered to the principles of hand hygiene as wel as microbiological investigations showed a high level of biocontamination in patients’ care with invasive devices. The amount of microorganisms on the nurses' hands exceeded the acceptable levels sixteen-fold, and medium to high levels of bio-contamination were discovered on patient's changed bed sheets as well as in nurses' hair and their work wear. Our data demonstrate some evidence that the pathogenic flora (β haemolytic Streptococcus, E. coli) remains unchanged both 72 h and 7 days after the insertion of the urinary catheter. It leads to the conclusion that the urinary catheter is contaminated during the first 72 hours after insertion and should be changed at least once every 72 hours instead of once a week as indicated by the manufacturer of the catheters. Conclusions of epidemiologic research are inconsistent when evaluating the effect of changing intravascular or urinary artificial implants less frequently than once every 72 hours (Moureau 2009; Morris et al, 2008; Ramritu et al, 2008). Some authors point out that 24 hours is a sufficient period of time for a biofilm to form on the catheter surface, consisting of microorganisms such as Staphylococcus epidermidis, Staphylococcus aureus, Pseudomonas aeruginosa, etc. making the catheter a source of bacteremia (Donlan 2001; Ferrieres et al, 2007). The most of devices-related infections are not severe and self-limiting, therefore microbiological investigations in such cases are not performed routinely in regional multi-profile hospitals of Latvia. This study showed that microbiological investigation is essential in patients’ care with invasive devices and ensure the checking of hospital environment for better prevention of devices-related infections. Conclusions The main risk factors of device- related infection in nurse practice are: 1) lack of unified nursing protocols on performing invasive procedures in the intensive care Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 176 units and in surgical units, 2) disregard of basic principles of hand hygiene while carrying out invasive procedures, 3) antiseptic and aseptic mistakes during patients' care with invasive devices, 4) excessive workload of nurses working in ICUs and in surgical units, 5) high levels of microbiological contamination during invasive procedures, including medium to high levels of bio-contamination of changed patients' bed sheets, nurses' work wear and hair. Acnowledgements: This study has been supported by the project of Europen Social Fond (ESF). References Allegranzi, B., & Pittet, D. (2009). Role of hand hygiene in healthcare-associated infection prevention. The Journal of Hospital Infectio, 73, 305-15. Donlan, R.M. (2001). Biofilms and Device-Associated Infections. Emerging Infectious Diseases, 7, 277-281. Donlan RM. (2008). Biofilms on central venous catheters: is eradication possible? Current Topics in Microbiology and Immunology, 322, 133-161 Farmer, J.C. (2009). Notice: all employees must wash hands before returning to work. Critical Care Medicine, 37, 2307-2309. Ferrières, L., Hancock, V., Klemm, P. (2007). Specific selection for virulent urinary tract infectious Escherichia coli strains during catheter-associated biofilm formation. FEMS Immunology And Medical Microbiology, 51, 212-219. Gotelli, J.M., Merryman, P., Carr, C., McElveen, L., Epperson, C., Bynum, D. (2008). A quality improvement project to reduce the complications associated with indwelling urinary catheters. Urologic Nursing, 28, 465-467. Graves, N., & McGowan, J.E. (2008). Nosocomial infection, the deficit reduction acts, and incentives for hospitals. Journal of the American Medical Association, 30, 1577-1579. Guidelines for the Prevention of Intravascular Catheter- Related Infections. (2002). MMWR. 5-6. Hugonnet, S., Chevrolet, J.C., Pittet, D. (2007). The effect of workload on infection risk in critically ill patients. Critical Care Medicine, 35, 76-81. Kusachi, S., Sumiyama, Y., Arima, Y., et al. (2006). Creating a manual for proper hand hygiene and its clinical effects. Surgery Today, 36, 410-415 Maki, D.G., & Mermel, L.A. (1998). Infections due to infusion therapy. In: Bennet, J.V., & Brachman, P.S. Hospital Infections. Philadelphia, Lippincott Williams&Wilkins, 689- 724. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 177 Morris, W., & Hong Toy M. (2008). Strategies for preventing peripheral intravenous cannulae infection. British Journal of Nursing, 10, 14-21. Moureau, N.L. (2009). Reducing the cost of catheter-related bloodstream infections. Nursing, 39, 14-15. Ramritu, P., Halton, K., Cook, D., Whitby, M., Graves, N. (2008). Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis. Journal of Advanced Nursing, 62, 3-21. Safdar, N., & Makki, D.G. (2002). The commonality of risk factors for nosocomial colonization and infection with antimicrobial- resistant Staphylococcus aureus, Enteroccocus, Gram-negative Bacilli, Clostridium difficile, and Candida. Annals of Internal Medicine, 136, 834-844. Saint, S., Meddings, J.A., Calfee, D., Kowalski, C.P., Krein, S.L. (2009). Catheterassociated urinary tract infection and the Medicare rule changes. Annals of Internal Medicine, 150, 877-884. Spencer, A., & Clifford, C. (2009). An evaluation of the impact of a tracheostomy weaning protocol on extubation time. Nursing In Critical Care, 14, 131-138. Stamm, W.E. (1998). Urinary tract infection. In: Bennet, J.V., & Brachman, P.S. Hospital Infections. Philadelphia, Lippincott Williams&Wilkins, 477- 486. Stoodley, P., Sauer, K., Davies, D.G., Costerton, J.W. (2002). Biofilms as complex differentiated communities. Annual Review of Microbiology, 56, 187-209. Weigel, L.M., Donlan, R.M., Shin, D.H., Clark, B., McDougal, L.K., et al. (2007). High-level vancomycin-resistant Staphylococcus aureus associated with a polymicrobial biofilm. Antimicrobial Agents and Chemotherapy, 51, 231-238. Wilson, J. (2006). Infection control in clinical practice. London, Elsevier. Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 178 Cure for Hemophilia: Gene, Stem Cell or Transplant? YO KOK Yong Loo Lin School of Medicine National University of Singapore, Singapore Email: [email protected] SHAUN SY TAN University of Glasgow, Scotland Email: [email protected] Abstract Background: Hemophilia has been a major focus of research due to its low minimum therapeutic range required (>5% of normal) and importance (1 per 8000 birth and high cost of replacement therapy). Vector-based gene therapy, stem cell or endothelial cell therapy and gross surgical transplantation are 3 modalities that have gained interest with breakthroughs in recent years. They are holy grails as they result in a permanent phenotypic correction of hemophilia. In the future, these may eventually supersede expensive and troublesome exogenous replacement therapy, which is the only current accepted mainstay treatment. Aim & Objectives: Many reviews in hemophilia literature focus mainly on one modality. We attempt a highly referenced extensive review of the latest literature in these 3 ‘holy grail’ modalities of potential permanent exogenous cures to give an idea of the current status across the fields. Methods/Study Design: Review of literature via MEDLINE and scientific/medical journals. Results/Findings: Vector-based gene therapy includes viral and,transposons. They have been successful in animal models. Human phase I trials have not been promising due to current hurdles include low achieved therapeutic levels, loss of transgene expression, potential mutagenesis, high vector doses required and small therapeutic index for vectors. Cell therapy and transplantation includes hematopoietic stem cells, hepatocytes, endothelial cells and have been achieved in animal models. Concerns include the toxicity of immunosuppressive or tissue remodelling therapy needed, development of FVIII inhibitors, difficulty of integration into liver architecture and long-term safety. A plethora of interesting advances have been developing that will spearhead breakthroughs, including non-viral vectors, transposons, iPS and various enrichment factors (MGMT, FLP) and immunomodulators and clinical phase I trials may be imminent. Surgical liver transplantation, though uncommon in hemophilia, is the only consistently permanent phenotypic correction of hemophilia demonstrated reliably in Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 179 humans and animals. Current barriers include transplantation associated mortality and morbidity, lack of transplant donors and ethics regarding concurrent HIV and Hepatitis C infected recipients. Study Limitations: Unpublished data may not be available to reviewers. Conclusion: Liver transplantation is an appropriate and viable therapy for hemophiliacs with end stage liver disease, curing both liver disease and hemophilia. With future surgical research that reduces transplant morbidity and mortality, it may become more acceptable in mainstream. Genetic and Cell therapy are more ideal as they are less invasive. However, though they are showing promising progress in animal studies, many hurdles remain before success in human clinical trials can be obtained. Keywords: Liver Transplantation, Gene Therapy, Cell Therapy, Hemophilia Introduction Hemophilias are a heterogeneous group of sex-linked bleeding disorders due to mutated genes on the X chromosome which result in pathological deficiency of coagulation factors. They are usually inherited but can be occasionally spontaneous up to 30% of the time(Mannucci & Tuddenham, 2001). The most common are Hemophilia A (Factor VIII-FVIII) and B (Factor IX-FIX) with incidence of 1 in 5000 and 1 in 30 000 male live births respectively (Tuddenham, et al., 2008). In most patients, the plasma level of FVIII/FIX predicts the clinical severity of the disease. Hemophilias is stratified to mild, moderate, and severe forms (corresponding to plasma coagulation factor levels of 6 to 30 percent, 2 to 5 percent, and 1 percent or less of normal, respectively) (Mannucci, 2003b). Although patients with mild hemophilia usually bleed excessively only after trauma or surgery, those with severe hemophilia have an annual average of 20 to 30 episodes of spontaneous or excessive bleeding after minor trauma, particularly into joints (hemearthrosis) and muscles. Treatment consists of replacing the missing coagulation factor from exogenous clotting factor concentrates, either plasma-derived or recombinant. For the past decades, data of various major efforts to phenotypically cure haemophilia have been emerging. The Aim of this study is to highly reference an extensive review of the latest literature in these 3 ‘holy grail’ modalities of potential permanent exogenous cures to ascertain the current status across the fields and their respective challenges. The two authors coreview and discussed literature via PUBMED, MEDLINE and scientific/medical journals searched with the keywords “Hemophila, Haemophila and/or Gene, Cell, Therapy and Transplant”. History Therapy has evolved much over the years. In earliest descriptions found in the Egyptian papyri and Talmud, no treatment was available and affected males of Review of Global Medicine and Healthcare Research - Vol. 1 No. 1 (2010) 180 Vol. The main advantages of recombinant factor concentrates are safety in terms of potential of viral transmission. 1966). hepatitis B virus (HBV) and hepatitis C virus (HCV). In 1929 the first plasma substitution therapy for hemophilia was introduced by precipitation of a globulin from plasma with low pH water (Hecht.. rFVIII rarely triggers inhibitor development (Schwartz. The rather strange name 'hemophilia' meaning 'love of blood' was first coined in Hopff's treatise of 1828 (Ingram. 1969). The public interest associates hemophilia as the royal gene from the famous lineage of royal haemophiliacs. In the late 1980s. During the 1980s. In the mid-nineteenth century it was recognised that transfusion therapy could treat bleeding in hemophilia patients (Ingram. up to 90% of hemophiliacs were infected with blood-borne viruses. 1976). 1 (2010) 181 . pharmaceutical companies developed two preparations of full-length recombinant FVIII (rFVIII): Recombinate® (Baxter Healthcare) and Kogenate® (Bayer Healthcare). Mammalian cells are the only cells that have the capacity to perform the required post-translational glycosylation of the FVIII protein. 1984) and subsequently inserted in a plasmid vector and transfected to mammalian cells that express and secrete the FVIII protein. et al. 2002). activated prothrombin complex Review of Global Medicine and Healthcare Research .. The screening of plasma samples using polymerase chain reaction testing was made obligatory in Europe in 1999 (Mannucci. et al. et al. 2003b)..families uniformly died from fatal bleeding after minor surgery. Access to treatment in developed countries has improved the quality of life for patients by dramatically increasing their level of education and employability. the incidence of inhibitor development in previously untreated patients is estimated to be 15 – 30%(Lusher. Farrugia. 1984. prothrombin complex concentrates. Shapiro. 2003a). hepatitis A virus (HAV) and emerging pathogens such as prions (Evatt. 2004). The interest in developing recombinant FVIII/FIX concentrates was driven by the concept of safer therapies for hemophilia. Toole. The human FVIII gene was cloned in 1984 (Gitschier. rendering them unresponsive to further FVIII protein Infusions. Conversely. e. 1 No. 2007). & Wilde. The breakthrough which is our modern mainstay management of exogenous concentrated forms of plasma-derived coagulation factors occurred in the 1970s after extensive research (Mannucci. However. 1990). the risk still exists for parvovirus. The development of neutralizing inhibitor antibodies against FVIII is up to 30% of hemophilia A patients. from plasma derivatives manufactured from pooled plasma obtained from thousands of donors and invariably contaminated before good viral-cidal measures and screening were in place(Mannucci. 1976). such as circumcision (Rosner.. Acute treatment for high-titer inhibitor patients includes the use of fVIII-bypassing agents. Recombinant clotting factors offer less risk but are more expensive and associated with development of antibody inhibitors. In hemophilia patients who have previously been treated with plasma-derived FVIII concentrates.g:. including hepatitis C and HIV. Challenges This modality is fraught with challenges. 2001). 2003a). especially in the royal Russian Romanov family (Mannucci & Tuddenham. et al. Improvements in viral inactivation methods and improved donor selection have significantly reduced the threat of contamination with HIV. and that the manufacturing process of recombinant products does not rely on plasma supply(Dargaud & Negrier. Historically. which effectively eradicates inhibitory antibodies in 60–80% of inhibitor patients. Moreover. Chirmule. Lambert. Extensive researches have made many hemophiliac animal models available for preclinical testing. infusion of plasma-derived porcine fVIII can work also. With regards to therapy efficacy. ("Natural history of primary infection with LAV in multitransfused patients. several challenges remain." 1986). Only a low therapeutic threshold of success is needed. 2006). which circulates in minute amounts in plasma. and difficulty of using these agents in a prophylactic manner (Dargaud. Tazelaar. Long-term treatment for inhibitor patients involves frequent high-dose hfVIII infusion. Future-Gene as Cure Hemophilia is a condition most attractive for gene therapy because of a combination of reasons. but are not amenable to long-term use owing to financial cost. But it is extremely expensive. Future improvements on bioengineered FVIII/FIX Concentrates are targeting at increased efficacy with longer half-life and decreased immunogenicity (Dargaud & Negrier. By the AIDS-Hemophilia French Study Group. all of which can provide short-term hemostasis. & Kazazian. 2002. 2003. 1 No. and the site of synthesis is not critical to function. However. et al.Vol. but often less) are insufficient to free Review of Global Medicine and Healthcare Research . Nichols. Sarkar. The clinical manifestations of this monogenic condition are also entirely attributable to the lack of a single gene product. There have been numerous enduringly successful gene therapies in hemophiliac murine and canine models (Chuah. the plasma levels of factor VIII or IX reached so far with the use of gene therapy (1 to 2% of normal.. eliminating a problem that hampers efforts for other disease entities. Tissue-specific expression of transgenic FVIII is not required. 2000). Response to treatment of the disease is also welldefined by easy quantifiable coagulation assays. Hemophilia B also has a relatively small size of FIX cDNA for ease of insertion into different gene transfer vectors and allows the addition of numerous transcriptional regulatory elements to both improve and restrict transgene expression in select cell types. Gao. et al. & Trossaert. the same cannot be said for humans. To date. or recombinant activated factor VII. of which persistent therapeutic levels of clotting factors was demonstrated for years. many different types of cell are capable of making coagulation factors. only that the protein is secreted into the bloodstream. 2009). lack of efficacy in chronic arthropathy. This treatment was effective because of the general lack of inhibitory reactivity of anti-hfVIII antibodies to porcine fVIII. et al. 1 (2010) 182 .. Challenges Although the preliminary data are encouraging. Long-term expression of 2–3% of normal levels achieves a substantial reduction in the clinical manifestations of the disease (Herzog. 2008). Expression of greater than 30% of the normal level of the coagulation factor would result in a phenotypically normal patient even in haemostatic challenges(Plug.. 2007). the 6 Phase I human clinical trials on hemophilia gene therapy only have limited clinical efficacy (Table 1).concentrates. termed immune tolerance induction.. et al. The results are promising with hemophilia A mice exhibiting activated partial thromboplastin times comparable to wild-type mice even at 50 weeks. et al. For example. et al. 1999).Vol. & High. Mah. et al.. In summary. The Review of Global Medicine and Healthcare Research . et al. et al. 2002) and insertional mutagenesis resulting in cancer.. challenges to gene success include insufficient transgene expression levels of Factor VIII.. 2006). 2003). Olivares. VandenDriessche.patients from the need for exogenous coagulation factors (Mannucci. Out of ten children.. 2006). Other concerns are the possibility of germline transmission (Kazazian. 2005. 2002). Ohlfest. 2003). & Kay. & Gringeri. vector immunogenicity and potential mutagenesis. 2002). inhibitor antibody formation. 2001). which are promising alternatives because they avoid the immunological problems associated with viral vectors. particularly in previously untreated patients. The previous lack of long-term expression from nonviral vectors has recently been overcome by the use of specialized vectors such as strong endogenous promoters. one patient receiving the highest dose achieved 10% of normal plasma FIX activity for 8 weeks but had a subsequent decrease of FIX levels associated with a substantial elevation of transaminase levels. et al. emphasising that immunological barriers continue to represent the main obstacle to achieving successful gene transfer in patients(Lillicrap. One model used intravenous administration of the FVIII-expressing Sleeping beauty transposon with a promoter complexed with polyethyleneimine (PEI) DNA to correct Hemophilia A mice phenotypically (Liu. The risk of developing inhibitors is still of concern. 2009.. et al. in a clinical trial of gene therapy for hemophilia B(Manno. Mendolicchio. 2002. Gene therapy has been dominated by the use of viral vectors and the immunogenic and oncogenic concerns that accompany these strategies. This was due to destruction of transduced hepatic cells by cytotoxic T lymphocytes attacking liver cells expressing viral capsid proteins. 1 (2010) 183 . Alternatives There are also nonviral vectors for gene delivery. and have no size limitations of the delivered DNA(Liu.. Levels of at least 5% of normal are required to prevent episodes of spontaneous bleeding and to guarantee that supplementary factors are needed only in cases of trauma or surgery (Mannucci. & Fletcher. 2005. et al. including hemophilia (Ehrhardt. Xu. systemic inflammatory responses related to the use of high doses of adenoviral vectors(Ehrhardt & Kay. et al. Kren.. Another used dispersed atomisation of hyaluronan and asialoorosomucoid-coated nanocapsules containing FVIII-expressing Sleeping Beauty transposons over liver sinusoidal endothelial cells and hepatocytes before injecting intravenously (Kren. Huang. 1 No. 2006). et al.. HIV-infected patients who are receiving highly active antiretroviral therapy may have a poor response to retrovirus-based approaches. Yant. 2009). Examples are the integrating DNA transposable elements such as Sleeping Beauty (SB) transposon and the phage fC31 integrase in several animal models(Liu.. Engler. 2006). two developed T cell leukaemia after gene therapy for severe combined immunodeficiency (SCID) using a retroviral vector (Hacein-Bey-Abina. 2003). The root problem is related to host immune responses.. those with chronic hepatitis may have a poor response to the insertion of viral vectors into the liver(Manno. have reduced production costs. .development of nonviral DNA delivery methods may provide an efficient and safe alternative for the treatment of hemophilia A. 2005). et al. 1 (2010) 184 . One way is using Fibronectin-like Polymer (FLP) which engages extracellular matrix receptors to facilitate stem cell engraftment to liver tissue matrix without causing cell damage (Follenzi.Vol. HSCs has been tested clinically as a treatment option for a variety of human autoimmune disorders. several studies established the possibility of phenotypic cure of hemophilia mice with various transplanted stem cells (Table 2). 1 No. systemic lupus erythematosus. This is supported by Matsui et al in their model where there was no evidence of any significant in vivo expansion of the implants or in other endothelial tissues. 2008. However. The risks and challenges such as in vivo immunogenicity and mutagenesis remain similar.. Endothelial cells found in liver. which may be in the near future (Gabrovsky & Calos. rheumatoid arthritis. lung are the main producers of clotting factors and are another main target of therapy(Follenzi.. suggest that nonviral gene therapy has curative potential and justifies its clinical development.. such as transposons and the success of several nonviral animal studies. Even a small proportion of platelets (1%) that contained FVIII improved hemostasis in hemophilic A mice with pre-existing FVIII immunity. including multiple sclerosis. A novel approach that helps to overcome FVIII antibodies is to sequester FVIII within quiescent platelets using a platelet-based promoter transfer–based strategy. 2008) .. Another interesting model of transplantation is the use of a subcutaneous implant of endothelial cells in a basement membrane scaffold (Matsui. 2007). Hematopoietic stem cells (HSCs) are an attractive target cell population for hemophilia A gene therapy because they are readily accessible for ex vivo genetic modification and allow for the possibility of sustained expression of a FVIII transgene in circulating peripheral blood cells for the lifetime of the patient following bone marrow transplantation. & Spencer. before in vivo transplantation. Review of Global Medicine and Healthcare Research . More research on identification of compounds that promote proliferation of transplanted cells should provide impetus for further success. Implant removal and replacement can be easily done. Dukart. 2007). This allows for sequestration of potentially mutagenic cells at an anatomic site and avoids disseminated delivery. peripheral blood. 2008). Of special mention are innovative ways of improving engraftment. Kumaran. et al.. et al. et al. Gangadharan. These platelets will deliver FVIII after platelet activation at sites of vessel injury. 2008). Future-Stem cell as Cure Stem cells and gene therapy are invariably related therapies distinguished by the main difference that in Stem cell therapy ex vivo gene transfer occurs first with pretransplanted cells if any. et al. New types of nonviral strategies. and Crohn disease (Doering. Recently. at 30 weeks no FVIII was detected in any of the mice and the scaffold degraded by 35 weeks. avoiding inhibitory antibody inactivation even in its presence and achieving hemostasis (Shi. 2009). Non-bone marrow cells are used also. liver transplantation is the best treatment modality for patients with end-stage liver diseases (Ng & Lo.. toxicity of conditioning regimens (Cyclophosphamide. et al. Hemoglobin synthesis and red blood cell development were not disrupted too... Stephan. 1 (2010) 185 . monocrotaline. 2008). Lisowski. et al. higher levels of FVIII mRNA were also detected in spleen.Enrichment of the gene-modified cells after engraftment of bone marrow cells is also possible. 1969) . irradiation. Immunorejection and hepatic artery thrombosis plagued the first few operations and resulted in a survival less than the first posttransplantation year (Starzl. The history of liver transplantation dates back to 1963 when Starzl first attempted cadaveric liver transplantation (CLT) in a male. Challenges The ideal therapy is that of transplant immune hyporesponsiveness and stable long term tolerance to an expressed transgene product. 2009) and also the standard treatment for many inherited metabolic disorders(Lerut. & Sadelain. 1 No. Mistry. et al. & Lee. Others include suboptimal transgene expression as a result of poor vector design. . Some challenges include achievement of sustained production of therapeutic levels of FVIII. Future-Gross Transplant as Cure According to Lerut et al. This is via clonal expansion through methylguanine methyltransferase (MGMT) drug resistance gene selection (Chang. and kidney tissues of injected animals despite local therapy to the liver only. Lu. To date.. 1995). curing hemophilia through liver transplantation is a well established but not commonly done therapy (Gordon. It has been landmarked as one of the most important advances in the medical field. Sabin. as well as the risk of insertional mutagenesis associated with the use of long terminal repeat–driven retroviral vectors(H. They engrafted within the hepatic parenchyma via injection and functionally integrated to provide the therapeutic benefit necessary for phenotypic correction of hemophilia.. 1998).Vol. 2008). et al. heart. Interestingly. good engraftment of transplanted hepatocytes into liver architecture require disruption of the sinusoidal endothelial barrier(Follenzi. 2008). For example. only 40 plus Review of Global Medicine and Healthcare Research . Fibroblast cells were induced back to a pluripotency stage (induced Pluripotent Stem (iPS) cells) and differentiated to endothelial progenitor cells which expressed the FVIII protein(Xu. et al. low gene transfer in HSCs and gene silencing after vector integration. This is because of the morbidity associated with transplantation and the established efficacy of the current FVIII replacement regime. These MGMT-selected erythroid stem cells were capable of expanding without loss of repopulating ability as demonstrated by sustained high levels of transgene expression for a total of 18 months with relatively low initial cell numbers. acetaminophen) needed to achieve good engraftment of transduced cells. Though much has advanced since. 1998). Lewis. et al. if the viral load is not managed.. Ragni. 1985. et al. thrombosis of the surgically “traumatised” and anastamosed hepatic artery can occur if overuse of coagulation factors occurs(Dargaud. & Negrier. 1993). & Hottenrott. 1988. At one extreme. In a case. The expense of transplant surgery and the subsequent antirejection therapy may be considerably less than the yearly cost of factor replacement therapy(Gibas.Vol. 1990. Liver transplantation cures hemophilia. 1 No. Dodson. 1998). 1 (2010) 186 . Campbell. 1998). et al. Challenges The drug-induced immune suppression is necessary to prevent organ rejection puts transplant recipients at risk for many of the same opportunistic infections associated with AIDS. 1988). The main indications for liver transplant in hemophiliacs are end stage liver disease due to Hepatitis B and/or C where the risk/benefit ratio is justified (Gordon. & McAlister. et al.. 1985). 1987. et al. Lerut. 1995.. & Starzl.. 2005. 1996)... et al. Thus. et al. At the other extreme. Bontempo. the immediate risks of bleeding during surgery. 1995). 1998). 2008. et al. Stabile. Delorme. Ghosh. Authors also note that the survival of HIV-negative hemophiliac liver recipients is similar to that of nonhemophiliacs (Gordon. et al. et al. Encke. et al.. Another unfortunate challenge is that even after transplant.. Merion. There is also the operative challenge of maintaining a fine line between coagulopathy and hepatic artery thrombosis. Marotta.such cases have been reported in literature internationally but is increasing (Bontempo. HIV. Scharrer. 1999. Ragni. Schliefer.. 1988. & Turcotte. The limited experiences reported by different investigators and the various strategies for clotting factor replacement make it difficult to define a single approach with respect to the Review of Global Medicine and Healthcare Research . Gibas. liver transplant might be a common and acceptable cure of hemophilia. Hep C cirrhosis recurred five years after the transplant (Lerut. McCarthy. although the patient remains genetically hemophiliac. 1996.. Gordon. Hepatitis B or C can reinfect the new transplanted organ. et al. With appropriate factor replacement prior to the operation. Bontempo. Hunt. et al. However.. Rossi.. 1988. Delius. et al.. Meunier. & Piseddu... If transplantation morbidity can be reduced acceptably in the future. et al. The first was performed by Lewis in 1985 (Lewis. & Fung. Federici. Mannucci. when the benefits outweigh the risks of transplantation mortality and morbidity (McCarthy. the new liver synthesizes clotting factors at normal levels within 24 hours of the operation(Gordon. 1993. there are many benefits to the use of liver transplantation. These are chronic infections that are always terminally fatal without liver transplant. and arterial thrombosis after transplantation are similar in both hemophiliac and non-hemophiliac patients (Fischbach & Scharrer. end-stage liver disease together with hemophilia exposes patients to greater risks of bleeding complications during the perioperative period with consequent difficulties in managing coagulopathy (De Pietri. 2004). Fischbach & Scharrer. the caveat is that surgical transplantation is only suitable for endstage liver disease. Spero. Hep B and C are blood-borne diseases and commonly transmitted from pooled plasma before reliable virus-cidal therapy was introduced. 1995. 2000). H. they have been proven to be enduringly successful on mice and dogs.. Of course. & Eby. iPS and various enrichment factors (MGMT.. including non-viral vectors. Mol Ther. Spero. Review of Global Medicine and Healthcare Research . Stephan. M. et al.. We may eventually achieve these holy grails in the future but in the meantime. both live and cadaveric. It must be emphasised that the main therapeutic purpose of transplant surgery is resection and ‘cure’ of end stage liver disease which have a poor prognosis. However with advances in current anti-viral therapy. et al. M. J. F.Vol. any new therapeutic modality must be equally efficacious and provide assurances of the long-term safety. 69(6). White.. (1987). which is hard to answer. Despotis. A. et al. Current guidelines still advocate the proven exogenous factor replacements (Goodnough. Liver transplantation in hemophilia A. J. Till date. The tissue and genetic level of therapy are less invasive and can be deemed as ‘holy grails’ of curing hemophilia. the prognosis of both Hep C and HIV has improved tremendously. which are valuable healthcare resources always in shortage. Human phase I trials have not been promising due to problems of inadequate takeup and persistent production of therapeutic level of FVIII. H. 1721-1724. 2004. 1 (2010) 187 . P. the benefits of saving on the costs and trouble of FVIII replacement do not outweigh the morbidity and mortality risks of transplantation. the donor’s wishes take paramount importance over such healthcare utility considerations. in Living Donor Liver Transplant (LDLT). 1745-1752. there is the ethical issue of whether liver donors. 2008). should be used for carriers of Hep C and HIV. Curing hemophilia is an added bonus that should not be the primary purpose of surgery until risks of morbidity associated with transplant can be addressed adequately.optimal dose and method of administering FIX to achieve perioperative hemostasis and this warrants further research(De Pietri. V. they are currently still under trials on animals and humans. We live in exciting times where we may eventually see a permanent endogenous cure of hemophilia within our lifetimes.. Lewis.. & Sadelain. (2008). Erythroid-specific human factor IX delivery from in vivo selected hematopoietic stem cells following nonmyeloablative conditioning in hemophilia B mice. References Bontempo. J. 16(10). Lublin. Hoots & Nugent. M. Gorenc. transposons. Zhang... Chang. T. Blood. L. However. FLP) and immunomodulators. Ragni. Currently. one should not forget about the surgical avenue of gross liver transplantation... Conclusion: Since hemophiliacs already have a safe and effective mode of clotting factor replacement. A. So far. only the method of liver transplantation is practical and enduringly successful on humans thus far. Also. 2006.. J. T. 2001). A plethora of interesting advances have been developing that will spearhead breakthroughs. Lisowski. A. 1 No. Scott. G. T. 695-706. Dargaud. J. Masetti. L. T. A. D. Delorme. M. De Pietri. P. (1990).. A new adenoviral helper-dependent vector results in long-term therapeutic levels of human coagulation factor IX at low doses in vivo. Hematopoietic stem cells encoding porcine factor VIII induce pro-coagulant activity in hemophilia A mice with pre-existing factor VIII immunity. A. & Spencer. J. Y. B. R. Int J Clin Lab Res.. B. Farrugia. 14 Suppl 4. M. 651-663. S. Z. (2002). Rossi. & Kay.Vol. B. A. & Wall... Schiedner. S. L. Dargaud. V. Haemophilia. (2003). 11(5). F. C. D. A. A. G.. C. & Kay.. M. 2077-2079. Orthotopic liver transplantation in a patient with combined hemophilia A and B. A. Dukart. Raut. A. C.. Doering. Ghent. J Clin Invest. Johnston. A. H. (2008). Transplanted endothelial cells repopulate the liver endothelium and correct the phenotype of hemophilia A mice.... Faulkner. A. Novikoff. 8(3). Mannucci. & Scharrer. Haemophilia 2002: emerging risks of treatment.. Ehrhardt. Mol Ther. R.Chuah.. (1995). Begliomini. Engler.. M. & Negrier. I. L. I.. A. (2008). Barbieri. 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H. & Gupta.. Shibata. et al. R. Schwartz.. D. Mannucci. J.. Sarkar.. Liver transplantation and haemophilia A. 3(9). Blood. 1 No. G. L. Stage I clinical trial of gene therapy for hemophilia B. A. V. T.. R. Lavenne-Pardonge.. M. A. C. Adv Exp Med Biol. Mah. Xue. et al. L. 344(23). F. 312(18). P. et al. 2065-2069. P.. L. et al. 59-64. M. 489. (2006). Chew.. M. V.. Sarkar. J. Arkin. J. (2001). (2005). 1-9.. Ragni. (2002). Qiu. V. B. R. Stem Cells. K. (1988)... L. Hawley. Correction of murine hemophilia A by hematopoietic stem cell gene therapy. 50(2). C. (2003). Tibbs. 12(6). C... & Turcotte. Ohlfest. J. R. ILAR J. 52-56. K. hemophilia B. M. Review of Global Medicine and Healthcare Research . J... R. E. Rela.. Olivares. C. R. 1 No.. P. F. and factor VII deficiency. C. H. von willebrand disease. Phase 1 trial of FVIII gene transfer for severe hemophilia A using a retroviral construct administered by peripheral intravenous infusion. (2005).. M.. M. C. K. T.. M. J. A. Nichols. 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Human recombinant DNA-derived antihemophilic factor (factor VIII) in the treatment of hemophilia A. 216-222. 11(6)... Pittman. M. Starzl.. Chirmule. et al. J. Brackmann. L. Kuether... (2000). & Hottenrott. P. 1(1). Kumar. 14 Suppl 3. S. Sorensen. Syngeneic transplantation of hematopoietic stem cells that are genetically modified to express factor VIII in platelets restores hemostasis to hemophilia A mice with preexisting FVIII immunity. L.. L. D.. Abildgaard.. L. Buecker. Fink. H. (1969). (2009). Tazelaar. F.. A. Orthotopic liver transplantation in man. A. (2001). C. A. et al. L. M. 808-813. G. Sultzman. recombinant Factor VIII Study Group. Shi.. Paar. Rosendaal. N. 113-118. & Selden. N Engl J Med. Gao. S.. J.. E.. G.. J. M. Arkin. A.. M.. Saxena. Nature.. K. (1990). 125(17). L. R... P. J. 1 (2010) 192 .. N... N Engl J Med. Spengler. Tuddenham.. W. J. Jr.. D. H.... J. Yadav. K. White.. Alipio.. Brettschneider. O'Brie n. Tawa.. 2003) Liver 7 (3 doses each) B AAV (Jiang. 2000) Numbe r of Subjec ts Duration of Factor VIII/IX Expressio n 6 months Hemophil ia Type Vector Target Cell Skin Fibroblast Success Results 1 patient: FIX> 1 IU/dL 1 patient: FIX>1 IU/dL 3 patients: reductio n in Factor Use 3 patients: FVIII>1 IU/dL Side Effects B Retrovira l 2 No significant side effect Skeletal Muscle B AAV 3 4 months No significant side effect (Roth. et al. 20(10). Table 1: Human Clinical Gene Therapy Trials Clinic al Trial (D. Ehrhardt. et al... et al.. Mikkelsen. 1 No. & Kay. FIX: Factor IX. 2006) B AAV Skeletal muscle 2 9 patients: FVIII>1 IU/dL 5patient s: reduced bleeding frequenc y 2 patients at highest dose: FIX>>1 IU/dL 1 patient: FIX>1 IU/dL 1 month Transient positive PCR signal of vector in semen 2 months Elevation of liver transaminas es Vector DNA in semen No significant side effect 6 months AAV: Adeno-associated virus. et al. G. R. FVIII: Factor VIII. et al. L. Pham.. J. Nat Biotechnol. S. A. Meuse.. IU: International Units. Treco. Review of Global Medicine and Healthcare Research .. PCR: Polymerase chain reaction. 2001) (Powel l. Lu. R... T. A. M.. & Selden. 1 (2010) 193 .Vol. 1993) (Kay.Yant. Transposition from a gutless adeno-transposon vector stabilizes transgene expression in vivo. (2002). 999-1005. 2003) Omentum Fibroblas t transfecte d with FVIII plasmid Blood Mononucle ar cells A Retrovira l 13 A 6 10 months Invasive laparoscopy No significant side effect (Mann o. et al. et al. et al.4% 6/7 survived tail clip average FVIII level: up to 12% 5/6 survived tail clip FVIII level: up to 48% 25/31 survived tail clip average FVIII level: 20. 1 No. et al. 2005) (Yadav... 2007) Murine A with anti hFVIII antibodies Murine A Bone Marrow Cells (BMC) encoding porcine FVIII Blood outgrowth endothelial cells Irradiation 9 months (Follenzi. 1 (2010) 194 . 2006) (Xu. et al.. 6/6 survived tail clip FVIII level: up to 12% 12 months 18 months 3 months Review of Global Medicine and Healthcare Research .. & Hawley. Jiang... 2009) Cell Line Bone Marrow Cells (BMC) Target Organ Liver (via Intravenous tail vein) (Kumaran. Liver (via intravenous portal vein) Cyclophosphamid e 7 months (Shi...5mU/ml 13/15 survived tail clip FVIII level: 19. 2005) Murine A Liver Sinusoidal Endothelial Cells (LSEC) Peritoneal cavity (via Intraperitoneal ) Peritoneal cavity (via Intraperitoneal ) Liver (via Intravenous tail vein) Blood (intravenous) 1month ongoing (Moayeri. et al. et al. 2008) Murine A Liver Sinusoidal Endothelial Cells (LSEC) Subcutaneous depot on neck in a Matrigel scaffold.48 mU/108 platelets All survived tail clip FIX level: (>500 ng/ml). et al.4% Duration of Factor VIII/IX Expression 18 months Experiment (Yadav.. et al.. 2008. 2008) Murine A with anti hFVIII antibodies Murine B Bone Marrow Cells (BMC) encoding platelet only expressed FVIII Haemopoietic Stem cell. 2009) Murine A Bone Marrow Cells (BMC) Irradiation Busulfan or > 6 months Murine A Bone Marrow Cells (BMC) Acetaminophen 18 months (Doering.4% 11/11 survived tail clip FVIII level: >1U/ml 6/6 survived tail clip FVIII level: 22. Monocrotaline and Low dose cyclophosphamid e Irradiation 3 month (Chang. 2007) (Matsui. Hawley.Vol. 2009) Blood (intravenous) Murine A Liver (direct injection) Methylguanine methyltransferase (MGMT) and busulfan Irradiation 14/16 survived tail clip FVIII level: 0.Table 2: Stem Cell Cure of Hemophilia in Animal Experiments Hemophilia Type Murine A Engraftment procedure Acetaminophen to induce liver injury and regeneration incorporating BMCs None Success Results 25/31 survived tail clip average FVIII level: 20. et al.derived erythroid cells Fibroblast-derived induced Pluripotent Stem (iPS) cell differentiated endothelial cells and progenitors Blood (intravenous) Fibronectin-like polymer (FLP). stagnant water at construction sites and abandoned mills have led to mosquitogenic conditions. Aim & Objectives: This study aims to determine personal and household measures undertaken for malaria prophylaxis in an endemic area in Mumbai and estimate their efficacy. Mumbai.J. Chi-square test showed a statistically significant association between ongoing construction work and malaria occurrence. 1 No. Methods: Using a questionnaire. Nearly 77% of Group 2 had not used any protective measures while over 65% of Group1 used two-four protective Review of Global Medicine and Healthcare Research . Chi-square test confirmed that repellent creams and insecticides were effective. Around 10 percent of malaria cases are reported from the urban areas. It will also be analyzed whether the study sample has received accurate health education on malaria related protective measures. It will be determined if any associations can be made between the practiced protective measures and recurrence of malaria. Data was analyzed using tables and stacked and clustered column graphs. Hatim Attar K. Somaiya Medical College & Hospital. Results: 73. Logistic regression was used on some variables to determine functional relationships and chi-square test for associations. as well as the cases in the last year and in the last month.Efficacy of Prophylactic Measures for Malaria Dr. 87% respondents mistakenly blamed dirty water for malaria. Logistic regression also showed construction sites increased the chances of malaria recurrence. Comparison of two groups was done: people who have never had malaria (Group1) and people who have had malaria last year (Group2). Kowli Department of Preventive and Social Medicine. 44% respondents practiced ineffective measures like cleaning surroundings and using coils.com Abstract Background: Malaria is a major health problem with over 8 percent of the Indian population exposed to malaria risk in varying degrees. 77% households were aware of nets but only 8% employed them. K. efficacy of the measures in preventing the incidence of malaria will be estimated. 200 households from Mumbai’s “E” Ward were covered during the monsoons. The general occurrence of malaria in the study sample will then be ascertained. There were large gaps between awareness and use of protective measures especially for mosquito nets. 1 (2010) 195 .Vol. Only 16. Somaiya Medical College & Hospital E-mail: [email protected]% respondents had not received malaria education. industrialization without proper drainage facilities. Variables representing practiced protective measures were cross-tabulated in proportions and frequencies.5% knew that construction sites could constitute breeding grounds. In this way. The development of supporting infrastructures like rail and roads without keeping in mind the natural flow of surface water have led to the formation of extensive vector breeding grounds. Unplanned rapid expansion of urban areas. poorly constructed overhead tanks in old buildings. Shobha S. India Mr. 1 Malaria is a major health problem with over 8% of the Indian population exposed to malaria risk in varying degrees.8. Prophylaxis.687 cases of malaria in June 2008. as much as 30-fold. there were 1. the actual incidence of malaria may be much higher. 70% patients visited private practitioners and 26. The other reasons for the urban malaria problem include non-promulgation of civic laws for elimination of mosquito breeding places.2 Malaria remains endemic in all of India except at elevations above 1800 meters and in some coastal areas. The diagnosis of malaria by doctors of laboratories could not be confirmed by an independent test. Prevention.5% went untested. the results are limited in their ability to be generalized to the wider population. the number of malaria cases in India account for 60% of cases in the South-East Asia region. Conclusion: Education focusing on distinction between malaria prevention and antimosquito measures.739 people have tested positive for malaria in July 2008 in the civic hospitals alone. The main urban malaria vector. by active government surveillance. As with the nature of qualitative research. 1 No. The situation has been made more complicated by rapid development and construction activities in urban areas. the officially reported incidence is considered grossly underestimated. Keywords: Malaria. Around 10% of malaria cases are reported from the urban areas. Sometimes breakdown of active surveillance machinery causes low reporting of malaria cases. containing substances less harmful to human health.9 The lower immunity of urban residents to malaria makes these areas more epidemic prone. poor case-finding mechanisms and insufficient staff for carrying out anti-larval operations. A survey conducted in Delhi slums6 shows that majority of urban slums lack proper sanitation and have poor drainage facilities resulting in water stagnations. and thus undetected.4 Therefore. while 1. Efficacy Introduction According to the World Health Organization. Study Limitations: The correct use of preventive measures by respondents could not be verified by observation. Yet. along with the correct usage of protective measures would help prevent malaria. poorly constructed overhead tanks in old buildings.7 Unplanned rapid expansion of urban areas.3 The private medical care sector is popular and flourishing in India. The development of supporting infrastructures like rail and roads without keeping in mind the natural flow of surface water have led to the formation of extensive vector breeding grounds. A study5 in Ahmedabad found that estimated malaria incidence was found to be nearly 9 times more than the numbers reported.measures. Private institutions often do not keep or report information related to malaria incidence to Government agencies.Vol. stagnant water at construction sites and abandoned mills have led to mosquitogenic conditions. Research into more effective protective measures. Anopheles Stephensi Review of Global Medicine and Healthcare Research . In Mumbai itself. such as plant-based repellents is needed. 1 (2010) 196 . industrialization without proper drainage facilities. From the list of vulnerable areas for malaria in “E” Ward.962 P( 1-P)/e where n is the sample.11 Therefore.656 people. The study will also help emphasize that a stronger educational component should be introduced in the National Vector Borne Disease Control Programme (NVBDCP) and the Urban Malaria Scheme (UMS).12 This will prevent and control the incidence of malaria infection in the future. the Tadwadi Health Post was randomly selected. “P” is the expected proportion of households aware and “e” is the error of the estimate ( +10%). It will be analyzed whether the study sample has received accurate health education on malaria related protective measures.9 Focus is needed more on preventive aspects than treatment of the disease. Study Population The households were stratified into residential buildings and chawls. as well as the cases in the last year and in the last month. The general occurrence of malaria in the study sample will be ascertained. 1 (2010) 197 . This is because of the awareness campaign against monsoon related diseases which is under way since the launch of Disaster Management Plan after the deluge of 26th July 2005. n = 1. Material and Methods Study Area Mumbai is governed by the civic body Brihan Mumbai Mahanagarpalika. households from a middle income group have been enrolled. Review of Global Medicine and Healthcare Research . It is divided into 6 zones which include 23 wards for administrative purposes. It will be determined if any associations can be made between the practised protective measures and recurrence of malaria. Efficacy of the measures in preventing the incidence of malaria will be estimated. 1 No.463 houses and a population of 83.breeds in stored water and domestic containers. The Health Officials informed that this malaria endemic Health Post Office covers 18. chosen because it reported maximum number of malaria cases in Mumbai in 2007.13 The sample size was calculated according to the formula. This study will demonstrate that the correct and stringent use of personal and household prophylactic measures can in fact prevent malaria and its recurrence to a large degree. This study aims to determine the personal and household measures undertaken for malaria prophylaxis in an endemic area in Mumbai and estimate their efficacy. This cross-sectional exploratory study was conducted in “E” Ward. Use of prophylactic measures are dependent on socioeconomic status which is an important factor associated with malaria.Vol. Health education is necessary to impress upon a population the benefits of personal and household protective measures against malaria. The sample size was based on the hypothesis that at least 50% of households would be aware of one or the other protective measures against malaria. Selection of the first household was made randomly using the last digit on the currency note. which may be associated with the causation and recurrence of malaria. It was prepared in English and if necessary. Results Review of Global Medicine and Healthcare Research .J. Door to door interviews were conducted during the months of July and August 2008 because malaria becomes an even more major cause of morbidity and mortality in the midst of the monsoon season. Statistical Analysis The data was entered in Microsoft Excel 2003 and was analyzed using SPSS 16 (Statistical Packages For Social Sciences Software). A written Free and Informed Consent was taken from all participants. Thus 200 households in the middle income group were covered. chi-square test has been used to check associations.Vol. For the nominal qualitative data. logistic regression has been used to show the functional relationship between certain variables in our findings more effectively. 1 No. This led to a sample size of 192. Mumbai and carried out as per the Ethical Guidelines for Biomedical Research on Human Participants. Ethical Considerations The study was initiated after approval from the Ethics Committee of K. Some variables have been cross-tabulated in proportions and frequencies. Locked households on first visit were excluded. Data has been tabulated and represented graphically in the form of tables and graphs. Study Methods and Duration The structured questionnaire was pilot-tested before being administered and appropriate revisions were made. Indian Council Of Medical Research 2006. 1 (2010) 198 . The interviewed household members were in the age group of 18 years and above and have been living in the specified area for at least one year. A list of residential colonies was obtained from the Health Post Office and 25 colonies were selected randomly. Thereafter eight houses were covered consecutively keeping pace with the time at hand. Somaiya Medical College & Hospital. especially behavioral factors. As there are multiple factors. verbally translated into Hindi.The sample “n” was multiplied by two because of the design effect associated with cluster sampling. Persons were included in the study only if they wished to participate/were co-operative and there was no communication barrier. 22% 72. None of the households denied participation in the survey.5% of respondents admitted that mosquitoes caused them trouble. a name for a common housing system in India. 1 No.56% 100% Male 21.Age and Sex Breakdown Of Recipients Age Group 18-25 26-55 >55 Totals Female 22.22% 5. 106 households were located in residential buildings. 1 (2010) 199 . Review of Global Medicine and Healthcare Research . A usual tenement consists of one all purpose room and a kitchen.08% 47.9 70 60 50 Percentage of respondents 40 troubled by 30 mosquitoes 20 10 0 Dry Season Rainy Season Throughout The Year 4.63% of the respondents were females and 37% were males.62% 31. 89.Vol. Families on a floor have to share a common block of 4-5 latrines.6 Figure 1 Figure 2 shows that mosquitoes seem to bite people most at night. The mean age of the respondents was 39. Season during which mosquitoes cause trouble 65. Figure 1 displays the times of the year at which respondents are troubled by mosquitoes. The buildings are often 4-5 stories with about 10-20 tenements on each floor. Table 1 gives the age and sex breakdown of the recipients.30% 100% Total 22% 57% 21% 100% 94 households were located in chawls. Table 1.5 29. D. the association was found to be statistically ( χ2 = 3.Vol. 1 (2010) 200 .5% respondents claimed that they never received health education related to malaria.1 18.Time of the day at which mosquitoes cause the most trouble 45 Percentage of respondents troubled by mosquitoes 40 35 30 25 20 15 10 5 0 Afternoon Only Evening Only Evening and Night Night Only All day Other 2. using chi square test.2 43 Figure 2 82% of the respondents claimed that they protected themselves from mosquitoes. When the presence of ongoing construction work was tested for association with the occurrence of malaria in any member of the household in the last one year. Their responses are tabulated in Figure 3.F.1) significant. Health Education Related To Malaria 73. 1 No. Most respondents specified that open tanks were classified as breeding grounds only if they let the water get really dirty. P value = 0. Respondents were quizzed on their awareness of potential breeding grounds for malaria-transmitting mosquitoes.187. which they claimed they did not. They were also asked whether they had stagnant water collection in/around their homes.4 30. Review of Global Medicine and Healthcare Research .2 5 1. = 1.0742 P<0. Vol.5 17 Open Toilets 87 12. Review of Global Medicine and Healthcare Research . 1 (2010) 201 .5 Open tanks 21.5 Ongoing Construction Work 74 16. “Keeping surroundings clean” was a malaria preventive measure suggested by a conspicuous 77% of the respondents.Multiple responses were allowed from each respondent (n=200) Potential Breeding Grounds Of Malaria-transmitting Mosquitoes 22.5 Potted Plants 39 0 10 20 30 40 50 60 70 80 90 Percentage of respondents Prescence of stagnant water collection in/around respondents' homes Awareness of a potential breeding ground for malaria-transmitting mosquitoes Figure 3 General Malaria Prophylaxis The results tabulated in Figure 4 explain which measures respondents took to protect themselves against malaria.5 42 Open Gutters/ Drains 32. 1 No. 5 Insecticides (mats. 1 (2010) 202 .5 Preventive Medicine 0 86 Repellent Creams/Lotions 32.Vol. it was seen Review of Global Medicine and Healthcare Research . Regarding indoor insecticides.Multiple responses were allowed from each respondent (n=200) Personal And Household Malaria Preventive Measures 77 Mosquito Nets 8 7.5 Coils 44.vaporizers)/ Sprays 80. 1 No.5 89.5 42 77 Keeping Surroundings Clean 45 23 Plant-based repellants 15 2 None 18 0 10 20 30 40 50 60 70 80 90 100 Percentage of respondents Awareness of a personal or household malaria preventive measure Use of a personal or household malaria preventive measure Figure 4 Over 84% users of coils and/or creams reported only night-time use and only 12% used these measures at dusk and night. 10 for these variables. vaporizers and sprays were the insecticides of choice. Less than half were able to recall the name “chloroquine”.8% do not remember what treatment was given. 1 (2010) 203 . vaporizers and sprays respectively. 94% thought that the number of bites post-spraying had decreased. 5. logistic regression was performed. 66% of the respondents said that a household member did the spraying.Vol.that mats. The variables in Table 2 are found to be statistically significant as p-value (Sig in the Table 3) P< 0. 1 No. Figure 5 From Figure 5. it is clear that a large number of malaria cases last year. 20. Review of Global Medicine and Healthcare Research . 13. 71.5%. Of the 25% households that had spraying done in the last twelve months as a prophylactic measure against malaria. 28% and 6% engaged a private company to do the spraying and had their home sprayed by a government worker/program respectively. A majority of 61.2% sought malaria treatment from private establishments. the main drug for malaria treatment. Many used more than one type of insecticide. in this study sample atleast. Episodes of Malaria in the Household A total of 971 people have been covered in our survey of 200 households. To study whether or not the recurrence of malaria of any member of the household was affected by the breeding grounds for mosquitoes and use of the preventive measures. 56% of the participants did not even express any interest in owning a net.9% have obtained malaria medication directly from a pharmacy without medical consultation or testing.5% and13% households used mats. missed the net of government surveillance and were officially undetected. all the respondents found the net effective and none who had been using the net had ever had malaria. Presence of ongoing construction work around the house 2.384 3.066 0.104 1 1 1 1 1 0.961 1.078 2.803 -0. P value = 0.1) significant.423 0.Table 2: Variables in the Equation Step 1(a) B S.Use of traditional plants Mosquito nets and other methods which were used by less than 10% of the study sample were not tested for association. = 1. the association was found to be statistically (χ2 = 3.Coils . D.10 for these variables: 1.877 -0. Exp(B) Ongoing Construction Work Potted Plants Using Insecticides and sprays Using Creams/ Lotions Constant 0.Vol.Insecticides/Sprays . using chi square test.910.05 9.Keeping surroundings clean .048 P<0.F. chisquare test was performed using those variables which denoted the most popularly used protective measures of our respondents: .446 4. Wald df Sig.459 0.456 The following variables are found to be statistically significant as p-value (Sig in Table 2) P< 0.044 0.614 6.067 0.477 0.E. It may be noted that of the minority 8% households that used a mosquito net.597 0. Presence of plants outside the house 3. Use of insecticides/ sprays as a protective measure for prevention of malaria 4.416 0.778 -0. 1 (2010) 204 . Review of Global Medicine and Healthcare Research .494 3. Use of creams as a protective measure for prevention of malaria Efficacy of Protective Measures To confirm the results obtained by logistic regression for the protective measures. (These were mostly children) When the use of repellent creams/lotions as a preventive measure was tested for association with the recurrence of malaria in any member of the household.786 0. 1 No.003 0.114 4.Creams/Lotions .034 0.414 0. Number Of Protective Measures Used By People 90 80 70 60 Percentage of 50 people 40 30 20 10 0 None One Two-Four Five Or More 6. = 1.006 P<0. = 1.1) insignificant. D.F. P value = 0.When the use of coils as a preventive measure was tested for association with the recurrence of malaria in any member of the household.1) significant.381 P>0.Vol. the association was found to be statistically (χ2 = 3.76 11.550. using chi square test.841. P value = 0. P value = 0.01 7. D.1 11. the association was found to be statistically (χ2 = 7. When the practice of keeping surroundings clean as a preventive measure was tested for association with the recurrence of malaria in any member of the household. D.F. D. = 1. using chi square test.86 76.767.76 0 21. the association was found to be statistically (χ2 = 0. using chi square test.03 People who have never had malaria People who have had malaria last year Figure 6 Review of Global Medicine and Healthcare Research . = 1.884.F. When the use of insecticides/sprays as a preventive measure was tested for association with the recurrence of malaria in any member of the household.1) insignificant. P value = 0.47 65. 1 No. 1 (2010) 205 . -People who have had malaria last year: Majority were not using any protective measures or were employing one or more protective measures very sparsely. a comparison has been done between -People who have never had malaria: These have been more inclined to use protective measures with many people using multiple protective measures.05 P<0. When the use of plant based repellents as a preventive measure was tested for association with the recurrence of malaria in any member of the household.347 P<0. In Figure 6 and Figure 7.F.1) significant. using chi square test. the association was found to be statistically (χ2 = 0. 94 Creams/Lotions 43.71 51. The sex bias is not considered problematic since women of childbearing age are not only the care-takers of the household but also considered the gatekeepers to household adoption of protective measures against malaria.Vol.58 0 20 40 60 80 100 Percentage of people People who have never had malaria People who have had malaria last year Figure 7 Discussion 63% respondents were found to be female and about 72% of these were in the age group of 26-55 years reflecting the fact that interviews were carried out during daytime when most women were at home and men were out working.Measures Undertaken To Prevent Malaria By Two Groups Of People 0 Mosquito Nets 2.76 Coils 48. This is supported by the fact that in the older (retired) age groups there were more male than female respondents.vaporizers)/ Sprays 14.63 Insecticides (mats.19 2.94 18. almost 66% respondents have complained of mosquito trouble throughout the year. 1 No. This may be due to the perennial nature of mosquito breeding sites in urban areas such as construction sites and open Review of Global Medicine and Healthcare Research . Though mosquito density is highest in the monsoons.17 11.37 Plant-based Repellents 2. 1 (2010) 206 . are known to bite at night including Anopheles stephensi which bites mostly at nights before midnight14. curing water at construction sites etc. monetary restrictions or lack of availability of protective measures were not marked obstacles and at least one method of malaria prevention was in use by most respondents. 43% and 18. A significant 30.87% knew that open toilets were breeding grounds while only 16. In another recent study18 majority of the respondents had mentioned that malaria vectors breed in dirty stagnant water. specified that it classified as a potential mosquito breeding ground only when the water lasted more than a week and got dirty. studies14 show that Anopheles stephensi is an important vector of malaria in urban areas. 1 No. However. The above is further emphasized when it is learnt that 77% respondents suggested that “Keeping surroundings clean” was a malaria preventive measure.5% knew of construction sites.16 The respondents’ awareness levels of various potential breeding grounds of malariatransmitting mosquitoes shed light on several important facts. 1 (2010) 207 . The most likely reason for this is the incorrect dissemination of malaria education messages. As this is an urban study.4% respondents complained of mosquitoes biting at nights and at dusk extending into the night respectively. open gutters/drains) to be potential malaria mosquito breeding grounds as compared to simply stagnant or clean stagnant water. who chose “open tanks” as a potential mosquito breeding ground in a multiple choice question. Yet.Open gutters were also incriminated by respondents though only 17% had open toilets near their home. A one year long longitudinal study17 found that the habitat-wise proportion of Anopheles stephensi was highest in masonry tanks followed by overhead tanks. The apathetic state of health education on malaria has probably led to inadequate personal and household malaria preventive practices. too few are aware that it implies a neighboring mosquito breeding ground. school children could act as health information messengers from schools to communities for malaria control. The malaria transmitting mosquitoes – Anopheles species.The recent and current spate of intense construction activity in Mumbai with the erection of numerous high rises is evident when 74% respondents say that there is ongoing construction activity in the neighborhood. The message “Clean up the surroundings of the house” (which means cutting grass. although some mosquito Review of Global Medicine and Healthcare Research . 73. clearing up water containers and puddles) is aimed at reducing mosquito breeding and hence malaria. . Evidently.Most of the respondents. .Vol. Using Lao PDR15 as a model. . a higher percentage of respondents consider dirty stagnant water (open toilets. Health education was found to play a major role in malaria control and was the main reason for increase in knowledge of the disease in Equador and Nicaragua. .drains/gutters. Also. especially in India and is found throughout the year.5% respondents cited that they had never received any form of health education related to malaria.2% respondents alleged daytime biting which is a cause of concern too as the dengue-transmitting Aedes mosquito is a daytime biting mosquito. Legislative measures and building by-laws must be in place and rigidly followed during the construction phase and proper maintenance should be ensured to prevent mosquito breeding. These drums did not contain stagnant water as the water was constantly disturbed by daily removals. the value B=0. There is no denying that there has been an impressive growth of India’s private health sector during the past decade. as well as clean water spilled during watering.803. In many urban homes in Mumbai.5% of those who had malaria last year were not tested and of these 72% and 28% went to private establishments and pharmacies respectively. we can say that as the number of households having potted plants in/around the home increases. Excess water from pots.961. Anopheles mosquitoes do not breed in dirty water (preferring small bodies of unpolluted water usually some distance from human habitation). were undetected by active government surveillance. it emerged that over 70% people visited private practitioners for treatment. a significant association was found between ongoing building construction work and the occurrence of malaria in any member of the household in the last one year by chi square test. clearing up around houses has no impact on malaria disease whatsoever. Since in Table 2. stagnate here and develop into a breeding ground.20 Open tanks do not appear to have any impact on the recurrence of malaria in any member of the household as per logistic regression method. The most prominent gap was seen for mosquito nets with 77% being aware but only 8% households using them. In the study a large gap was obvious between awareness and usage of various malaria preventive measures. we can say that as the number of households having ongoing construction work around the home increases. This was noticed in an urban Delhi study21 too. This helps prove that the malaria transmitting Anopheles are partial to clean stagnant water. In our study. as proved in our study.Vol.19 As an intervention.species breed in close association with humans. In malaria related health education messages. A large number of malaria cases. Yet. It logically follows that these would not be responsible for malaria. 1 No. 26. the chance of having recurrence of malaria in the household increases. the chance of having recurrence of malaria in the household increases. As expected. 56% of our respondents were not Review of Global Medicine and Healthcare Research . we may need to address this inaccuracy directly and focus on preventing malaria by preventing mosquito bites alone and not by trying to reduce mosquito breeding sites. These would be potential Anopheles breeding grounds. Respondents confused “drums” and “tanks”. Anopheles stephensi may breed in jars or cisterns. but the question was misunderstood. the value B=1. the impact of the presence of open toilets and open gutters/drains on the recurrence of malaria in any member of the household was seen to be insignificant. In our study. Since in Table 2. a similar study in Mumbai22 found that many practitioners did not rely on a peripheral blood-smear test to make a diagnosis and gave one day treatments in response to patient demands and to retain their popularity and patronage. Plants make excellent resting sites for Anopheles mosquitoes during the day. 1 (2010) 208 . recurrence of malaria was seen to depend on the presence of potted plants. when logistic regression method was used in our study. While tracking the episodes of malaria in each household. potted plants were seen to be arranged in long trays on shelves outside the window. In this study. Insecticide Treated Nets (ITN)/ Long Lasting Insecticidal Nets (LLIN) have proved effective against vector borne diseases especially malaria. we can say that as the number of people who use insecticides(mats and vaporizers) and sprays as the protective measure increases.Vol.29 Review of Global Medicine and Healthcare Research . 1 No. The chi-square test too confirmed the association between use of creams and prevention of malaria recurrence. Coils have to be switched on at dusk and rooms should not be wellventilated. Numerous studies in Gambia25 and Suriname26 have demonstrated that mosquito nets provide privacy and a barrier to mosquito’s nuisance. Unfortunately. 25% of our respondents have used sprays of which 66% used household sprays available in the market and carried out the spraying themselves. they do confer a certain degree of protection. Chi square test confirmed this association. majority of the respondents use coils at nights only. Yet. Like coils. Considering indoor insecticides and sprays. However there can be no doubt that insecticide treated mosquito nets remain one of the most fool-proof measures of malaria prevention. mats and vaporizers too. In Mumbai homes.even interested in owning a net.23 In a previous study amongst fever patients in India24 34% respondents mentioned mosquito net as a prime preventive measure against mosquito bite. are subject to ventilation. Breeze may dampen the effect of the coil.877.778. A WHO Report28 states that coils are of “doubtful effectiveness”. It must be realized that many respondents used more than one type of mats. Creams and lotions when applied to all exposed portions of the body especially the necks. so there is urgent need to inform people about the significance of spraying all of their rooms including the kitchen and worship-room to boost the malaria control program. in Table 4. the value B=-0. The recurrence of malaria in any household member appeared to be independent of the use of coils by logistic regression and chi-square test.19 Since. especially in summer. these should not be used indiscriminately for fear of spawning insecticide resistance or affecting health adversely. we can say that as the number of people who use creams as the protective measure increases the chances of having recurrence of malaria decreases. the chances of having recurrence of malaria decreases. In recent years. This is due to a variety of reasons. wrists and ankles. logistic regression showed no relation between mosquito nets and malaria prevention as the sample using nets was miniscule. For the purpose of calculation. Yet. This casts doubts on the effectiveness of the spraying technique as not all the home spraying may have been done adequately all over their home or enough number of times. 1 (2010) 209 . may confer protection even up to 4-6 hours hours. these two measures were clubbed together. There are health concerns over the use of coils too. logistic regression method (Table 2) showed that as the value B=-0. vaporizers or sprays. Peak vector biting occurs at night when people are asleep and during the day mosquitoes rest in the unsprayed rooms. this is not feasible. Studies27 have shown that coils are not very effective against malaria. Even if the individual capacity of various practiced protective measures to actually prevent malaria is debatable and the exact methods of use are ambiguous. Figure 6 also shows that people who have never had malaria have concentrated on keeping their surroundings clean unlike those who had malaria in the previous year. Pyrethroids and DEET (N. Though burning mosquito coils indoors generates smoke that can control mosquitoes to some extent.e. vaporizers contain pyrethroids as the principal ingredient. The cumulative effect serves to offer some degree of protection. the main malaria vector in Mumbai. Studies30 show a myriad of health hazards and risks posed by hydrocarbon and other fillers in these repellents such as changes in the tracheal and alveolar epithelium. Yet indiscriminate use of household sprays by the public has led to Review of Global Medicine and Healthcare Research . effect on the incidence of malaria. Anopheles stephensi. If carried out by trained personnel on the walls and ceilings of dwellings. Indoor Residual Spraying (IRS) is a highly effective measure against mosquitoes and hence malaria. This disparity can be explained when we consider that those are the more healthconscious and /or educated people.Not all available household sprays utilized are effective. mats. reproductive dysfunction. Logistic regression method (Table 2) and chi-square method showed that plant-based repellents did not influence the recurrence of malaria. people’s capacity to buy repellents is increasing steadily. our study shows that of the plant-based repellents in use. 1 No. is discovered to rest at a height of at least 30cm above ground level and selects hanging objects for resting. sprays. who adopt multiple malaria preventive measures and have a more positive attitude towards health and its promotion. have had adverse effects on human health. Most commercially available repellents i. especially at prevention level. it is a cost-effective and efficient vector control method. However. 1 (2010) 210 . In Mumbai. From Figure 6 and Figure 7. As per the WHO and NVBDCP. there is no doubt that when they are combined randomly. creams/lotions. N-Diethyl-metatoluamide) themselves. As discussed before. they are proving efficient. development impairment and cancer. Yet. we can come to only one indisputable conclusion. as discussed later are showing promise in terms of malaria prevention. A study31 identified carcinogens in the coil smoke and suggested that exposure to the smoke of one mosquito coil would release the same amount of PM2. the chi-square test showed an association between keeping surroundings clean and recurrence of malaria in any member of the household. In fact. the smoke contains pollutants of health concern.14 Unlike the logistic regression method. This would have limited. They would be likely to keep their surroundings clean to prevent other diseases besides malaria hence the result of the chi-square test. if any. coils. Neem and other plant-based products.5 mass as burning 75-137 cigarettes. It is also not clear if household members sprayed only at floor level or whether hanging fabrics such as curtains have been sprayed regularly. keeping the surroundings clean has no impact on malaria transmitting mosquitoes while it does prevent other mosquitoes breeding. nearly 74% consisted of just placing the Tulsi plant at home to ward off mosquitoes.Vol. South Asian Regional Study on Climate Change Impacts and Adaptation-Implications for Human Development. namely An. derivatives of lemon eucalyptus plant and essential oils for preventing mosquito bites. 6:105 3.Vol.01-1 %) mixed in kerosene and used as an insecticide reduced biting of human volunteers and catches of mosquitoes resting on walls in the rooms. World Health Organization. References 1. Educating urban residents on all aspects of malaria (such as Anopheles breeding grounds) is the need of the hour. extracted from the seeds of Azadirachta indica was used in a study. The high rate of occurrence and recurrence of malaria in the urban population is being masked due to lack of testing and fractional reporting by private practitioners. To this end. they are proving deficient. Neem oil (0. The line between anti-malaria measures and eradication of mosquito menace needs to be distinctly defined since vague awareness does not translate as complete knowledge. is the order of the day. such as coils. An effective result33 was obtained by vaporizing neem oil from mats: 5% neem oil was more effective at reducing both biting and numbers of resting mosquitoes than 4% allethrin on mats. vaporizers and sprays of Indian brands. mats. UNDP Human Development Report 2007/2008 Review of Global Medicine and Healthcare Research . Bhadwal S. Prophylactic measures are being undertaken but as they are based on the shaky foundation of out-dated concepts and sketchy hearsay. 1 (2010) 211 . Conclusions Large gaps are present between awareness and correct practice of protective measures. Sharma VP. World Malaria Report 2008. Of the six principal vector species. longer-acting personal and household protective measures which incorporate substances less damaging to human health. 1 No.32 Neem cream was found to be a safe and suitable alternative to insecticide impregnated coils. pg 75. A few grey areas have been identified. two. Kelkar U. Malaria Journal. Chemical sprays are in any case very dangerous to the environment and human health. as is seen in this study. 2. (2003) Battling the malaria iceberg with chloroquine in India. such as plant-based repellents. More detailed studies should be undertaken in urban areas of India to determine volume of use and subsequent health effects of various protective measures.culicifacies and An. innovative approaches and alliances must be forged to increase financing and improve research efforts.development of resistance.stephensi have begun to show wide spread resistance. creams. Discovery and research into more effective.34 Several other studies propagate the use of neem35. Neem oil.36 It is suggested that further research be done in the area of plant-based repellents as they show tremendous potential fighting the onslaught of malaria. 2002 TNN 10. March) Knowledge. December) The burden of malaria in Ahmedabad city.whoindia. 10. December) Health education for community-based malaria control: an intervention study in Ecuador. (2008. Parasitology International. Nonaka D. Review of Global Medicine and Healthcare Research . No. Annals of Tropical Medicine and Parasitology. Jan) Re-emergence of Malaria in India. Vilaysouk B. Sharma VP. Issue 1. March) Malaria education from school to community in Oudomxay province. March) Malaria related knowledge. Sunday. Malhotra MS. Southeast Asian Journal of Tropical Med Public Health. Bhatt RM. Yadav RS.4. (http://www. Pages 76-82 16. Gonzalez M. (1996. A Profile Of Malaria Research Centre Completing 25years (1977-2002) Pages 7. Banjara MR.htm) 11. 19-31. Tyagi P. India: a retrospective analysis of reported cases and deaths. Srivastava HC. June) Malaria outbreak in a tribal area of Gujarat state. Vol 97. (2005. 9. Kohli VK. Kroeger A. Disaster Preparedness Plan Update 2008 Leaflet. Banguero H. (2000. Ashwani K. Indian Journal of Malarialogy.org/EN/Section3/Section128/Section235. Vol 29. Phommasack B. Colombia and Nicaragua. Sharma VP. Lao PDR.(2003.Oct 19. 1(6):836-846 17. Mancheno M. 31(2):219-224 5. Daily News & Analysis (DNA) Newspaper.(1996.. 19(10):1099-1104. Waikagul J. J Vector Borne Dis. Bionomics Of Malaria Vectors In India.103:26-45. Tsukamoto K. Joshi AB. Jimba M. 15. Municipal Corporation Of Greater Mumbai 14. Indian J Med Res. Sharma A. Communicable Disease Surveillance (CDS). Thavaselvam D. Health for the Millions. 2008 8. Roy A. J Vect Borne Dis. World Health Organisation. (2008. Aug 27 (4): 22. Kobayashi J. (2001. 7. Singhasivanon P. Kano S. Malaria scare: Four More Dead. pp 35-40 18. 1 No. National Anti Malaria Programme. Public Health Department. (1992) Breeding habits and their contribution to Anopheles stephensi in Panaji. India.8. Yadav RS. July) Health in Delhi slums. semi-rural and bordering areas of east Delhi (India). awareness and practices towards malaria in communities of rural. Tateno S and Takeuchi T. 42: 30–35.Vol. Central Mumbai in malaria grip. pp 793-802 6. Meyer R. practices and behaviour of people in Nepal. 12. Articles Tropical Medicine & International Health. Sundar R. Social Science and Medicine. The Times Of India Newspaper. 1 (2010) 212 . 45(1):44–50 13. Volume 57.(1984) Socioeconomic factors associated with Malaria in Colombia. July 20. Ind J For the Practicing Doctor. (1986) Gambian cultural preferences in the use of insecticide-impregnated bed nets. 89. Khokhar A. J Vect Borne Dis. Malaria Vector control and Personal Protection: WHO Technical Report Series. 21. pg 13. 23. 31. Dua VK. 1 (2010) 213 . 2004. [Medline] 24. Attitude and Practice about Malaria and Mosquito Nets in Two Villages of Nepal. Datta U. 341–343. Environmental Health Perspectives. 32. 26. 33. Issue 2. Paudel IS. 27-31. Van Hoof JPM. Transactions of the Royal Society of Tropical Medicine and Hygiene 1993. Malaria Research Center (ICMR). Zhang J. vol. Health and PopulationPerspectives and Issues. Knowledge. Med. Effectiveness of Neem oil mats in repelling mosquitoes. Nagpal BN. Niraula SR . Vet. Vorham J. Kamat VR. 87. 295-302. (1995 Jun) Repellent action of neem cream against mosquitoes. Vol. Volume 80. Volume 52(6):885-909. 2007 March-April. Rozendaal Jan A. Sachdev TR. Curr. Oostburg BFJ. Das ML. Mosquito Coil Emissions and Health Implications. Journal Of Travel Medicine. Private practitioners and their role in the resurgence of malaria in Mumbai (Bombay) and Navi Mumbai (New Bombay): serving the affected or aiding an epidemic? Social Science and Medicine. Lengeler C. Volume 11. (2008 March) Efficacy of mosquito nets treated with permethrin in Suriname. 27. Vector control-Methods for use by individuals and communities. Sharma VP. 22. Urbanization and Vector Borne Diseases Commentary. 4(1). Entomol. Do mosquito coils prevent malaria? A systematic review of trials. 20. J Trop Med Hyg. . Sharma VP. Croft A. Goldstein BD. 141. Lawrence C. Matta S. 25. 1 No. 41. Mac Cormack CP.Roy L.. Aggarwal MK. pg 626 Review of Global Medicine and Healthcare Research . Report Of a WHO Study Group. Health hazards of mosquito repellents and safe alternatives. Pages 92-96. 29. Jalaludin J. Sharma VP. 353-365. 2001. Hashim Z. Sci. Snow RW. The Cochrane Library Database Syst Rev Issue 2: CD000363. (2004) Assessment of knowledge about malaria among patients reported with fever: a hospital based study. Liu W.(2000) Insecticide treated bed nets and curtains for preventing malaria. 2003 Sept 111(12). Book published by World health Organisation. 27 (2): 95-116. Tekhre YL: Knowledge. 55 138. Hashim JH. Attitudes and Practices of community in anti-malaria activities in a Delhi slum. 28. Rozendaal JA. Nagpal BN. 30. Srivastava A. Vol 3(4). Indian J Malariol. 32(2):47-53 .19.Vol. Page 38. Sharma VP. Vol. Chapter 14 Vector Biology & Disease Control Unit. 1994. Sharma VP.34. Department of Infectious & Tropical Diseases. Moore S. 36. Plant based Insect Repellents. 1 (2010) 214 . 35.A Profile Of Malaria Research Centre Completing 25years (1977-2002) Pages 171-174. Review of Global Medicine and Healthcare Research . Ansari MA. Personal protection from mosquitoes (Diptera: Culicidae) by burning neem oil in kerosene. London. Lenglet A. 1 No. 31(3): 505-507. Plant Origin Repellents And Insecticides. Journal of medical entomology. Hill N. thyroid hormone receptor activity. Current Contents. British West Indies. 1 No. diabetes. and primary L-carnitine deficiency was observed in a variety of nutritional deficiencies. Sarangapani Sreelatha2. Carnitine exerts hypolipidaemic effect by augmenting β-oxidation of long chain fatty acids. inhibiting the activity of HMG-CoA reductase the rate limiting enzyme in cholesterol biosynthesis as well increasing bile salts and bile acid synthesis by sparing vitamin C which is also one among the precursor of carnitine biosynthesis in vivo. plasma fibrinogen and serum homocysteine levels and hence reduces the risk factors of thrombogenic burden and Cardiovascular Diseases (CVS). metabolic syndromes. Carnitine increases lipoprotein lipase activity. Cayman Islands. ST Matthew’s University School of Medicine. Singapore * Corresponding Author. Email: kumarp@smu. Gandhi Kavitha2. 2 Faculty of Science. Therapeutic applications and pharmacological effects of L-Carnitine and its congeners were studied through a systematic review of the literature by searching MEDLINE. male infertility and aging was not described until 1970s. On administration L-Carnitine will be converted in to its acyl derivatives and can easily penetrate in to the membranes and blood brain barriers. HDL-C and heat-shock protein biosynthesis and decreases LDL-C. a conditionally essential quaternary amine.ky Abstract L-Carnitine (LC) otherwise known as Vitamin BT (β-hydroxy-γ-trimethyl amino butyric acid). pathological conditions and xenobiotics-induced toxicities including antibiotics and antineoplastic agents and heavy metals. alleviates alcohol induced toxicities and spares choline and methionine hence exerts hypolipidemic antiatherosclerotic effects. leptins and adipokinins and certain lipolytic enzymes. 1 (2010) 215 . inhibits xanthine oxidase Review of Global Medicine and Healthcare Research . prostacyclin (PGI2). insulin-like growth factor (IGF-1) and exerts insulin mimetic effect and prevents the formation of advanced glycation end products (AGEPs). Although L-carnitine was originally discovered in 1905. National University of Singapore. On supplementation carnitine and its derivatives interacts in the membrane molecular level and enhances expression of uncoupuler of oxidative phosphorylation.Therapeutic and Clinical Applications of LCarnitine and its Congeners as a Potent Nutrigenomic Membrane Molecular Antioxidants in Health and Disease Ponnusamy Kumar1 *. its crucial role in metabolism was not elucidated until 1955. Uma Senthilkumar1 1 Department of Biochemistry And Biomedical Genetics. Entrez PubMed from 1960 to Dec 2009 and delineated the molecular mechanism of Levo-carnitors as a nutrigenomic regenerative antioxidants.Vol. Carnitine alters membrane fluidity and increases membrane stability. There is a decrease in the concentration of carnitine in blood and tissues in a variety of nutritional deficiencies. Carnitine enhances glycolytic and TCA cycle enzymes. Grand Cayman. plays a vital role in lipid metabolism and production of ATP through β-oxidation and subsequent oxidative phosphorylation. lysine. 1998. L-Carnitine prevents oxidative stress.. 1984.2003. Melegh et al. Keywords: L-Carnitine. Cha. anti-aging antioxidants. Supplementation of carnitine improves overall energy metabolism and ameliorates toxicities induced by a variety of genotoxic agents and xenobiotics (Loots du et al. 1971). with radicals. Stevens et al. nutrigenomics. spares / increases protein synthesis. 1 (2010) 216 . 1991). 2004). 1993 & 1997. Acetyl-Lcarnitine... 1996. 2008).Vol. being released in a primary reaction. methionine. 1981). antimutagenic. increases melatonin biosynthesis in addition maintains normal metabolism in a variety of pathological conditions and experimental studies. vitamin B6 and iron are the precursor molecules and cofactors required for the biosynthesis of carnitine (Rebouche. Fe2+ and Fe3+ ions are involved in the triggering of peroxidation reactions. can easily cross the blood-brain barrier to improve energy transport and repair mechanisms in nerve tissue.(XO) and neutrophil superoxide radical formation. Ascorbic acid. sequestrates calcium. Kopple et al. hyperlipidaemia. prevents the accumulation of protein carbonyl content (PCC). lipotropic. L-Carnitine increases mitochondrial electron transport chain (ETC) complex enzymes. Carnitine deficiency is associated with innumerable pathological conditions and nutritional deficiencies (Walter. Administation of several antibiotics causes carnitine depletion and hence carnitine supplementation is recommended (Arrigoni-Martelli & Caso. 1 No. membrane stabilizing.. 1987. Introduction L-carnitine is a conditionally essential quaternary amine plays a vital role in the metabolism (Rebouchi and Engel.. Loots du et al. L-Carnitine enhances immunity. prevents mitochondrial myopathies. Deeks. 2003. and its supplementation will be beneficial in health and disease as well as aquaculture and agriculture especially during infection. Carnitine exerts neuroprotective effect by forming acyl derivatives with a variety of xenobiotics and enhances the clearance and mitigates the toxic onslaught of the xenobiotics (Mazzio et al. 2002). immuno-modulatory. Carnitine enhances thermogenin and bile acids biosynthesis and hence prevents obesity (Sundin et al. Iron deficiency limits carnitine biosynthesis and at the same time impedes haematopoiesis. 2001. increases urea cycle enzymes. apoptosis and enhances nitric oxide radical (NO·) and proatacyclin (PGI2) synthesis and enhances sperm count and motility activity and beneficial in erectile dysfunction. proteogenic.. erectile dysfunction.. 2004 . iron-chelating. immunomodulation. chelates iron and hence prevents lipid peroxidation (LPo) and exerts anti-anaemic effect. 2002). These hydroxyl radicals (OH·) continue the peroxidation reaction. and their consequent catalytic effects.. which eventually results in the destruction of membrane Review of Global Medicine and Healthcare Research . A 3-hour pre-treatment with L-Carnitine increases the expression of brain m-RNA in aged rats and augments neuronal DNA biosynthesis and neurotrophic factors and hence exerts anti-ageing effects. anti-aging antioxidants.. Thoma and Henderson. xenobiotics-detoxifying. Hence Levocarnitors are potent nutrigenomic regenerative molecular medicines. Challoner et al. increases poly(ADP)ribose polymerase and hence prevents DNA single strand breaks and anneals point mutations and exerts anti-mutagenic and anticancer effects. L-Carnitine and its derivatives are potent hypoglycemic. 1990. antiperoxidative. Virmani et al. . and the resulting improvement in circulation. As a result. Propionylcarnitine appears to sequester the Fe2+ ions (Reznick et al. In a placebo-controlled study with 24 patients. Donatelli et al (1987) observed that administration of Lcarnitine resulted in an increase in Na-K-ATPase activity. Dayanandan et al. thus facilitating more economical use of the expensive haematopoietic hormone.. for a constant rate of haematopoiesis there is an increase in haematocrit value.. 1982. 1992). hyperactivity and sleeplessness. 1990). 1992) in addition chelates iron (Reznick et al. each of whom received 1. 2001)... erythropoietin.. H. Pola et al (1991) observed as a result of L-carnitine a reduction in the time taken for haemofiltration and an increased erythrocyte flow rate. 1 No.1993. L-carnitine occurs mainly in its esterified form (approximately 10 times the concentration found in plasma). Igisu. Alvarez.. Sachan & Yatim. and protects endothelial cells against permeability changes caused by lipopolysaccharides. in erythrocyte count.Vol. which have Review of Global Medicine and Healthcare Research . ameliorates metal ions and ammonia induced toxicities (Belli.. Lcarnitine prevented fibrinogen-mediated aggregation of erythrocytes. 1992). 1993). Fritz et al (1991) were able to show that. Carnitine detoxifies potent hepatotoxic/carcinogenic xenobiotics and exerts antimutagenic/anticarcinogenic effects (Yatim & Sachan. Supplying L-carnitine can prevent the formation of radicals and propionyl carnitine itself need not be given since L-carnitine is converted into propionyl carnitine inside the cell. in contrast to choline or ß-methylcholine. and helping to stabilise the cell membrane and acting as a buffer for Na-KATPase. 2001. It has been shown that acyl carnitine can facilitate the ATP-free incorporation of both long and short-chain activated fatty acids into phospholipids of the erythrocyte membrane (Arduini et al. A deficiency of L-carnitine in blood plasma resulted in weakening of the erythrocyte membrane and an increased rate of haemolysis and ultimately anemia (Tein et al. No toxicity related to L-carnitine therapy was observed and dose reductions were not necessary (De Simone et al. In erythrocytes. and increases liver P450 detoxification support by enhancing drug-metabilizing enzymes and prevents lipid peroxidation induced by environmental pollutants (Messineo et al.. Corsico et al (1993) noted that free L-carnitine and short-chain L-carnitine esters protect against the occurrence of vascular lesions. might also be responsible for side effects such as increased alertness. sequestrates Ca2+ (Messineo et al. 1982). Boerrigter et al. Reichmann et al (1994) found that erythrocytes contain about four times as much L-carnitine (240 μmol/l) as the ambient blood plasma (60 μmol/l). 1982. and thus discouraged thrombosis (Martinez. The vascular dilatational effect. 1996).lipids. and also in haematocrit and haemoglobin values.. 1988. Carnitine enhances membrane stability (Berard & Idorche. 1992) thus preventing them from taking part in the primary reaction. 1992. it was possible to save 38% of administered haematopoietic hormone.000 mg L-carnitine every time they had dialysis treatment. 1995). et al. 1993).. 1992). 1 (2010) 217 . Carnitine prevents anthracycline-induced toxicities in sarcoplasmic reticulum by sequestering calcium (Ronca-Testoni et al. tumor necrosis factor-α (TNF-α) or other inflammatory factors (Uhlenbruck. erythropoietin (Labonia et al.. 1992). Tremblay & Bradley. Matsuoka. thus contributing to a loosening of molecular packaging of polar phospholipids in the bilayer region. Other studies have shown that L-carnitine enhances the blood supply to peripheral vessels (Corsico et al 1993).. 1992). 1993). Through administration of L-carnitine and the resulting improvement of membrane properties it is probably possible to increase the life of the erythrocyte membrane and reduce haemolysis (Ahmad et al. The key to improving oxygen supply and increasing erythrocyte stability lies modulating lipid composition of the erythrocyte membrane and in increasing the activity of Na-K-ATPase.. Franceschi et al. 2005. 2000). 1995). Leukocytes (granulocytes. 1996. 1984). who had been unresponsive to other forms of therapy. In 14 of the patients (80%) the trophic lesions and ulceration of the skin disappeared completely. Carnitine increases humoral immune response. improved healing of ulceration wounds on the extremities was observed (Pola et al.1990).. Jirillo et al (1991) and (1993) found that as an immunostimulant L-carnitine was capable of helping in the treatment of infections such as tuberculosis and leprosy. Uhlenbruck. and improves metabolic parameters of AIDS patients (Patrick. 1993. shows good activity against a wide range of bacteria. and fungi. 1993). L-carnitine increases the proliferative responses of both murine and human lymphocyte following mitogenic stimulation and increase polymorphonuclear chemotaxis (Moraru et al. Carnitine increases the monoclonal antibody production of mouse-hybridoma cells in culture (Athanassakis et al. L-carnitine reduces lymphocyte apoptosis and oxidant stress in HIV-1infected subjects treated with zidovudine and didanosine (Deeks.. L-carnitine treatment which was accompanied with a significant enhancement of chemotactic and phagocytic activity being restored to control levels.. 1998). In another study. Carnitine posses a versatile immunoprotective effect in a variety of experimental studies (Deufel et al. 1990). Dietary L-carnitine supplementation (100 mg carnitine/kg added to feed) increases antigen-specific IgG production in broiler chickens (Mast et al. 2000). and exerts antiviral effect (Kang et al. 2003). these findings demonstrated that L-carnitine is capable of restoring the age-related changes of neutrophil functions (Moraru et al.. preliminary observations suggest that L-carnitine-preloading also protected peripheral blood lymphocytes from old donors when such cells were exposed to an oxidative stress (Boerrigter et al. Review of Global Medicine and Healthcare Research . 2000). A new class of carnitine derivative antimicrobial amphiphile.. Böhles et al (1994) observed a massive increase in L-carnitine content in granulocytes and lymphocytes in cases of bacterial infection and Crohn's disease. "soft". L-carnitine therapy also led to a drop in the frequency of apoptotic CD4 and CD8 lymphocytes and increases T cell counts (Athanassakis et al.. 2001).. through the administration of L-carnitine it is also possible to produce a dosedependent increase in leukocyte ATP production... AIDS patients were found to have depressed levels of plasma L-carnitine and low Tlymphocyte counts. 1990).. and are thus dependent on a rich supply if they are to maintain a high level of activity (Guzman et al 1996). Eighteen patients. 1991).frequently been reported (Tesch et al. were given Lcarnitine. 1994). of the type (CH3)3N+-CH2-CHOCO(R1)-CH2-COO(R2) Cl-.. Various authors have reported on the mitigating and protective effects of L-carnitine in the treatment of septic shock (Fritz and ArrigoniMartelli. monocytes and lymphocytes) are relatively rich in Lcarnitine (Deufel et al. quaternary ammonium L-carnitine esters. This provides an initial indication of the importance of L-carnitine in respect to immunological processes. 1 No. Lcarnitine modifies the humoral immune response in mice after in vitro or in vivo treatment. antigenspecific IgG and overall immunity. Activated leukocytes consume up to 50% of their intracellular L-carnitine reserves within just one hour.. Increase of specific antibody response to bovine serum albumin in pigeons due to L-carnitine supplementation has been reported (Janssens et al. Famularo and De Simone. 1 (2010) 218 .Vol. Leukocyte L-carnitine levels were also depressed and administration of 2-6 g/d L-carnitine supplement improved these patients immune status (De Simone et al (1994). 1992). yeasts. 1989. Khairallah & Wolf. Torreele et al. Cederblad. 1987. and in damage to the musculature compared with those who had been given a placebo (Giamberdino et al. which have demonstrated a L-carnitine-mediated increase in muscle energy production and oxygen uptake (Angelini.. Sushamakumari et al. Claudicatio intermittens. or instead perhaps incorporated into fatty tissue or excreted. 1990 ). Researchers have observed that the addition of L-carnitine and propionylcarnitine facilitates the repair of damaged phospholipids (Arduini. and thus improve the utilisation of body fat reserves. Brevetti et al (1988) observed in patients with circulatory disorders of the legs. methionine. increases heat shock protein HSP in the brain (Abdul et al. 2001). creatine phosphate and erythropoietin (Takada et al. 2003). reduced glutathione. Carnitine exerts sparing effect on protein.1994) and alters acetyl CoA/CoA pool and enhances acetyl CoA decarboxylase (Hotta et al. Following Review of Global Medicine and Healthcare Research . (shop-window leg) a doubling of the pain-free distance that could be covered in 33 male test persons following administration of 2x2 g of L-carnitine / day. 1986.. The described clinical data have been confirmed in muscle biopsies.. Frösch. the increase in physical strength and bodily performance achieved through the administration of L-Carnitine is so great that it is now recommended globally by the Polio Association (1993) (Frosch. 1994). 1998. 1985.... 2002) by increasing poly (ADP)-ribose polymerase (Monti et al. Takada et al.. 2002. In Untrained test persons... 1992). 1993) and exerts hypolipidemic effect (Dayanandan et al. Administration of L-carnitine was found to increase lipolysis. Lcarnitine and its derivatives increases cytochrome oxidase subunits (Gadaleta. Corbucci 1984. Owen et al... Several studies on pigs. The test persons performed identical levels of physical exertion to the point of muscle damage. et al. Levine et al. Maggiani et al. in muscle weakness following exertion. Eclache 1984.. Evidence that L-carnitine increases fatty acid oxidation has been reported by various research groups (Scholte et al. prevents apoptosis and alters gene expression (Moretti et al. following which the damage was ascertained. Horl.. Lehmann-Bouri. supplementation of LC 3g/day led to a significant reduction in muscle pains.. Dragan 1984. 1976. Hoffman et al. L-Carnitine produced better results than the placebo. 1996). cyclists and marathon runners. 1986. RNA and ultimately proteins (Juliet et al... L-carnitine was found to increase physical performance and reduce recovery times (Angelini 1986. 1993). 1993 & 1995). foal.2005). Considering the large number of studies demonstrating a reduction in plasma triglycerides by L-carnitine. including cardiac arrhythmias and fibrillation as a result of ischaemia and oxidative stress are closely linked with the integrity of membranes (Fritz and Arrigoni-Martelli. Cooper.. 1996). enhances age-related reduction of mitochondrial DNA transcription (Gadaleta et al. Hibbert et al. while in Germany the health insurance companies reimburse the costs of treatment. 1994). vitamin C. 1988. 1987. Carnitine enhances the biosynthesis of DNA.. 1986. 1992. Angelucci et al. 2005. 2000). 2006). 1 No. 1994.Carnitine and its derivatives interacts in the molecular level and anneals the DNAsingle strand breaks (DNA-SSBs) induced by xenobiotics (Boerrigter et al..Vol. 1979). A series of pathological disorders. peripheral occlusive arterial disease. thiol. lysine.. Horiuchi et al. 2001. In the case of poliomyelitis patients. quail and broiler chickens demonstrate a positive nitrogen balance and growth improvement by feeding extra dietary L-carnitine (Greenwood et al. In rowers. 1992). 1993) and age-related mitochondrial DNA deletions (Hagen et al. fish.. one is bound to ask whether they were actually used in energy production.. 1 (2010) 219 ... Spagnoli (1990) found that one year of L-carnitine supplementation had an anabolic effect on the skeletal muscles of haemodialysis patients. 1-2 more piglets per litter survived and were stronger. the piglets developed more red muscle fibre and contained less fat while still in their mother's womb. De Simone (1999) found that in AIDS patients the mean level of IGF-I increased from 0. means that more of these amino acids are available for protein synthesis and muscle building. Musser et al (1999) found that giving L-carnitine to sows increased the levels of glucose. following physical stress. Cavallini et al (2004) reported that carnitine is more active than testosterone for improving symptoms of male aging such as sexual Review of Global Medicine and Healthcare Research . L-carnitine increased the proportion of branched amino acids from 22% to 41%). Lohninger et al (2000) elucidated the genetics of how the administration of L-carnitine results in an increased production of IGF-I. in addition. as did the haematocrit value.. L-Carnitine was found to increase BCAA´s from 22 to 41%. indicating improved energy production. 1 (2010) 220 . which were given L-carnitine. a positive nitrogen balance was achieved more speedily (Heller et al. compared with the control group. producing an increase in muscle size and in body weight. In in vivo experiments with human skin tissue. Increased levels of branched amino acids as a consequence of L-carnitine administration has also been reported by Berchiche et al (1994).06 ng/100 mL to 3. IGF-I is a potent growth factor which promotes the production of fat-free muscle tissue in the body.. Ahmad et al (1990). 1994). et al. Serum albumin also increased during supplementation by increased hepatic protein biosynthesis.. thus improving energy production. Heller et al (1986) observed that administration of carnitine promoted the burning of long chain fatty acids (LCFAs). a significant reduction in total body fatty in the L-carnitine group. Hudson et al (1996) were able to show that IGF-I significantly increases the activity of the carnitine acyl transferases CPT-I and CPT-II. protein synthesis and protein content (BCAA’s) following topical application of L-carnitine (Scholte et al (1979).Vol. Following birth. which. L-carnitine stimulates pyruvate dehydrogenase complex (Arenas. serum creatinine and phosphate in the patients' blood were decreased..17 ng/100 ml over a period of 8 weeks as a result of administering 3 g L-carnitine per day. These new findings may offer an explanation for a new mode of action of L-carnitine. 1994) and acetyl-L-carnitine decreases glycation of lens proteins in vitro studies (Swamy-Mruthinti & Carter. an increased rate of long-chain fatty acid oxidation was observed. while the levels of urea. and also promoting the reestablishment of a positive nitrogen balance.administration of L-carnitine. Tein et al (1990) found increases in fatty acid oxidation. 1 No. 1999). Brevetti et al (1988) found that long-term L-carnitine supplementation increased physical performance and had a trophic effect on skeletal muscle in patients with peripheral vascular occlusion disease. in which it reduces significantly the catabolism of muscle tissues (Böhles. Owen et al (1996) were able to demonstrate that L-carnitine supplementation increased palmitate oxidation. In a study with pregnant sows. At the same time. 1985). and protein synthesis in the liver of live pigs. the amount of branched amino acids. was observed. 1986). L-Carnitine has long been given to patients being fed parenterally. 2000). found that long-term L-carnitine supplementation increased physical performance and had a trophic effect on the skeletal muscles of haemodialysis patients. thus producing a better training effect (Berchiche. insulin and IGF-1 in their blood plasma. they grew more quickly and retained their favourable fat to muscle ratio (Eder et al. but after L-carnitine supplementation was discontinued muscle fibre diameter decreased. Within 12 months L-carnitine led to growth of type-I muscle fibres. Biochimica Biophysica Acta. R & Giorgio. 38. Ahmad. Arduino. and fatigue (Laurie Barclay & Charles Vega.. 912-918. (1990).. L. Calabrese. Effects of L-carnitine and its acetate and propionate esters on the molecular dynamics of human erythrocyte membrane. A. 2004). membrane stabilizing. (2006).A. A. Kurtin. Nerve growth factor binding in aged rat central nervous system: effect of acetyl-L-carnitine. antiperoxidative and anti-ageing antioxidant effects. Acetyl-Lcarnitine-induced up-regulation of heat shock proteins protects cortical neurons.A.. H. L-carnitine and its derivatives exerts potent immuno-modulatory.. and its supplementation will be beneficial in health and disease as well as aquaculture and agriculture especially during infection. 2001). Arduini A. Carnitine enhances sperm motility against xenobiotic induced toxicities in experimental studies (Mangano et al. G..M.). 491-496. DiMauro S. Sherwood G. Journal of Neuroscience Research.. R. S..Vol.. A. Arduini. M.. Francesco M. K. N. 398-408. Kidney International. Katz. (eds.. V.. H. Angelucci. WerrbachPerez.F. 2000).. Sciarroni. Neuroscience Research.M.D. M. M.. Nicora. kidney and renal dialysis... M. Hence Levo-carnitine and its acyl derivatives are potent nutrigenomic regenerative molecular medicines.A. 152. 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Seim. A.Vol.V & Oscar.and Clinical Applications. D. (2001). Maria. Walter. Journal of Inherited Metabolic Diseases. Annals of the New York Academy Sciences.... (pp. Patricia. 225-232.D. A. Carnitine alters binding of aflatoxin to DNA and proteins in rat hepatocytes and cell-free systems. Yatim. 1 (2010) 231 . & Sachan. methamphetamine... 32(5). Binienda. L-carnitine in inborn errors of metabolism: what is the evidence?. H...M.H. 26 (2-3). Oscar. H. Kidney International. Journal of Nutrition. S. S. Gaetani. & Ali. Löster. 181-188. J.H.S. (1987). To determine the reasons for the same. It is one of the most important factors for the social and economical development of the nation. India Email: sankalpy@yahoo. it leads to wastage of funds invested in school buildings. 5. To study the socio-demographic profile of school dropouts. Dropout does not mean mere rejection of school by children. teachers’ salaries. 3. India Abstract Background Education is attainment of knowledge.Determinants of school dropouts in children Sankalp Yadav Pravara Institute of Medical Sciences Maharashtra. India Email: drpiyushkalakoti@gmail. To know the health status of school dropouts. 1 No.com Nadeem Ahmad Department of Community Medicine Rohilkhand Medical College & Hospital. 4. 2. textbook and so on. and equipment. the government of India is trying its level best to ensure proper growth and development of the villages by providing education. To suggest recommendation. It also means the existence of some deficiencies in the organization of primary education system2. a source of employment. To know the prevalence of school dropouts in the tribal community of Chandrapur. The problem of drop out has been continually troubling the primary education system not only in India but in other developing countries also.com Piyush Kalakoti Rural Medical College Pravara Institute of Medical Sciences. Methods Review of Global Medicine and Healthcare Research . India is a country of villages. 1 (2010) 232 . Objectives 1. enrichment of culture.Vol. 153 were dropout.Design of Study: Cross-sectional prospective study. while strict teachers and failure in school was 40% and 37% respectively. 1 (2010) 233 . A high proportion of dropouts said they found difficulty in understanding language in school. Study subject: Children of age 6-14 years who were not attending school for 6 months or more. 33% males and 76% in the age group of 10-14 years and 24% in the age group of 6-9 years irrespective of their standard. Consent: Informed and written consent to be taken from community leader for the cooperation from the community. Hindu girls showed 88.Vol. 1 No. Statistical Analysis: Chi square test and logistic regression model used to analyze the data.1% dropouts and Muslim boys showed 36.4% females never enrolled in school. Help of Aanganwadi worker. as well as informed and verbal consent to be obtained from parents /guardian / elder sibling who will be present at home at the time of survey. 67% were females. 48% dropped out in primary and 33% dropped out in primary. Loni. This prevalence was significantly higher in females than males and in general more in the age group of 10-15. Thus. not all the members of the family could be educated regarding the importance of going to school. About 25. Conclusion The prevalence of school dropouts was high in the urban slums. Review of Global Medicine and Healthcare Research . about 63%. Results The results found showed that out of 286 children.4% dropouts. female health volunteer and Medical social worker will be taken. 68% of the dropouts had dropped out on account of domestic work and 56% as they had to look after their siblings. Study Area : Tribal community of Chandrapur village under field practice area of RMC. Study sample: All children belonging to the age group 6-14 years who had never enrolled or were not attending school from past 6 months or more. Whereas 73% of dropouts parents were unaware of importance of education. 77% were not interested in studying and 82% were not aware of importance of education Study Limitation Suggestions could not be given to all the members of the family as everyone was not present at the time when survey was done. Alone in Maharashtra 60% school dropouts are seen. a primary school was opened in every village in the state having a population of about 2000 and above2. The government has planned several projects to counter education to the children as its goal. The sixth five year plan. 1 No. harassment by classmates and teachers. particularly giving attention to the school drop outs and to those groups which were in danger of being left behind because of their special circumstances. competent manpower for implementing the process of development. It is one of the most important factors for the social and economical development of the nation. The goal for universal elementary education should have been achieved within a period of 10 yrs. even than many are deprived of it." But since then it has remained a long cherished dream.The dropouts are due to involvement in domestic work. It is in perspective the constitution states under article 45 of directive principles that "state shall endeavor to provide free and compulsory education for all the children up to the age of 14 yrs. India is a country of villages. Its approach was to ensure essential minimum education to all children up to the age of 14 years within the next 10 years. even then results obtained are less than satisfactory. lack of awareness in both children and parents etc. almost 50-60% children do not go beyond their primary school4. the government of India is trying its level best to ensure proper growth and development of the villages by providing education. During the sixth plan period. textbook and so on. ill health. earning money and failing in the exams. 1 (2010) 234 .Vol. pointed out the critical role of education in the process of economic development and how it was the principle means of creating human capital of trend. Since education is very important for the development of both the individual and the country. Dropout does not mean mere rejection of school by children. This alarming rate of school dropouts and illiteracy is a major setback to country’s social and economical development. teachers’ salaries. literacy and progress of the nation. School dropouts. there are various causes that leads to school dropouts like poverty. employment. socio-economic status. Keywords: Education. a source of employment. This condition is even worst in tribal communities. while almost 300 million people in India can't read their own name3. malnutrition. Village Introduction Education is attainment of knowledge. There are schools dropouts. But.1 education is the major factors affecting the health. it leads to wastage of funds invested in school buildings. The problem of drop out has been continually troubling the primary education system not only in India but in other developing countries also. enrichment of culture. and equipment. it becomes inevitably crucial to study the determinants causing this Review of Global Medicine and Healthcare Research . It also means the existence of some deficiencies in the organization of primary education system2. the estimated school dropout are around 50-60%. It is stated in the doctrine of human rights 1948 that everyone has right to education. grave problem of school dropouts. father's and mother's literacy and occupation status. family background and the various reasons like school dropout pertaining to family. Duration of study: The duration of study will be of 2 months. 2. Review of Global Medicine and Healthcare Research . information will be cross checked from senior family member present at the time of data collection. Loni. Children who were residing in the study area for less than 6 months. Study subject: Children of age 6-14 years who were not attending school for 6 months or more. Data Collection: House to house survey to be conducted to cover all children of school age group 6-14 years. It's high time to take up the cudgels against this menace. The children who had left school between 6-14 years of age. Materials and Methods Design of Study: Cross-sectional prospective study. Study sample: . > Exclusion criteria: Following criteria were used to exclude the subjects from the present study. who were not attending school for 6 months or more than 6 months to determine the prevalence and causal factors of school dropouts. Study Area: Tribal community of Chandrapur village under field practice area of RMC. 1 (2010) 235 . This study aims at achieving the same in the children between 6-14 years in tribal community of Chandrapur village in rural Maharashtra.Vol. Information will be collected regarding personal data. 1. 1 No. This 100% population will be considered for calculating prevalence. Data to be collected on pre tested structured proforma from each study subject and to confirm reliability. 1. The absence from school for 6 months and more. > Inclusion criteria: Following criteria were used to involve subjects in the present study.All children were belonging to the age group 6-14 years who had never enrolled or were not attending school from past 6 months or more. pertaining to school and to self of school dropouts which was followed by the physical examination of each subject. 8) 20(29. a)6-9years b)10-14 years 2. Particulars Age group Male N=33(%) Female N= (67%) Total N=100(%) P value 0. 1 shows that.out of 153 school dropout children.8) 17(25. Results The present study was conducted in the tribal area of Chandrapur village in which total number of children belonged to age group 6-14 years was 286 children from which 153 children were not attending school.4) 50(74.05 Table no. 1 (2010) 236 .Vol. Help of Aanganwadi worker.6) 24(24) 76(76) 0.4) 30(44.Statistical Analysis: .Chi square test and logistic regression model used to analyze the data.647 1.Informed and written consent to be taken from community leader for the cooperation from the community.5) 13(39. there were maximum numbers of female dropouts (67%) as compared to male children (33%). female health volunteer and Medical social worker will be taken.2) 26(78. I: Distribution of school dropouts according to their personal perspective Sr. Table No. But according to age group there was no significant Review of Global Medicine and Healthcare Research .9) 19(19) 48(48) 33(33) 0.9) 80(80) 20(20) 2(6.4) 59(88. The overall prevalence of school dropouts comes to 53. 100 children contacted by house to house survey considering inclusion and exclusion criteria for gathering information. Religion 7(21.49%. a)Hindu b)Muslim Educational status a)never enrolled in school b)dropped out in primary c)dropped out in secondary 21(63.6) 12(36.066* * p<0.1) 18(54. 1 No.004* 3.04) 17(25. as well as informed and verbal consent to be obtained from parents /guardian / elder sibling who will be present at home at the time of survey.No.1) 8(11. Consent: . 1) 2(6.6) 13(39.7) 43(43) 57(57) 0.280 13(13) 0. 2(6.7) 11(16.4%). Fathers education Female N= (67%) Total N=100(%) P value 0. almost 4 times the Muslim school dropouts.9) 42(45.Vol.No Particulars Male .4) 38(56. 20(60.9) 15(22. However.4) 6(18.4) 12(36. It was also observed that. 1 (2010) 237 . Review of Global Medicine and Healthcare Research . Fathers occupation 23(69.4) 23(34.3) 25(41) 9(14.3) 46(68.2) 27(44.2) 14(42.4) 7(21.4) 34(50.8) 2(2. a)Unemployed b)Unskilled labor c)Skilled labor d)Business Mothers education a)Illiterate b)Literate Mothers occupation a)Working b)Not working Socio-Economic Status a)Class 2 b) Class 3 c) Class 4 d) Class 5 Type of Family a)Nuclear b)Joint c)Broken 11(34.1) 13(39.4) 12(36. There is a marked significance difference in attending school among Hindu girls (88.3) 44(65. Table 1(a): Distribution of school dropouts according to their family perspective Sr.difference (p>0.2) 11(11.7) 18(26.7) 21(31.2) 27(81.8) 6(18.8%) while school dropouts was seen more in Muslim boys (36.6) 7(10.916 a)Illiterate b)Literate 5. there were more Hindu dropouts.7) 10(30. 1 No.066* 8.013* 7.607 48(48) 30(30) 22(22) 9. there is marked rise in school dropouts in the age group 10-14years.4) 9(9) 24(24) 50(50) 17(17) 0.8) 0(0) 38(40.2) 60(89.099* 6.3) 69(69) 31(31) 0.4) 11(16. who drops the school in the primary section as well as secondary.2) 7(10.2) 2(6. N=33(%) 4.05) in male and female population.4) 87(87) 0. The study reveals a high number of girls who had never enrolled in school and were about 4 times the number of boys.4) 17(53. 2) 19(19) 14(14) 22(22) 20(20) 58(58) 54(54) 0.2) 9(27.5) 68(68) 5(5) 0. 1 (2010) 238 .6) 19(57.003* 0. significantly higher proportion of Review of Global Medicine and Healthcare Research .3) 20(60.1) 56(56) 73(73) 0. 6. While high proportion of boys dropped out of school whose fathers were engaged in unskilled labor and business.fathers alcoholism(58%) and domestic violence(54%). but there is no significant difference between male and female dropouts according to fathers’ education.2) 7(21.360 5. High proportion of school dropout males were noted whose mothers were working.The high proportion of school dropout children observes with illiterate fathers (69%).8) 44(65.4) 26(78. 10.95) 7(10. 8.615 Domestic violence The high proportion of children dropped out of school mainly because parents were unaware (74%)of education followed by involvement in domestic work(68%) .No . The study reveals that in general a high number of school dropout belong to the group of fathers being unemployed and engaged in unskilled labor.733 3. where as highest proportion of females remained away from school even though their mothers were not working. whereas.4) 38(56.7) 35(52.372 0.019* 0. 12(36.6) 3(4. there is borderline significance (p=0.6%) and to look after siblings.3) 11(33.711 0. 4. 9. Both male (81. However there is no statistical significance observed. Almost half of the school dropouts were belonging to nuclear type of family but there is no significant sex wise difference noted according to the type of family. Table 2: Distribution of school dropouts according to causes related to family Sr.8%) and female (89.6) 14(20.Vol. 1 No.05) in the number of school dropouts being more in girls in unemployed and skilled labored father. However.145 0. Reasons pertaining to family Involved in domestic work Have to change residence frequently Look after siblings Parents unaware of importance of education Parents separated/died No books/clothes Unaffordable fees Earning money Fathers alcoholism Male N=33(%) Female N= (67%) Total N=100(%) P value 1.005* 0. 2. 7. 16(48.4) 9(13.1) 52(77.491 0. 5(15.7) 47(70.4) 13(19.5) 2(6.Significantly high proportion of girls were not able to attend school only because they were involved in domestic work(77.6%) dropouts were observed in high proportion with illiterate mothers (87%). 095* 0.9) 11(6. 4.5) too 2(6. unavailability of books and clothes. (p<0.3) 37(55.148 Finding language difficult Strict teachers Fear of punishment Harassment by teachers Unfriendly classmates Distance much Time is convenient 26(78. There is no significant difference in male and female population with regards to change of residence. 6. 21(31. unaffordable fees.357 0.037* 0. 2.5) 18(26. 5.Vol. 1 No.8) 18(54. parents being unaware of the importance of education . (p=0.075* 0. it was significantly higher in proportion by the boys.009* 0.005) Though the harassment by teachers was less prevalent.9) 8(11. 7. Table 3: Distribution of school dropouts according to reasons pertaining to school Sr. 1 (2010) 239 .2) 22(32.5) 13(39. Among these reasons.parents having separated or died. unfriendly classmates (34%) and fear of punishment (28%).5) Female N= (67%) Total N=100(%) P value 1.1) The study shows difficult language as the most prevalent (65%) cause of school dropouts followed by strict teachers (40%).8) 15(22. fathers alcoholism and domestic violence. all are showing statistically significance except failure in examination which is of borderline significance. failure in examinations (37%).4) 7(21.4) 3(4.1) not 2(6.4) 37(37) 63(63) 40(40) 28(28) 10(10) 34(34) 10(10) 13(13) 0. 3.No. Reasons Male pertaining to N=33(%) school Failed in exam 16(48.2) 16(48.022* 0.boys said they were not attending school because they were busy in earning money.05) Review of Global Medicine and Healthcare Research .032* 0. 8. of school dropouts are in the category of unaware of importance of studying and not interested in studying. However.093* 0. unaware of importance of education. Stepwise backward logistic variation of all O R the causes Failed 0.8%. 3.355 p B 1. 1 No.019* The study shows that major no.7% than females 44.271 Time problem Domestic work Earning money 4. Reasons pertaining to self No confidence No interest in studying Unaware of the importance of education Neglected by parents Mental retardation Mischievous Behavior Male N=33(%) 16(48. 4.No.1) Total N=100(%) 39(39) 77(77) P value 0.010* 0.603 4. 5.606 1.3) 2(3) 30() 41(41) 2(2) 53(53) 0. 12(36. 1 (2010) 240 .288 The study shows that domestic work is the commonest cause of school dropout amongst all causes.3) 51(76.766 1.4) 0(0) 23(69. 5. Table 5: Stepwise backward logistic variation of all the cause of school dropouts Sr.6) 82(82) 0. There is no significant difference in male and female with regards to no confidence. neglect by parents and mental retardation. 3.8) 54(80.172 0.Vol.508 0.7) 29(43. being 6 times more in females as compared to males.234 Unfriendly classmates 0. 0.452 -1.8) Female N= (67%) 23(34.001* 0. 2. 2.Table 4: Distribution of school dropouts according to reasons pertaining to self Sr.810 -1. 6. no interest in studying.039* -1.316 0.112 0.5) 26(78.983 6.No. 28(84. significant difference found in males and females with regards to mischievous behavior and is more in males about 69.044* 0. Review of Global Medicine and Healthcare Research .036 1. 281 0.461 1. Table 6: Distribution of school dropouts on the basis of their behavioral problems Sr. Review of Global Medicine and Healthcare Research . There is no significant difference in males and females in threatening others. 1: Pie diagram showing the addictions present in school dropouts The study shows that high proportions (39%) of school dropouts were addicted to mishri and females were highly addicted to mishri. Among smokers all the subjects were males.3) 14(20. 4. 1 (2010) 241 . Theft Threatening others Destruction of 1(3) property Verbal violence 15(45. there is no significant difference between males and females in this group.9) 3(3) 38(38) 27(27) 0. Behavior Male N=33(%) 2(6.4) 2(3) 23(34. of school dropouts involved in verbal violence to about 38%.042* 0. However more males than females are involved in theft and physical violence.Fig.990 0. destruction of property.1) Female N= (67%) 0(0) 4(4) Total N=100(%) 2(2) 4(4) P value 0. 1 No. 3.050* The study reveals a high no. 2.Vol.1) 2(6. 5. However.No.5) Physical violence 13(39. 05) and borderline significance in caries teeth (p>0. 1 (2010) 242 .002* 0. 14.92%.139 0.1) 14(42.7) Female N= (67%) 6(9) 57(85. Contradictorily.109 0. 6. it was observed that higher proportion of Hindu girls. Muslim boys are seen to dropout more than Review of Global Medicine and Healthcare Research .212 0. 15. there was higher significance in males in handicap (p<0.005) Discussion The present study highlights the prevalence of school dropouts and the factors influencing it.070* 0.V. 1 No.5) 32(47.1) 1(3) 23(69. mottling of teeth(42%) and undernourishment(33%). found 50-60% of school dropouts. Heath profile Male N=33(%) 11(33. 8. 4. Acute respiratory infection(46%).7) 2(3) 31(46.615 0.9) 6(9) 0(0) 42(62. By the study.Table 7: Morbidity profile of school dropouts Sr.139 0.489 0.3 From the study it is observed that there is no significant difference according to age group in male and female population. care of family members and looking after siblings.9) 2(3) 18(26.3) 0(0) 15(45. While literacy in Indian females is 55%. this study reports 67% (Table 1) school dropouts in primary itself.No.3) 24(72. Though the prevalence of handicap and caries teeth was less. This study reports school dropouts to be 53%.4) 2(6. 7. The high no.151 10(30.3) 10(30. 10.3) 2(6.3) 14(42. 3.4) 15(22.4) 20(29.1) 11(33.152 0.9) 21(21) 25(25) 34(34) 8(8) 1(1) 65(65) 6(6) 42(42) 5 (5) 46(46) 19(19) 2(2) 33(33) The study revealed a high proportion of school dropouts suffering from anaemia (81%) followed by Acute Suppurative Otitis Media (65%.733 0. almost 4 times the Muslim school dropouts. this study has found 67% of school dropouts in females.575 0.1) Total N=100(%) 17(17) 81(81) P value 1.8% dropped out (Table 1) while school dropout is seen more in Muslim boys 36.218 0.8) 10(14. no study was done on school dropouts on the basis of religion. Khokhar et al in Delhi. Handicap Anemia Scaly dry skin Boils Dermatitis Fungal Bitots spots ASOM Caries teeth Mottling Stomatitis ARI Diarrhoeal diseases Epilepsy Undernourished 0. 13.4% (Table 1).4) 9(27.3) 3(4.7) 4(12. 9.616 0. It is observed that there are more Hindu dropouts. 5. 11.Vol.390 0. 8 While Subodh V of Sunday Times reports that 50% of dropouts are by primary. 88. In the researches that were found.5) 11(16. 12.7 While the study conducted by Subodh . Sunday times found the overall dropout to be 61. of Hindu girls found in the study of school dropouts is probably because the Hindu traditions and norms do not allow a female child to go out of the house but are supposed to learn the culture of household work. 2. Here also the finding of Nidhi Kotwal et al was observed almost similar (78% in females) of females parents unaware of importance of education.Muslim girls. The study by Nidhi Kotwal et al in a study in J& K has found domestic activity as a cause of school dropout in 72% females. (Table 2).'5 This difference may be due to present study.Vol. Many boys were seen to attend Madarassa. The current study showed the higher proportion of school dropouts in children whose fathers were illiterate. 1 (2010) 243 .4% females and 33." . there are most boys dropping out of school in the primary section as well as secondary(Table 1 a).95% of cases dropped out as a cause of parents having died or separated. This indicates poverty as the reason for incomplete schooling.A high proportion of prevalence of school dropouts was observed in nuclear family with siblings. nuclear or joint.High proportion of school dropouts were observed in non-working mothers. While high number of school dropouts are seen in males who have working mothers. The World Youth Data Sheet stated that 35% of females and 50% of males in the age of 5-18 to be economically active.6% females and 48.85) were pulled out of schools by their parent's as Review of Global Medicine and Healthcare Research . The high no. (Table 2).5% males involved in domestic work as a reason of school dropout (Table 2). This maybe due to high illiteracy of mothers and their unawareness of importance of education.7% female population dropped out as they had to look after siblings. (Table 1 a)There is no significant difference noted in school dropouts according to the type the family whether broken.4 The difference between this and the present study maybe due to the present study being carried out in the slum area where parents are unaware of importance of education (71% for females and 78% for males).11 The current study reports 13. about 87% and 7 times the dropouts in literate mother cases (Table la). while 35 % of male and 65. This study has revealed that the main bulk of school dropouts are in the primary section and was found to be 48% and is comparable with the study by Pratinidhi et all who found 60% Of their dropouts in primary . high number of school dropouts are seen in females amongst non working mothers. However there is no significant difference between male and female according to mother's education. The present study revealed that in general a high number of school dropouts fathers were unemployed and engaged in unskilled labor (Table 1 a). This study highlights the fact that total of male and female who dropped out to look after siblings are 56%. This may be probably because females must learn domestic work and males must earn money according to the norms of the society. 1 No. Higher proportion of females 60/140 (42.4 77. This study shows 20.3% of males being economically active (Table 2). (Table 1 a) . Death in the family as a reason for school dropout is seen in 6% cases in Nidhi Kotwal studies et al. of school dropouts in illiterate mothers indicates that a female's literacy is of high value in the education of the family. There is high number of school dropouts in both male and females in cases with illiterate mothers. This maybe due to both the parents working and the child being left at home to do the household work The study revealed a high number of girls who had never enrolled in school and are about 4 times the number of boys. It was observed in the course of the study that the Muslim community prefers to educate the boys in their religion as compared to going to school. Pratinidhi et al stated 26% of the male population and 57% of female population engaged with domestic activities. 1 (2010) 244 . Pratinidhi et al have reported 9% males and 12% females having dropped out in account of school being too much and this study is comparable to it as it reports 11. This study found 76. It is not significant as probably during the survey.8% of males and 55. The study by Pratinidhi et al have found 13% males and 5% females having dropped out on account of harassment by the teacher. This may probably be because of lack of interest in studying or lack on behalf of teachers and education system. this study reports dropouts due to failing in exams as 37% (Table 3).9% males and 10% females having left school on account of distance of school being too much. This study reports 21. The study conducted by Pratinidhi et al states that 27% of male and 25% of female population dropped out on account of difficulty in understanding the language and subject matter. This was mainly done so that girls could look after their siblings 32/60 (53.Vol.2% of females who dropped out as they found the language difficult (Table 3). destruction of others property. The references found had no data regarding mischievous behavior being a cause of school dropout. A large no. this study found 77% of children not interested in studying. The dropouts in the group who change their residence frequently have been reported as only 5%. threatening others. While mental retardation.compared to males 21/139 (15. Anaemia has been found to be 95% in Review of Global Medicine and Healthcare Research . While Pratinidhi et al found that total of 48% children were not interested in studying. This study also reports 4% dropouts involved in smoking and is comparable with The Global Youth Survey which reports smoking cigarettes in 1-23% children. 38% were involved in verbal and 27% in physical violence. of children were found to have behavioral problems like theft. Mischievous behavior was found to be a significant cause of school dropout with p value 0. The reasons of school dropouts on basis of unaffordable fees. no clothes or books are not significant as most of the children were attending school that provided free education.5% of females dropping school on account of harassment by the teachers and is comparable with the study of Pratinidhi et al (Table 3). While a study in Delhi by Khokhar et al reports dropouts due to failing in exams as 4. Nidhi Kotwal et al found 20% of female dropouts not interested in studying.33%). During the study it was observed that several dropouts complained of lack of attention from the teachers. In their presence the significance of the data would have probably changed.(Table 3 ). 1 No. it is comparable with this study which finds 46% of dropouts using any form of tobacco. large proportions of the community had already left in search of labour and were not accessible.2%. It is seen as it is considered the job of a woman to look after the family members and it has to be learnt by the females from their childhood. verbal and physical violence.1% of female population and 78% of male population not interested in studying (Table 4).2% of males and 4. The references found had no data regarding these behavioral problems. While the global tobacco survey finds 5-6% adolescents using any form of tobacco.10%) by a study conducted in Delhi by Khokhar et al.019 (Table 4). lack of confidence in self and unawareness of importance of education were reasons found to be insignificant. free school books and uniform and mid day meals. This study reports 78. caries. Garg. New Delhi 2001. Janashala. 59:423-427. A. 8. 22 26. Bharti. 15th Review of Global Medicine and Healthcare Research . Office of Registrar General of India. Karulkar. Other health problems were related to skin infections like dermatitis. Rani. Acute respiratory tract infection was found to be 46% and disease as 19% (Table 7). change of residence. Community. Kotwal. Why India has 50 Million School Dropouts. 1998. The morbidity health profile shows high no. pg 15. Business Week. A.17 This study reports 85% of anemia in girls. Mumbai July 6 2008. Sunday Times of India. 7. Status of Primary Education of Urban Poor in India. S. 3. This picture can change but will show very gradual improvement with a change in the overall family background. 10. India: A Nation of Dropouts. 9. Indian Express. G. Indian Journal of Community Medicine 2005. Indian Journal of Pediatrics 1992. Dalai.5% males were undernourished. 32 Lakh Kids Don't Go to School. S. 2.7-9. overall anaemia in girls and boys to be 81% and anaemia in boys to be 72% in the school dropouts (Table 7). 22CD: 57-59. V. May. The study reveals that 33% of the children were undernourished. The dropouts are due to involvement in domestic work. Arun s. Determinants of Reasons of School Dropouts Amongst Dwellers of an Urban Slum in Delhi. 1 (2010) 245 . July 6 2008. The consequence of this is anti-social activities. 11.Census of India 2001. The references found had no data on school dropouts regarding occupation of parents. International Cover Story. harassment by classmates and teachers. Express New Service. Epidemiological Aspects of School Dropouts in Children between 7-15 Years in Rural Maharashtra. Times of India. Pratinidhi. M. K. UN System. dry scaly skin was found to be insignificant.. drug addiction.June 1999. 5. 30:3. This prevalence was significantly higher in females than males and in general more in the age group of 10-14. While others like mottling of teeth. Neelima. addictions and health profile. Garad. behavioral problems and lack of awareness of their own health needs. 4. N. of children suffering from anaemia. 2000. India's Illiterate Population Equals All the Population in USA. 6. Causes of School Dropouts Among Rural Girls in Kathua District. Government of India.9% females were found to be undernourished and 45.Vol. N. Mumbai. 14. Handicap was found to be in 17% cases. 15th May. Varma. earning money and failing in the exams. acute respiratory tract infection and diarrhoeal diseases along with skin infection and undernourishment. Varma. boils. 'Rights to Education: What Happens Outside School?' UNESCO 2008. Sunday Times of India. 1 No. S. Dec. 2007. 2005. fungal infections. Hum. Ecoi. J.Indian girls. S. 9 Out of 10 in Class I won't Get to College. Khokhar. Jan 31.Based Primary Education. Government of India. References 1. Ministry of Home Affairs. type of family. Conclusion The prevalence of school dropouts was high in the tribal area of Chandrapur village. S. P. 7%). Bangladesh Uttam Kumar Roy Department of Pharmacy Northern University Bangladesh.6%). Bangladesh Abstract Background: Responsible self medication with OTC drugs has been appreciated as a means of healthcare cost reduction worldwide. Review of Global Medicine and Healthcare Research .Vol.3%). People can obtain any drug from retailers even in the remote parts of the country. Cetirizine (79. In Bangladesh drugs have not been classified into prescription-only and OTC likewise FDA regulations. diseases and length of therapies of the respective drugs were also noted. for young educated population of Bangladesh. 1 (2010) 246 .com Fatema Tabassum Department of Pharmacy Northern University Bangladesh. all of them were interviewed within June 2009. including both prescription and non-prescription drugs. Pizotifen (71. Bangladesh Email: nischow@gmail. 758 students were found who used at least one of the 11 drugs listed.7%). By snowball sampling method. When said yes. Tramadol (100%). Results/Findings: The self medication rates for the 11 drug products Aspirin (83. Methods/Study Design: The study was conducted among the students of colleges and universities in Dhaka and Bogra city. State University of Bangladesh.3%). Aim & Objectives: The objective of this study was to investigate the patterns of selfreported pain relieving and H1 antihistamine medication use. Ketorolac (66. they were asked if they had any prescription for using those drugs. Loratadine (76. and to assess the possible predictors of selfmedication. The symptoms. Previous studies indicated that the self medication rate with OTC and prescription drugs among Bangladeshi educated young adult population was 16%. Desloratadine (85. Diclofenac (72. Dhaka. Dhaka. The students were asked whether they had used any of the drugs within 6 months prior to survey date. 1 No. Chlorphenamine (79. Dhaka.1%).8%).9%) were noted and analyzed. Paracetamol (67.Self medication with H1-Antihistamines and pain relieving agents among the educated young adult people of Bangladesh Nishat Chowdhury Department of Pharmacy. and Promethazine (85. The drug brands were selected after careful consultation with product managers and in house sales data of reputed pharmaceutical companies.4%). 11 categories of highest selling and most commonly used pain relieving agents and H1 antihistamines were printed in the questionnaire.1%). Vol. The duration of use of these medicines is upon the judgment of patients when self medicated. one report estimated that there were four million over the counter (OTC) drug misusers in the south Asian region with Bangladesh (1) accounting for nearly 500. and parents (or other caregivers) often do not perceive OTCs as medications (3). Conclusion: The prevalence of such a high self medication rate of prescription drugs like tramadol and ketorolac may bring about hazards to public health in Bangladesh. healthcare professionals and providers of self-medication products are to have a responsible framework in place for self- Review of Global Medicine and Healthcare Research . A recent survey in several districts of Bangladesh showed that 105 people died from perforation of a peptic ulcer and several thousand suffered from peptic ulceration after injudicious consumption of non-steroidal anti-inflammatory drugs (6. H1-Antihistamines. Hence. Keywords: Self-medication. allergy.Study Limitations: The study was focused on only educated people and a particular age group within 14 – 32. mild fever or diarrhea. Previous studies indicated that the self medication rate with OTC and prescription drugs among Bangladeshi educated young adult population was 16% (2). The challenge and opportunity for the Bangladesh government. Bangladesh Introduction Although responsible self medication with OTC drugs has been appreciated as a means of healthcare cost reduction worldwide. The status of H1-antihistamine use has also been sought to be unraveled here. is typically 10 hours but may be more than doubled in overdose (9). According to a previous study. Pain relieving medicine. propensity towards self-medication may have serious consequences for public health in developing countries. antibiotics. 1 No. Therefore the misuse of prescription drugs needs to be probed thoroughly. While the literacy rate of Bangladesh is only 48%. But no study on use of prescription pain relieving and H1-antihistamine drugs has yet been carried out. OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time (3). including common cold. The halflife of loratadine. Physicians often do not inquire about OTC medication use. The most common reported calls that involve OTC medications to poison control centers in USA are for the ingestion of acetaminophen and cough and cold preparations (8). for example. 7). 1 (2010) 247 . the findings of this study do not implicate the whole population. Antihistamine. 81% of Bangladeshi educated people maintain home medicines like painkillers.000. Seventy seven percent (77%) of higher educated people in Bangladesh sought advice from retail medicine sellers for minor ailments. In Bangladesh drugs have not been classified into prescription-only and OTC likewise FDA regulations (4). vitamins etc (2). People can obtain any drug from retailers even in the remote parts of the country. Paracetamol (80%) was the single mostly used OTC medicine (5). The drug brands were selected after careful consultation with product managers and in house sales data of reputed pharmaceutical companies. all of them were interviewed within June 2009. By snowball sampling method. this study was carried out to evaluate the potential consequence of this situation. Promethazine in this survey. Ketorolac. and Prescription H1-antihistamines like Desloratadine. The analysis was exploratory. Information from the written questionnaires was entered into an electronic database. The symptoms. Paracetamol and OTC H1-antihistamines like Chlorpheniramine.medication. This study also included Prescription pain relieving drugs like Tramadol. Field researchers doublechecked the responses at the field immediately after conducting interviews. Multiple cases of different drugs from one person was considered separately. for young educated population of Bangladesh. they were asked if they had any prescription for using those drugs. Loratadine. Cetirizine for survey. 11 highest selling and most commonly used pain relieving agents and H1 antihistamines were printed in the questionnaire. Pizotifen. Diclofenac. Data analysis The data thus gathered was analyzed using SPSS software version 13. When said yes. 1 (2010) 248 .Vol. Methods The study was conducted among the students of colleges and universities in Dhaka and Bogra city. The sample students were asked whether they had used any of the drugs within 6 months prior to survey date. Supervisors directly observed 5% cases during the interview conducted by field workers. including both prescription and nonprescription drugs. and to assess the possible predictors of self-medication. Ethics Review of Global Medicine and Healthcare Research . 1 No. diseases and length of therapies of the respective drugs were also noted. The trends in population characteristics across explanatory variables (e.) were assessed using Pearson’s chi square test for categorical variables and simple linear regression for continuous variables. 758 students were found who had used at least one of the 11 drugs listed. The objective of this study was to investigate the patterns of self-reported pain relieving and H1 antihistamine medication use.0. Self medication rate etc. Hence. Data management Supervisors in the field regularly reviewed questionnaires. This study included OTC analgesics like Aspirin.g. 1 No. Long term. 100% of its users haven’t visited doctors and used it upon self judgment. Loratadine has also been self medicated in more than 75% of cases.7%. More than 90% cases of prescription or self medication incidences of Paracetamol use was in Fever. The duration of use of Loratadine was significantly higher (p<0. The second and third most highly self medicated pain relieving drugs are aspirin and Diclofenac (72. We investigated whether the duration of therapy varied between Prescription Use or Self Medication Use of drugs. Promethazine and Desloratadine showed the highest incidence of self medication (85. reviewed the study before approval and approved accordingly. Only Promethazine showed more tendencies to be self medicated for long term duration than prescription.The Department of Pharmacy.3%. more than 7-day usage of drugs was more common when used with prescription. Pizotifen was self medicated for treating Fever.Vol. Aspirin was most frequently used to treat Headache during both prescription use (68.8% and 66. Paracetamol and Ketorolac have high self medication rates (67. which has been granted the accreditation of the Pharmacy Council. The rest of the population was from age group 14 – 21. Ketorolac was mostly (75%) used to treat Eye Diseases with prescription.9% and 85. In one incidence. 1 (2010) 249 . (Table 3 and 4) The drugs have been self medicated for various durations (Table 5). 4 misuse cases were found with Chlorpheniramine. Diclofenac was used to treat pain in more than 80% cases with or without prescription. n=423).1%). Tramadol was self medicated to treat Fever.7% respectively).e.8%. State University of Bangladesh. Desloratadine and Cetirizine were used (Both Prescription and Self Medication) for allergy most frequently. More than 50% of the population was of age 22-32 (51. Bangladesh and University Grants Commission. self medication rate for the H1 antihistamines are higher than the pain relieving medications. (Table 1) All of the drugs have been self medicated within 6 months prior to survey date (Table 2). Results More than 50% of the survey population was male (55. (Table 5) Review of Global Medicine and Healthcare Research . Pizotifen was used to treat Migraine with or without prescription.05) when used with prescription than self medication. It was self medicated to treat Pain (n=2) and Fever (n=2). (Table 3 and 4) Chlorpheniramine and promethazine have high incidences of use (in both Prescription Use or Self medication) in cold and cough respectively (Table 2). On average. The analysis was done on the basis of generics.6%) Chlorpheniramine (79. Bangladesh. this was noted in 6 out of 7 valid cases. i. n=112) and Pizotifen (71. n=392). The names of the brands from different pharmaceutical companies have not been elucidated.8%) or self medication (89%).4%. The self medication rate is highest among 11 drugs in case of tramadol. The second highest self medication rate was observed with Cetirizine (79. n=5). Loratadine.7% respectively) among antihistamines. People self medicated Ketorolac for both Eye Diseases (50%) and Pain (50%).. Loratadine. and Cetirizine need to be explained to the general public. Abuse of OTC drugs rising in South Asia. We recommend immediate establishment of community pharmacies run by qualified pharmacists who would spend more time for patients and FDA recommended prescription only status of selected drugs like Pizotifen. 3. Fatema Matin. All therapeutic forms of pains were classified under the theme ‘Pain’. Chlorpheniramine. Islam MS. Islam MS. Diclofenac. BMJ 1999.8% people who took diclofenac to treat pain without doctors prescription continued the therapy for more than 7 days. Misuse incidences were found in case of Chlorpheniramine and Pizotifen. Serwint JR. Int J Adolesc Med Health 2009. Limitations of the Study The limitation of this study was that the incidences of pain were not classified into musculoskeletal or visceral pain. The accurate use of OTC drugs like Aspirin.5:2. Mudur G. 2. Diclofenac has been self medicated in 72. Diclofenac etc. Liebelt EL. in Bangladesh. Further studies need to be carried out to evaluate the self medication of Diclofenac and Aspirin in depth.Vol. 1 No. and Sk Feroz Uddin Ahmed Chowdhury. While the literacy rate of Bangladesh is only 48%. 1 (2010) 250 . Indian J Med Ethics 2008. Toxicity of Over-the-Counter Cough and Cold Medications. 5. The study was focused on only educated people and a particular age group within 14 – 32. Taha SH. 108 (3) 4. the absence of pharmacists is being filled by self medication and random misuse of medicines. It’s not certain whether they used antacids simultaneously to minimize Diclofenac’s harmful effect on stomach acid secretion. References 1. Paracetamol. Educational advertisements and campaigns are needed to make people aware of the danger of self medication with Pizotifen. Self-medications among higher educated population in Bangladesh: An email-based exploratory study. Pediatrics.3% cases. Desloratadine. Medication taking behavior of the students of a private university in Bangladesh. the findings of this study do not implicate the whole population.21(3). Nishat Chowdhury.5(1):24-5. Review of Global Medicine and Healthcare Research .318:556. Ketorolac. Internet J Health 2007. The purchasing of prescription drugs should be thoroughly monitored by a qualified pharmacist. prescription drugs.Conclusion It’s apparent some OTC as well as prescription drugs are being misused in wrong indications. Ketorolac. Promethazine etc. 2. As there is no community pharmacy run by registered pharmacists in Bangladesh. Gunn VL. Therapeutic drug use in Bangladesh: Policy versus practice. 7 (392) Table 2: Rate of self medication among the survey population Therapeutic category FDA-defined Legal Status Name of drug No. Stomach perforation. Toxicity. Medscape. Cough and Cold Preparation.4 (5) 66. French LK. 1 No. Medscape.32 %n 55.1 (140) 76.Vol. Health and Health Sciences.6. Asiatic Society of Bangladesh. Oman J. Available at: http://emedicine.67 (8) 72. Toxicity.3 (29) 79. McKeown NJ. Antihistamine. of Population Sampled 284 587 8 7 12 155 177 38 142 7 92 % self medicated (n) Pain relieving agent OTC Prescriptiononly H1antihistamines OTC Prescriptiononly Aspirin Paracetamol Tramadol Pizotifen Ketorolac Diclofenac Chlorphenamine Loratadine Cetirizine Desloratadine Promethazine 83.8 (423) 44.3 (366) 51.com/article/812828-overview TABLES AND FIGURES Table 1: Age and Gender Distribution among the survey population (Descriptive table) Characteristics Based on all sampled individuals (n=758) Gender Male Female Age 14 -21 22 .medscape. Available at: http://emedicine.com/article/1010513-overview 9.6 (113) 85. Emergency Medicine Articles. 8. Lopez N.8 (398 100 (8) 71.9 (79) Review of Global Medicine and Healthcare Research . Gharahbaghian L.1 (236) 67. 7.7 (6) 85. Banglapedia. 1 (2010) 251 .medscape. Emergency Medicine Articles.2 (335) 48.3 (112) 79. Daily Shangbad 1993 Aug 3:1 (col 3). 9 (10) Promethazine (n=13) Cold <10 (1) Allergy <10 (1) Sedation <10 (1) Review of Global Medicine and Healthcare Research . 1 (2010) 252 .Vol.Table 3: Prescription use of medicines in different diseases/symptoms Total Incidence of Drug Symptoms/Diseases use with prescription %n Aspirin Fever <10 (1) (n=48) Headache 68. 1 No.8 (24) Asthma <10 (1) Fever <10 (1) Sedation <10 (1) Cough 76.8 (33) Pain 26.4 (35) Ketorolac Pain 25 (1) (n=4) Eye disease 75 (3) Tramadol x Pizotifen Headache 50 (1) (n=2) Migraine 50 (1) Chlorphenamine Cold 80 (30) (n=37) Influenza <10 (3) Allergy <10 (3) Sedation <10 (1) Loratadine Cough 44.7 (179) (n=189) Headache <10 (6) Pain <10 (5) Diclofenac Fever <10 (2) (n=43) Headache 14 (6) Pain 81.5 (14) Paracetamol Fever 94.6 (5) Desloratadine Allergy 100 (1) (n=1) Cetirizine Cough <10 (1) (n=29) Cold <10 (1) Allergy 82.4 (4) (n=9) Allergy 55. 9 (11) Allergy 51.Table 4: Self medication of medicines in different diseases/symptoms Total Incidence of Drug Symptoms/Diseases Self medication %n Aspirin Fever <10 (6) Headache 89 (210) Pain <10 (20) Paracetamol Fever 91.1 (71) Influenza 6.5 (9) Allergy 8.1 (21) Fever <10 (2) Headache <10 (2)) Loratadine Cough <10 (2) (n=29) Cold 37.5 (9) Pain <10 (2) Sedation 15.6 (12) Asthma 6.3 (109) Ketorolac Pain 50 (4) (n=8) Eye disease 50 (4) Tramadol Fever 100 (8) Pizotifen Fever 20 (1) (n=5) Headache 20 (1) Migraine 60 (3) Chlorphenamine Cough 8. 1 (2010) 253 .3 (69) (n=79) Cold 12.4 (364) (n=398) Headache <10 (24) Pain <10 (10) Diclofenac Fever <10 (1) (n=112) Headache <10 (2) Pain 97.7 (15) Sedation <10 (1) Desloratadine (n=6) Allergy 100 (6) Cetirizine (n=113) Cough <10 (6) Cold <10 (10) Allergy 76.1 (86) Asthma <10 (1) Fever <10 (1) Sedation <10 (1) Promethazine Cough 87.Vol. 1 No.6 (12) (n=140) Cold 51.7 (10) Review of Global Medicine and Healthcare Research . 4 (4) 2.Table 5: Long term use of drugs in the respective most highly self medicated symptom/disease Long Term Use (>7 days) Symptom/Disease Chi square With Self Drug Self medicated (Prescription Prescription Medication most frequently vs Self %n %n Medication) Headache 6.3 (2) 5.7 (1) P<0.05 Desloratadine Allergy 100 (1) 0 (0) Not Significant Cough 10 (1) 11.8 (5) Not Cetirizine Significant Loratadine Allergy 80 (4) 6.5 (1) N/A Pizotifen Migraine 0 (0) 0 (0) N/A Chlorpheniramine Cold 0 (0) 8.2 (8) Not Paracetamol Significant Pain 11.5 (6) N/A Allergy 8. 1 (2010) 254 .8 (3) Not Diclofenac Significant Pain 0 (0) 0 (0) N/A Eye disease 100 (1) 25 (1) Not Significant Ketorolac Tramadol 0 (0) 12.1 (2) 2.Vol.5 (8) 2.6 (8) Not Promethazine Significant Review of Global Medicine and Healthcare Research .4 (5) Not Aspirin Significant Fever 4. 1 No. sexual assault. Chhattisgarh. it is taking new form. of Pharmacology. Females have been a victim of this crime in one form or other but in recent past with modernization of society and liberalization of girls in social behavior. party. Creating awareness among the vulnerable groups is the only effective measure to check this crime. Raipur. to know most common source of information about such drugs and to get feedback on acceptable preventive measures against such sexual assault. Most of the time female is raped by someone she knows. The most common circumstance of use of such drugs is Party (7. Rape has always been a social problem. Chhattisgarh. residential background & level of education. friend or neighbor (Office of crime victims advocacy2). Chhattisgarh.N. awareness. In the rest 30% who were aware. India Email: [email protected]. J. Koss. Department of Community Medicine. Pt. Institutional sex education is most preferred choice of preventive measure (31. India Ram R. Pt. The predominant sources of information were movies (22%) and TV (21%) indicating that electronic media plays important role in creating awareness. coworker.M. Studies reveal that Acquaintance rape is the most common type of rape (Mary P. Medical College Raipur.M. media. 1 (2010) 255 .N. Review of Global Medicine and Healthcare Research . 56% didn’t know name of such drugs while remaining 44% who knew specific names reported mainly Sedatives and Hypnotics followed by Alcohol.78%) followed by banning of drug (20%). India Abstract The date rape drugs are being increasingly used in Sexual assault especially among adolescent girls due to their sedative and amnesic effect. Medical College.Vol. a cross-sectional study was conducted among 280 girls. 1 No.M.C. The awareness was found to be significantly linked with professional course of the subjects while it was not significantly linked with each of the socio-economic status. Medical College Raipur. J. In this backdrop. The perpetrator might be a partner. Key Words: date rape drug. This study finds that about 70% of girls were unaware about existence and use of such drugs. Introduction Since ages.2%) followed by Bar (2. J.com Agarwal Suraj Dept. A questionnaire was used to assess awareness about drug facilitated sexual assault.Date Rape Drug awareness among College Girls Patira Riddhi Pt. or loves.4%). trusts. 19881). cheap and easy available drugs. These are also known as Date Rape Drugs because usually they are associated with dating. To identify most common source of information about such drugs. Perpetrators make their use due to their amnesic effect. J. this study showed that almost 20 different substances were associated with this crime. Raipur.Vol. With the advent of better. 7). 3. Method A cross-sectional study was conducted by interviewing 280 Medical. 1 (2010) 256 . and GHB (Gamma hydroxybutyrate). colorless and tasteless. 1999)5 conducted on urine samples collected from victims of alleged sexual assault analyzed samples for alcohol and drugs which may be associated with sexual assault in United States.Drug Assisted Rape is a type of acquaintance rape where drugs are used without the consent of the victim (Hensley. with respect to alleged sexual assault cases. amphetamines. To get feedback on acceptable preventive measures against such sexual assault. While earlier only a couple of substances were supposed to be implicated with sexual assault. followed by cannabinoids. It showed that. the sedative drugs are being increasingly used in Sexual assault. the above study has been undertaken to find out the level of awareness of this problem among girls students of medical college Raipur. Socio Economic Status. 2. However apart from dating. 2. The victim is sedated during Sexual assault and is unable to recall the events thereafter under the influence of drug. benzodiazepines. The studies conducted worldwide reflected low awareness level (6. the date rape drug is odorless. Professional Review of Global Medicine and Healthcare Research . the prevalence of ethanol was very high. M. Chhattisgarh. Residential background. According to the National Institutes of Health. cases of date drug rape are also occurring in parties and other frequent hangouts (Sampson)4. To assess linkage between the awareness about date rape drugs with various SocioDemographic factors. 1998)8. Medical College. India. This study also raises the concern of illicit and licit drug use in sexual assault cases and suggests the need to test for a range of drugs in these cases. It can be put in someone’s drink unknowingly and will incapacitate the victim for hours. 2002)3. Marital status. In this backdrop. To assess awareness about use of date rape drugs in drug facilitated sexual assault. Aims and Objectives 1. This study intends to know about prevalence of awareness of date rape drugs and what girls generally think of the various preventive measures in this regard. It also highlights the need to test for GHB. Dental and Paramedical (Nursing and Physiotherapy) girl students of PT. A study (ElSohly MA. The victim is usually teenager girl and those in 20’s by an acquaintance (Rickert VI. which is not generally tested for in a normal toxicology screen. cocaine. N. A pre-tested questionnaire consisting of subject’s details viz Age. Creating awareness among the vulnerable groups is the only effective weapon to check this crime. 1 No. course they are pursuing and their awareness about use of such drugs. 2. The analysis was done manually and on excel sheet. the prevalence of problem was unknown.42 66. The ethical approval was taken (No.42 100 76 43 10 10 141 280 27./09/2479-82).35 100 32 155 57 11. Hence a relatively large size of 280 subjects was purposely undertaken.Vol.14 15./09/2478 and No. Study Limitations 1.35 Review of Global Medicine and Healthcare Research . Sampling was based on non-random purposive method.MCR/Ethical Comm. source of awareness and opinion towards different preventive measures was used. No other statistical package was used.07 6. Due to paucity of studies on this subject. SPSS was not used. Dental and Paramedical girl students due to ethical issues. 1 (2010) 257 .57 50.35 3. chi square test have been employed to analyze the data and validate the findings. The Study was limited to Medical.57 3. 1 No. Therefore minimum required sample size based on parameters could not be ascertained.MCR/Ethical Comm.42 55.07 21.35 20. The socioeconomic status was determined as per Modified Prasad’s Classification which is: Class I II III IV V Family income per capita per month in Rupees >2399 2399-1200 1199-750 749-360 <360 Appropriate statistical tools namely percentage. Observations: Table 1: Background characteristics of girls Background characteristic Residential Background Tribal Rural Urban Skip Total Socio-Economic Status I II III IV Skip Total School Background Paush Medium Average Number Percentage 17 60 185 18 280 6. Vol.64 13. Majority of girls (45%) were students of Nursing College followed by Dental College (25%) and Medical College (20. 1 (2010) 258 . Figure 1: Awareness level of girls Interpretation: Awareness level was very low and this is shockingly low in medical and paramedical students who should all aware of such drugs.14%) belonged to SES (SocioEconomic Status) I as per Modified Prasad Classification.35 25.00 9.78%) didn’t tell their year of studying. almost freshman and sophomores together constituted the majority (37.85 100 57 70 27 126 280 20. More than half (55.64 45. Majority (41.85%). Nearly half (50. highest percentage (27. 1 No.21 19.57 6. Review of Global Medicine and Healthcare Research .07%) of girls belonged to urban background. There were no girls belonging to SES grade V.35%) of the girls were reluctant to tell their family income.Skip Total Professional course Medical Dental Physiotherapy Nursing Total Year of education Freshman Sophomore Junior Senior skip Total 36 280 12.35%) girls belonged to medium school background.65% girls were aware of date rape drugs.00 100 51 55 38 19 117 280 18.78 100 Interpretation: Two thirds (66. In those who mentioned their family income. Among those who did. Only 29.78 41.35%). Table 4: Awareness in association with school background: School Background Awareness Present Absent 6 26 Total Paush Medium Average Skip Total 32 155 57 36 280 50 22 5 83 105 35 31 197 x2: 0.Table 2: Awareness in association with professional course Professional Course Awareness Present Absent 24 33 4 66 5 22 50 76 83 197 Total Medical Dental Physiotherapy Nursing Total 57 70 27 126 280 x2: 7.05 and hence p-value is insignificant.05 hence p-value is significant.047.032. degree of freedom: 4.05 hence p-value is insignificant. the p-value comes out to be 0. 1 (2010) 259 . 1 No. Interpretation: The professional course was found to be significantly linked with the level of awareness. Interpretation: The residential background was not found to be significantly linked with the level of awareness. the p-value comes out to be 0. the p-value comes out to be 0.Vol. Table 3: Awareness in association with residential background Residential Background Awareness Present Absent 62 123 19 41 0 17 2 16 21 74 83 197 Total Urban Rural Tribal Skip Total 185 60 17 18 95 280 x2: 0. degree of freedom: 1.86. degree of freedom: 3. Review of Global Medicine and Healthcare Research .049 which is < 0.8284 which is > 0.9999 which is > 0. 1 No. the p-value is comes out to be 0.05 hence p-value is insignificant.0699 which is > 0. Interpretation: The Socio-Economic Status was not found to be significantly linked with the level of awareness.05 hence p-value is insignificant. the p-value comes out to be 0. Table 5: Awareness in association with socio-economic status: Socio-Economic Status Awareness Present Absent 23 53 17 26 3 7 4 6 7 13 36 105 83 197 Total I II III IV Skip Total 76 43 10 10 20 141 280 x2: 8. Review of Global Medicine and Healthcare Research .5849 which is > 0. Interpretation: The Education Level was not found to be significantly linked with the level of awareness.Interpretation: The school background was not found to be significantly linked with the level of awareness. Table 6: Awareness in association with year of education Education Level Awareness Present Absent 19 32 Total Freshman Sophomore Junior Senior Skip Total 51 55 38 19 117 280 14 17 8 25 83 41 21 11 92 197 x2: 2.84.67. degree of freedom: 4. 1 (2010) 260 . degree of freedom: 4.Vol. 20 7.57%.22 4. the majority of drug reported were multiple drugs (14.58% knew the name or chemical nature of the drug while.42 100 Interpretation: Even in 83 girls.89 12.53 6.42% didn’t know the name of drug while 44.Table 7: Name of Drugs Name of Drugs Number Percentage of aware girls (83) Cannabinoids Alcohol Barbiturates Opioids Sedatives and hypnotics Benzodiazepines Multiple Skip Total 1 6 4 4 9 1 12 46 83 1. The electronic media (T.Vol.20 32.61 1. Also none mentioned any real life instance of drug assisted sexual assault. 78 (94%) mentioned the source of awareness.V Movies Newspaper Friends Novel Multiple Skip Total 18 19 10 3 1 27 5 83 21.V & Movies) was chief source of information which together constituted 44.84%).81%).02 100 Interpretation: Out of 83 girls who were aware.81%) and Opioids (4. Table 8: Source of information regarding Date Rape drugs Source of information Number Percentage of aware girls (83) T. None reported name of any Hallucinogen.45 55. 1 (2010) 261 .84 1.20 14.04 3. The specific names chiefly reported were mainly Alcohol (7.81 4. newspaper constituted only 12.04%. 1 No. Review of Global Medicine and Healthcare Research .81 10. Among printed media. 55. Out of these who knew. None reported Family members or Radio as their source of information.45%) followed by Sedatives and Hypnotics (10.22%) followed by Barbiturates (4.68 22. 45%) followed by Sedatives and Hypnotics (10. Results The respondents under study were the girls belonging to 18-24 years of age group. residential background. Thus people engaged in partying and drinking are more prone to fall victim to drug assisted sexual assault.78%) followed by Banning of drug (20%) and Electronic media exposure (14%).58% knew specific names of such drugs while rest 55. 44. The most common circumstance of use of such drug is Party (7.42% didn’t know their names but were aware about existence and use of such drugs. 1 (2010) 262 . Institutional sex education is most preferred choice of preventive measure (31.28 Institutional Sex Education 89 31.40%) were the most common circumstance of drug use as per the girls.22%) and bar (2.61 Not known 73 87.Vol. the drug may go undetected. school background & level of education.Thus electronic media plays main role than printed media in creating awareness.81%) and Opioids (4.22%) followed by Barbiturates (4.81%). Of these.84) however the specific names of drugs chiefly reported were mainly Alcohol (7.22 Bar 2 2.65% who were aware. The predominant sources of information were movies (22%) and TV (21%) while newspaper constituted only 12.35% were unaware about existence and use of such drugs. Table 10: Preferred preventive measure as per respondents Preventive measure Number Percentage Banning drug 56 20.78 Skip 31 11. This highlights the fact that the majority of would-be medical professionals may remain unaware & hence in cases of rape examination. about 70.40 Camping 1 1.95 Total 83 100 Interpretation: Party (7. The awareness was found to be significantly linked with professional course of the subjects while it was not significantly linked with socioeconomic status.Table 9: Circumstance of use of Date Rape drugs Instance of real use Number Percentage of aware girls (83) Party 6 7. 1 No.78%) as per the girls.07 Total 280 100 Interpretation: Almost equal support was given to all Preventive measures to increase spread of awareness but the leading accepted preventive measure was institutional sex education (31.20 Multiple 3 3.04%. Among those who knew the name of drugs.78 Multiple 61 21. multiple names were reported (14.22%) followed by Bar (2.00 Sensitize boys 3 1. Review of Global Medicine and Healthcare Research .40%). None reported Home or restaurant as circumstances where drug assisted assault is thought to take place.07 Electronic Media exposure 40 14. In the rest 29. 5.nih. U.Discussion Southwest Wisconsin Youth Survey (SWYS) survey (Bev Doll. L. Dziuban' A. (2002).Vol. In contrast we found that the Education Level was not found to be significantly linked with the level of awareness (p-value: 0.5849).pdf.usdoj. Prevalence of drugs used in cases of alleged sexual assault[Abstract]. Office of crime victims advocacy. R. G. S. (1988). Conclusion The awareness level is very low among the girls. Retrieved February 15.nlm. Similarly the awareness level in our study was found to be 29. 301-10. It is influenced by type of professional course and electronic media exposure chiefly Television and Movies. (1999). A. E. 1 No. Psychology of Women Quarterly .ncbi. 12. Acquaintance rape of college students. (2006. Mary P. Date rape among adolescents and young adults.d.). The knowledge about "date rape drugs" among Polish students. S.S. 10.uwex. ElSohly MA.5. W. Thus the awareness is quite low in this particular area of Raipur. 06 30). (1998). 11(4). Department of Justice. 2006)6 conducted by 15 school districts and more than 3700 students reflected an awareness level of 46% only. older females are more aware of the drug. Drug-Facilitated Sexual Assault on Campus: Challenges and Interventions.aspx 3. 8. Koss.gov/pdf/e03021472.65%. Institutional sex education is accorded highest priority. R. 2010. Office of Community Oriented Policing Services. People engaged in partying and bar are more prone to fall victim such drugs. Hensley. 29% of 12th grade females and 38% of 11th grade females have never heard of GHB. 4. Many teens unaware of “date rape” drug.html 7.gov/pubmed/10369321 6.commerce. 141-6. . 2. Retrieved from http://grant. Journal of pediatric and adolescent gynecology . STRANGER AND ACQUAINTANCE RAPE. P. Retrieved from http://www. Recommendation The low level of awareness calls for informative media exposure and promotion of institutional sex education.cops.gov/site/261/default. which is commonly referred to as the date rape drug. References 1. Przegl Lek. Journal of College Counseling .wa.edu/tap/SWYS2005Report. (n. Also in SWYS. Journal of Analytical Toxicology . Over half (54%) of southwest Wisconsin teens have never heard of GHB. 23(3). Retrieved from http://www. 167-75. Review of Global Medicine and Healthcare Research . Among the preventive measures. vol. 1-24. from Department of commerce: http://www. 1 (2010) 263 . H. p175-81. Sampson. Rickert VI. Bev Doll. Southwest Wisconsin Youth Survey (SWYS) . (2009). C. T. p. sarah@gmail. Current recommendations advocate enteral feeding in the event that the gastrointestinal tract is functioning because it is safer. This occurs when disease. Scotland Email: shaunnietan@hotmail. addressing the conundrums faced in the aspect of nutrition in the surgical patient encountered by medical students and junior doctors. audits. PUBMED and EMBASE was performed on scientific journals published within the last twenty years.com Sarah Weiling LI University of Glasgow.The Dilemma of Enteral against Parenteral Nutrition for the Surgical Patient – A Review Shaun Shi Yan TAN University of Glasgow. These included meta-analyses. 1 (2010) 264 . dysfunction or resection of the intestinal tract results in inability to meet nutritional requirements by enteral means. patients are often provided total parenteral nutrition because of ease and reliability of administration.com Yee Onn KOK National University of Singapore. Such was the number of studies that 5 meta-analyses were conducted over the span of the last 20 years. on the other hand. Singapore Email: liang_zhen_chang@hotmail. and to expound on some of the ideas surrounding various routes of nutrition in surgical patients. Delivery of nutrients to the gut may also help maintain gut barrier function and reduce postoperative complications. randomised trials. Scotland Email: ling. We seek to discuss the importance of perioperative nutrition in the surgical patient. Although clinicians agree that the gastrointestinal tract is the preferable route for nutrient administration. Aims and Objectives: The aim of this study is to present a comprehensive scientific review.Vol. 1 No. The safety and post-operative outcomes of patients offered either type of nutrition is still an ongoing dilemma. Parenteral nutrition. Methods: A retrospective review via MEDLINE. Singapore Email: [email protected] Zhen Chang LIANG National University of Singapore. less expensive and more physiological.com Abstract Background: One of the perennial debates in the surgical field is that between enteral and parenteral nutrition. The gravity of the problem is highlighted by the plethora of research conducted to compare enteral feeding with parenteral feeding head to head. original research and recent Review of Global Medicine and Healthcare Research . is indicated when nutritional support is required but effective enteral nutrition is not possible. developed markedly elevated plasma insulin levels. but have an accessible gastrointestinal tract or are due to undergo major abdominal procedures should be considered for pre-operative enteral tube feeding. less expensive and physiological. Enteral Nutrition. reducing the incidence of septic complications in the stressed patient. 2008).guidelines published by Health Boards. Quick. Current recommendations advocate enteral feeding in the event that the gastrointestinal tract is functioning because it is safer. early administration of TPN should be considered. 1 No. Delivery of nutrients to the gut may also help maintain gut barrier function and reduce postoperative complications (Thomson. Results and Findings: Several prospective randomised trials have been performed to compare the efficacy and safety between the routes of nutrition. but should the enteral route not be available for more than one week. One compared a group of major abdominal trauma patients undergoing laparotomy over a 28 month period. Preoperative Feeding Introduction One of the perennial debates in the surgical field is that between enteral and parenteral nutrition. Surgical Nutrition. O'Connell. The NICE (2006) guidelines advocates that surgical patients who are malnourished through inadequate or unsafe oral intake. some multi-centre studies have concluded that the use of pre-operative TPN can be used in patients who are severely malnourished. This occurs when disease. Russell. Bulstrode. driving excess glucose into the fat cells and increased lipolysis. Their clinical study demonstrated that traditional protein markers such as albumin and transferrin were restored much better in the enteral group. Study Limitations: This review is limited by published data found on the databases as well as only those in the English language. 2008). & Reed. such as intravenous injection. on the contrary. Nutrition.Vol. & Bailey. Williams. Notwithstanding a paucity of supporting literature for parenteral nutrition. Patients given TPN. Parenteral nutrition is derived from the Greek words “para” which means beside. Some of the specific Review of Global Medicine and Healthcare Research . dysfunction or resection of the intestinal tract results in inability to meet nutritional requirements by enteral means (Burkitt. and “enteron” meaning intestine. Parenteral nutrition is indicated when nutritional support is required but effective enteral nutrition is not possible. A recent meta-analysis of 27 randomized control trials also showed that TPN has no statistically significant effects on the overall mortality and morbidity of surgical patients. 1 (2010) 265 . Evidence-based medicine employed in clinical practice is emphasized. Another randomised trial concluded that glucose metabolism was more physiological in the enterally fed group as they maintained normal insulin levels and had no fatty-acid deficiency. It involves the administration of nutrients in a route other than that of the digestive tract. 2007. Conclusion: Principal lessons from these collective studies support that the enteral route should be used whenever possible. Keywords: Parenteral Nutrition. 1985). ileus and severe pancreatitis (O'Connell et al. 1 No. 1985). attended to King George III and pioneered the use of nasoenteric tube-feeding in London. He was famed for his astute skills of observation and keen scientific mind. In 1973. leading to fatal dehydration. Such was the number of studies that 5 meta-analyses were conducted over the span of the last 20 years (Thomson. In 1831. managing to quickly restore her to health (Deitel.. Although clinicians agree that the gastrointestinal tract is the preferable route for nutrient administration. a cholera epidemic in England became a stimulus to the development of intravenous infusions techniques. also a Scottish doctor. he injected a large amount of saline solutions into her antecubital vein. By selecting a patient who was at terminal stages. The safety and post-operative outcomes of patients offered either type of nutrition is still an ongoing dilemma.. 2008). he managed to successfully feed a patient whose muscles of glutition were paralysed by passing it down to the oesophagus (Deitel. History of Nutrition in Surgery Nutrition in surgery has seen many eminent founding fathers in its ranks. These examples illustrate the humble beginnings of the importance of nutrition in surgery and medicine. The techniques of artificial feeding were further refined and developed until today. the administration of fluid by mouth or rectum was impossible. We seek to discuss the importance of perioperative nutrition in the surgical patient. Research and creativity allowed these doctors to save many lives. patients are often provided total parenteral nutrition because of ease and reliability of administration (Kudsk et al. His research was based on ‘diluting’ patients’ blood with water and salt. addressing the conundrums faced in the aspect of nutrition in the surgical patient encountered by medical students and junior doctors.Vol. John Hunter. inflammatory bowel disease. devising ways for aiding patients who were afflicted with disease. The gravity of the problem is highlighted by the plethora of research conducted to compare enteral feeding with parenteral feeding head to head. Hence. Using an eel-skin over whale-bone. Thomas Latta. massive intestinal resection. The aim of this study is to present a comprehensive scientific review. 1 (2010) 266 . managed to successfully infuse saline solutions into his patients.indications for parenteral nutrition include proximal intestinal fistula. Cholera induced fluid losses from vomiting and diarrhoea. 1992). and to expound on some of the ideas surrounding various routes of nutrition in surgical patients. black and cold. but the principles of improving the health of the patients they treated remains the same. a distinguished Scottish surgeon. 2008). Nutrition in Surgery – Why is it important? Review of Global Medicine and Healthcare Research . which was initially thick. occasionally with vitamin and trace element deficiency as well (Burkitt et al.. Deitel. Injuries can encompass surgery. 2003). lasting until circulating blood volume has been replenished. 2003).Nutrition in surgical patients is an important issue. which may occur with further depression of metabolism (O'Connell et al. The release of cytokines such as interleukin-1 and interleukin-6 during this phase also contribute to the catabolic nature of this phase (Hill. sepsis or acute medical illness. 1992. and in a manner that minimizes the risk of complications. Dr David Cuthbertson of Britain divided the metabolic response to injury into an early ‘ebb phase’ and a ‘flow phase’. Malnutrition is defined as a wasting condition resulting from energy and protein deficiency. The ebb phase begins immediately after injury and lasts for typically 12-24 hours. 1992). burns. the severely malnourished patient may suffer from impaired wound healing. A combination of pain. 2003). Hill. and the prompt assessment of nutritional needs with appropriate management plans remains a crucial component of surgical care (O'Connell et al. The flow phase then ensues over the next 14 days where there is oxidation of muscle protein to provide glucose. 2003). dehydration. which is an essential fuel for the brain and healing tissue and has become depleted... The appearance of the pale. 2007). Malnutrition may be present in close to 50% of patients admitted to surgical wards. hypovolaemia and acidosis triggers the activity then of the sympatho-adrenal system. An example is excessive skeletal muscle proteolysis. 2008). the aim of nutritional support is to identify patients in need and to ensure that their nutritional requirements are met by the most appropriate route. 2003). The cumulative effects of the body’s response can result in extreme changes in fluid balance and electrolyte concentrations. 2003). 1985. Ward. Hill. Hyperglycaemia during this phase results from hepatic glycogenolysis secondary to catecholamine release (Burkitt et al. Whilst the adequately nourished patient may tolerate major surgery well with rapid recovery. 1992). This stress response to injury represents a complex interaction between the neuroendocrine and cytokine systems (Mizock. where protein and energy stores lost during the post-injury period are Review of Global Medicine and Healthcare Research . growth hormone (GH) and glucagon. It is characterized by hypovolaemia and a subsequent sympathetic and adrenal response. 1985. clammy and tachycardic patient visited by the surgeon soon after surgery is indicative of the ebb phase (Hill.. 2007. infections or even multiorgan failure should malnutrition be severe (Howard & Ashley.Vol. The metabolic response to surgery The physiological insult of bodily injury results in a surge of stresses on the body accompanied by a metabolic response (Ward. Although these changes are transient. 1 (2010) 267 . Mizock. Hence. 1992). A nutritionally depleted patient undergoing surgery can lead to higher incidences of postoperative morbidity and mortality (Howard & Ashley. The flow phase eventually merges into the anabolic phase. This is accompanied by the release of adrenocorticotrophic hormone (ACTH). 1 No. a prolonged hypermetabolic state associated with a pronounced negative balance can ensue if adequate nutritional support is not rendered (Deitel. 2008. 1988). A variety of nutrient formulations are available for enteral feeding. osmolarity. Postoperative nutritional support in patients has also shown to significantly reduce morbidity and length of hospital stay (Askanazi et al. 2007. wheras monomeric feeds contain nitrogen in its peptide or free amino acid form (Deitel. Salvino et al. 2003. Windsor & Hill. which is broadly based on clinical assessment. a prospective audit was conducted on 100 patients. Adequate body protein stores are essential for normal body function and the prevention of postoperative complications which include sepsis. The use of perioperative nutrition such as enteral and parenteral feeding seeks to reduce the harmful catabolic sequelae and to hasten the anabolic process of healing. 1987). psychologic.. allowing an improved quality of life (Robinson. 2003). 2008).. to improve nutritional status through interventions (Salvino et al. more subtle degrees of nutritional impairment are often overlooked (Salvino. fat. varying in terms of energy content.. 2004). pneumonia. Dechicco. both enterally and parenterally. of which clinical assessment is the most accurate. 1985. the severity of malnutrition is proportional to the amount of surgical risk involved (Burkitt et al. Table 1 highlights the basis of assessment. The aim of nutritional assessment is to identify patients who are at increased risk of postoperative complications due to malnutrition. 2004). 1 No. Feeding tubes are appropriate when spontaneous oral intake in not adequate for nutritional requirements.. 1992. & Levine. 1988).Vol. Polymeric feeds contain intact protein and thus requiring digestion.repleted. To determine the relationship between nutritional status of the patient to length of stay and hospital charges. Assessing the Nutritional Status in Surgical Patients Although severe malnutrition. & Seidner. Goldstein. 2004). nitrogen content and nutrient complexity. respiratory and skeletal muscle dysfunction (Hill. 1 (2010) 268 . In general. is easy to detect. Conversely. has led to improved nutritional status and clinical outcomes in the malnourished patient and is largely supported by literature (Ward. anthropometric assessment and blood indices. Their results showed that a patient’s good nutritional status translated into reduced costs associated with the length of hospital stay and morbidity. Basic Principles of Surgical Nutrition A) Enteral Nutrition Enteral nutrition may be administered orally or through feeding tubes.6g of protein per millilitre. Benefits of Good Nutrition to the Surgical Patient Nutritional support. Ward. They are inserted into the stomach or small intestine via the Review of Global Medicine and Healthcare Research . Most contain 12kcal and up to 0. Thomson. 1986). and where possible. poor nutritional support leading to weight loss associated with organ impairment is a significant surgical risk factor in modern practice (Windsor & Hill. such as wasting of proximal limb muscles. 1992). where the amount of functioning gut is below the minimum required for adequate digestion and absorption of nutrients (Burkitt et al. however. Jeejeebhoy subsequently showed in his clinical work that through the use of parenteral nutrition. PEG tubes. Its aim is to provide sufficient nitrogen and energy to counter the catabolic demands of surgery. minerals and vitamins. trauma and its complications. 1968). a tunnelled line with the skin access point remote from the venous entry point. It is delivered mostly via the superior vena cava into the internal jugular or subclavian vein. Parenteral nutrition.. should be reserved for appropriate cases of intestinal failure. lipids.. Known as gastrostomies. complete enteral nutrition may still be delivered through a fine-bore nasogastric tube. without the use of the gastrointestinal tract (O'Connell et al.. amino acids. The Groshong line. 1992). are contraindicated in peritonitis. & Rhoads. obstructing lesions or in those with an upper gastrointestinal anastomoses. TPN formulations consist primarily of a mixture of glucose. This led to the its more accepted and widespread use. Parenteral nutrition has a very recent history. minerals and vitamins are encouraged (Burkitt et al.Vol. If a patient is able to eat and does not have dysphagia. sip feeds containing easily absorbed calories. Hill. The technique employed is usually by percutaneous endoscopic gastrostomy (PEG) which is an endoscopic procedure. 2007).nose or the abdominal wall.. February 2006). This is to reduce the complications of line infection (NICE. however. 2007). is adopted when long periods of nutritional support are anticipated. 1973). first described by Dudrick et al in the late 1960s (Dudrick. This allows the high venous flow to rapidly dilute the hyperosmolar TPN solution. 2007). with more clinicians beginning to adopt TPN in their practice (Kudsk et al. Even if the patient is unable to swallow due to reasons such as bulbar palsy. unconsciousness or facial fractures. 1985. 2008). they are often used in patients after stroke. including overspills and lack of cooperation. Current NICE (National Institute for Health and Clinical Excellence) guidelines recommends its use when more than 30 days of bedstay is required post-surgery. and minimizes the risk of thrombosis. Discussion Review of Global Medicine and Healthcare Research . Tube feeds are indicated in patients suffering from swallowing difficulties.. Wilmore. protein. Feeding tubes can also be placed percutaneously into the stomach or jejunum either at operation or with endoscopic and laparoscopic help.. These tubes can be negotiated into the jejunum endoscopically or radiologically such as a naso-jejunal tube (O'Connell et al. his patients managed to rehabilitate much faster within 23 months and without complications (Jeejeebhoy et al. 1 (2010) 269 . Vars. ascites and prolonged ileus (Burkitt et al. B) Parenteral Nutrition Total parenteral nutrition (TPN) is defined as the intravenous provision of all nutritional requirements. as well as to compensate for pre-existing malnutrition (Deitel. 2008).. 1 No. . illustrated by a prospective randomised study (Dudrick et al.The decision to use enteral or parenteral nutrition for surgical patients.. Review of Global Medicine and Healthcare Research . compared a group of major abdominal trauma patients undergoing laparotomy over a 28 month period (Moore.. developed markedly elevated plasma insulin levels. is one that is fraught with conundrums. Patients given TPN. increasing secretory immunoglobulin A and mucin. as reported in a review by Thomson et al. Palmason. Enteral nutrition is the preferred route of administration in surgical patients.Vol. in the intensive care unit. 1974). 2008). 1981). The normal wellfed intestine absorbs nutrients whilst maintaining an effective barrier against intraluminal toxins and bacteria (Kudsk et al. 2008). 1988. 2008). A randomised trial also concluded that glucose metabolism was more physiological in the enterally fed group as they maintained normal insulin levels and had no fatty-acid deficiency. & Specian. Their clinical study demonstrated that traditional protein markers such as albumin and transferrin were restored much better in the enteral group. Jones. intolerance causing flatulence and hyperglycemia. enteral nutrition is not without its critics. driving excess glucose into the fat cells and increased lipolysis (McArdle.. as it is safer. 1992). involve perforation of the intestine and the inadvertent introduction of the feeding tube into the tracheobronchial tree. hyperinsulinaemia and hypertriglyceridaemia (Ryan et al. 1992. “When the gut works use it” is the common dictum expressed by proponents of the enteral route (Kudsk et al. Other complications which were commonly exhibited included complications related to the feeding regimen. Catheter-related complications were also found to have a high incidence due to its invasive nature. 1992). 1 (2010) 270 . reducing the incidence of septic complications in the stressed patient. However. a consequence of high osmolarity and low pH of feeding solutions. although supplemented by myriads of literature. normal gut motility is promoted having a protective role in preventing infections (Baker. Moore. Complications related to nutrient delivery include diarrhoea. This can lead to aspiration of feed and perforation of the respiratory tract. Moreover.. conducted by Moore et al. 2008). Berg. complications can be divided into those resulting from intubation of the GI tract and those related to nutrient delivery (O'Connell et al. Animal research has also shown that by maintenance of peristalsis. O'Connell et al. on the contrary. 1968. such as electrolyte abnormalities. bloating and interruptions to feeds (Kudsk et al. 2008). Nutrients delivered enterally may therefore be used more efficiently through reaching the liver via the portal circulation rather than by vein (O'Connell et al. Deitch. 1 No. 1987). Ryan et al. McCroskey. Li. Catheter-related complications.. One of which. 1989)... Several prospective randomised trials have been performed to compare the efficacy and safety between the routes of nutrition. Their study described a high proportion of patients having catheter infections after being given TPN as compared to Enteral feeding. Moreover. Discussed herewith are some of the landmark papers describing previous clinical research. Saito et al. Morency. & Peterson. the capacity to administer TPN peripherally is limited by the development of thrombophlebitis and venous thrombosis. & Brown. introducing the feed into the pleural cavity (Thomson. In enteral nutrition.. 1974). less expensive and more physiological as compared to the parenteral route (Thomson. it is easier to infuse nutrition through an existing indwelling central line than to deal with diarrhoea.. For these patients at risk. there are often dilemmas amongst medical students and junior doctors. potassium and water increases (Burkitt et al. insulin secretion rises and cellular uptake of glucose. February 2006). are depleted in the process. Enteral tube feeding and parenteral feeding are considered if there is inadequate spontaneous oral intake. some multi-centre studies such as the one by the Veterans Affairs TPN Cooperative Study Groups have concluded that the use of pre-operative TPN can be used in patients who are severely malnourished. As a result. Refeeding problems are a dangerous and life threatening complication of incorrect treatment. 1985. phosphate. parenteral nutrition should be used to supplement or replace enteral tube feeding (NICE. or the problem of dysphagia in the patient. 1 No. Intracellular electrolytes. Clinical guidelines. with the relatively contradictory evidence. but have an accessible gastrointestinal tract or are due to undergo major abdominal procedures should be considered for pre-operative enteral tube feeding. or perforated gastrointestinal tract also supports its use. Current Guidelines Hence. This arises when at first. in particular phosphate which is essential for vital phosphorylation reactions. 2000. 2003). The current NICE guidelines (2006) recommend the following: A) That surgical patients who are malnourished through inadequate or unsafe oral intake. February 2006). are produced to aid healthcare professionals and patients in making informed decisions about appropriate healthcare. The latest ESPEN (European Society for Clinical Nutrition and Metabolism) 2009 guidelines also reinforce that post-operative parenteral nutrition is beneficial in patients with postoperative complications impairing gastrointestinal function. Supplementary peri-operative parenteral nutrition should be indicated in malnourished surgical patients who have an inadequate or unsafe oral and enteral nutritional intake. A non-functional. Hill. the NICE guidelines recommends the ‘start low go slow’ rule where nutrition Review of Global Medicine and Healthcare Research . malnourishment reduces carbohydrate intake leading to catabolism of fat and protein instead of carbohydrate. inaccessible. B) General surgical patients should not have enteral feeding within 48 hours post-surgery unless they are malnourished or at risk of. A recent meta-analysis of 27 randomized control trials concludes that TPN has no statistically significant effects on the overall mortality and morbidity of surgical patients (Heyland et al. who are unable to receive and absorb adequate amounts of oral/enteral feeding for at least 7 days (Braga et al. They should have an inadequate oral intake and possess a functional and accessible gastrointestinal tract (NICE. 1992). It is recommended that these patients are assessed carefully for risk factors of refeeding problems.Notwithstanding a paucity of supporting literature for parenteral compared to enteral nutrition. 1 (2010) 271 . Deitel. Another prospective randomized study performed by Bozzetti et al showed that 10 days of preoperative TPN continued postoperatively is able to reduce the complication rate by approximately one third and was able to prevent mortality in severely malnourished patients with gastrointestinal cancer (Bozzetti et al.. 2009).. 2007.Vol. Should intestinal intolerance persistently limit enteral tube feeding in surgical or critical care patients. Giving nutrients and fluid to these malnourished patients reverses fat to carbohydrate metabolism. Ward... based on the best available scientific evidence. 2001). seen in Table 2. Deitch. et al. It has an essential role in nitrogen transport and acid-base homeostasis. the safety and well-being of the patient should be the prime concern of surgeons and doctors alike. 2009). a relatively new regimen.. (2000)... early administration of TPN should be considered. It is important to adopt and inculcate good clinical practice guidelines based on evidence-based medicine.. 2000... W. Immune-enhancing formulaes are intended to boost the function of the immune system of patients suffering from the stresses of surgery and acute illness (Salvino et al. (1988).. C... References Askanazi. Ann Surg. Hensle. N. Other studies have shown that the incorporation of glutamine to parenteral nutrition regimens. D. F.Vol. R. M. During severe stress and nutritional depletion. P. given to patients post abdominal surgery results in improved nitrogen balance and a quicker lymphocyte recovery. Hemorrhagic shock induces bacterial translocation from the gut.. In the ethos of holistic and patient-centred care.. H. S. W. 2003). Effect of immediate postoperative nutritional support on length of hospitalization. E.. Ward. 896-906. is developing. Starker. The importance of nutrition in surgical patients cannot be over-emphasized. This translated into decreased length of stay and morbidity (Mertes et al. Looking to the Future Amidst ongoing studies that seek to validate the roles and benefits of the various routes of delivery. C. 1 No. J. T. Understanding the various viewpoints of authors allows us to craft a better picture of how to better manage the malnourished patient undergoing surgery. There is also reduced complications such as infections and wound complications in patients treated with immunonutrition as compared to standard enteral nutrition (Braga et al.. J. R. 1998. M. Perioperative total parenteral nutrition in malnourished... LaSala. but should the enteral route not be available for more than one week. principal lessons from these collective studies support that the enteral route should be used whenever possible. et al. Conclusion In conclusion.. L. D. (1986). Li. 2004. Berg. & Specian. Baker. Rossi. Glutamine is actively involved in antioxidant defence mechanisms through the influence of glutathione synthesis. Miceli. A. A. Mariani. Lockhart. R. interest in immunonutrition. Olsson. J Trauma. P. 28(7). Ward.. Cozzaglio. 2003). Morlion et al.. 203(3). the demand for glutamine may exceed its production. L. Bozzetti.. Gavazzi.support at a maximum of 10 kcal/kg/day slowly increasing to meet or exceed full needs by 4-7 days. gastrointestinal Review of Global Medicine and Healthcare Research . 236-239. 1 (2010) 272 .. . Langer. A. Total parenteral nutrition at home for 23 months.. J. 378386. C. & Drover. Fabian.. 29(7). A. Clin Nutr. Weimann. E. Minard. J. D.. Kuhn. J. 714. & Rhoads. (2001).cancer patients: a randomized.. 1 (2010) 273 . without complication. R. E. R.. 24(1). (2009). Su. S. New York: Churchill Livingstone.. K.. B.. G. D. A rationale for enteral feeding as the preferable route for hyperalimentation. S. A. E. H. G. development..... Kudsk. ESPEN Guidelines on Parenteral Nutrition: surgery.). K. M. H.. Enteral versus parenteral feeding. Tolley.. 102-111. 134-142. (1981). Effects on septic morbidity after blunt and penetrating abdominal trauma. L. M. Deitel. Jeejeebhoy. 616-623. Zohrab. discussion 922-913. clinical trial. MacDonald.. B. A. Schulzki. Kuksis. A. J. Braga. E. Heyland. 65(5). Rev Endocr Metab Disord. 64(1). Clin Nutr.. et al. TEN versus TPN following major abdominal trauma--reduced septic morbidity. Benzing. Annu Rev Nutr. Vars. G. J.. F. Blood glucose management during critical illness. W... A. Palmason. Long-term total parenteral nutrition with growth. M. N.. A. (2007). S. 215(5). & Ashley.. Essential surgery : problems. Moore. G. Review of Global Medicine and Healthcare Research .. B. (1973). and positive nitrogen balance. Edinburgh . J. Nutrition in the perioperative patient. K... K. (2003). N. 916-922. M. (2000). 19(6). Quick. & Anderson. (1989).). H. Wilmore. Nutrition in clinical surgery [print] (2nd ed. Edinburgh . 395-401. Mertes. 187-194. Mizock. G. A. G. Surgery. 28(4). 23. C. L. Poret. A. (1968). Howard.. New York: Churchill Livingstone. I. Hill. M. T. (1992). Total parenteral nutrition in the surgical patient: a meta-analysis. H. (2003). C. M. O. Y.. (1992). P. T. C. Ljungqvist. M. (1985). & Brown.. L. & Reed. B. Keefe. diagnosis and management (4th ed. 1 No. L. J Trauma. 263-282.. Fearon. Croce.. A.. H. Cost containment through L-alanyl-L-glutamine supplemented total parenteral nutrition after major abdominal surgery: a prospective randomized double-blind controlled study. W. discussion 511-503.. Phillips.Vol. Gastroenterology. V. 4(2).. & Bozzetti. Burkitt. Montalvo.. Moore... Baltimore: Williams & Wilkins. 90(4). C. et al. Soeters. and with good rehabilitation. S. Disorders of nutrition and metabolism in clinical surgery [print] : understanding and management. 811-820. Ann Surg. JPEN J Parenter Enteral Nutr.. F. Can J Surg. Winde.. C. Surgery. Morency. Dudrick. 503-511. N. Goeters. & Peterson. K. Jones. 44(2). McCroskey.. McArdle. X. W.. A study of technical and metabolic features. & Seidner.. et al.. M. P. 290(14). Cleve Clin J Med. N. Bulstrode.. Abbott. (1998). K. Jr.. L. Nutrition support to patients undergoing gastrointestinal surgery. 1 No. M. S. 227(2). M. S.. 11(1). 71(4). Impact of nutritional status on DRG length of stay. G. Wachtler. Colley. N. Windsor. Ann Surg. controlled study.. The importance of protein depletion. H. Williams. 11(1). 18. Salvino. 1-7. C. A. Ann Surg. Siedhoff. G. A prospective study of 200 consecutive patients. Trocki. H.. Risk factors for postoperative pneumonia.. J. & Joffe. The effect of route of nutrient administration on the nutritional state... & Hill. N Engl J Med. (2004). M. 757-761. R. R. enteral tube feeding and parenteral nutrition. A.Morlion. L. 345-351. C. Ryan. W. 1 (2010) 274 .. M.rcseng. London: Hodder Arnold. (2003). (1974). Stehle. T. (2008). Perioperative nutrition support: who and how. P. et al. Ward. & Levine. P. 208(2). Hopkins. JPEN J Parenter Enteral Nutr. (February 2006). D. Dechicco. Thomson. Catheter complications in total parenteral nutrition. & Bailey. G.. R. M. R. (1988). A.Vol. Koller. 49-51. JPEN J Parenter Enteral Nutr. R. Russell. S. The enteral vs parenteral nutrition debate revisited. 2. (1987). 209-214. (1987). Heyd.). Abel. from www. N... catabolic hormone secretion... T. Alexander. Total parenteral nutrition with glutamine dipeptide after major abdominal surgery: a randomized. J. 32(4)....uk O'Connell.. Nutr J. B. NICE. (2008).. J. J. C... Kopcha. Robinson. P. W. Review of Global Medicine and Healthcare Research . R. Chesney. J. Konig.ac.. H. O.. 302-308... double-blind. M. JPEN J Parenter Enteral Nutr. Bailey & Love's short practice of surgery (25th ed. and gut mucosal integrity after burn injury. Saito.. G. W. Goldstein. 474-481. Nutrition support in adults Oral nutrition support. R. C. chemotherapy. Review of Global Medicine and Healthcare Research . Or patient has two or more of the following: • BMI less than 18.1: Assessments for identification of the patient at risk A) CLINICAL Malnutrition seen in the ‐ following: ‐ body mass index (BMI) of less than 18. 1 (2010) 275 .5 kg/m2 • unintentional weight loss greater than 10% within the last 3–6 months • little or no nutritional intake for more than 5 days • a history of alcohol abuse or drugs including • insulin.Tables Table 1. 1 No. antacids or diuretics.Vol. ‐ Lack of nutritional intake for 5 days or more B) ANTHROPOMETRIC Reduced Tricep skin fold thickness.5 kg/m2 ‐ unintentional weight loss ‐ greater than 10% within the last 3–6 months is a poor ‐ prognostic outcome ‐ a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months. which shows body density and overall fat content Reduced Mid-arm circumference Weak Hand grip strength: This is easy to perform but lacks reproducible baseline data C) BLOOD Low serum albumin levels of < 35g/L is associated with a 5-fold increase in complications and 10-fold increase in death rate. Reduced plasma prealbumin Reduced lymphocyte count ‐ ‐ ‐ Table 2: NICE Criteria for determining people at high risk of developing refeeding problems Patient has one or more of the following: • • • • BMI less than 16 kg/m2 Unintentional weight loss greater than 15% within the last 3–6 months little or no nutritional intake for more than 10 days low levels of potassium. phosphate or magnesium prior to feeding. To study the role of possible associated factors and relation of type. District. India Mahagaonkar AM Abstract Background In India smoking is a common habit prevalent in both urban and rural areas. 1 No.Pulmonary Lung Functions in Sugarcane harvesters who Smoke Rubeena Bano Department of Physiology Rohilkhand Medical College and Hospital. Objectives 1.Vol. India Email: drpiyushkalakoti@gmail. Review of Global Medicine and Healthcare Research . 1 (2010) 276 . India Piyush Kalakoti Rural Medical College Pravara Institute of Medical Sciences. Loni. Materials & Methods: The pulmonary function tests were assessed on computerized spirometer in 400 male subjects comprising of 200 smokers and 200 non smokers and results were compared. Study design: Cross sectional study. Methods Setting: Pravara Rural Hospital. Maharashtra.Ahmednagar. Cigarette and bidi (lower unrefined form of cigarette without any filter) smoking has extensive effects on respiratory function and is clearly implicated in the etiology of a number of respiratory diseases. To study and compare the pulmonary function tests among smokers in sugarcane harvesters in a rural area.0. quantity and duration of smoking on the pulmonary function tests. 2.com Nadeem Ahmad Department of Community Medicine Rohilkhand Medical College & Hospital. Statistical analysis: was done using SPSS Statistical Software 15. In India. tobacco is consumed mainly in the form of bidis (54%). and bronchial carcinoma8. pipes. followed by smokeless tobacco (27%) and cigarettes (9%) 5. duration and pattern of smoking on the pulmonary functions in smokers.Vol. Almost all the pulmonary function parameters were significantly reduced in smokers as compared to non smoker controls and obstructive pulmonary impairment was commonest in smokers. particularly chronic bronchitis. the early changes in airflow obstruction may be detected.Results Almost all the pulmonary function parameters were significantly reduced in smokers and obstructive pulmonary impairment was commonest. Bidi smoking was most common as the study setting was in rural India. Bidi smoke may be more injurious because bidi contains unrefined form of tobacco as compared to cigarettes6. Spirometry. bidis.7. by computerized pulmonary function testing. Review of Global Medicine and Healthcare Research . 1 No. cigar. Keywords: Smoker. Thus. 1 (2010) 277 . by spirometry a spectrum of lung disorders may be detected at an early stage and subsequent morbidity can be minimized. PIMS.e. Tobacco smoking rates have decreased in industrialized countries since 1975. Cigarette smoking has extensive effects on respiratory function and is clearly implicated in the etiology of a number of respiratory diseases. Conclusion The present study reveals the effect of type. Loni. emphysema. cigarettes. tobacco related death would increase to about 10 millions a year3. in district Ahmednagar. By the early 2030. Pulmonary functions. Materials and Methods The present cross sectional study was conducted in Pravara Rural Hospital of Rural Medical College. rural area Introduction Cigarettes kill an estimated 5 million people annually world wide1. Maharashtra from January 2007 to August 2008. In India smoking is a common habit prevalent in both urban and rural areas irrespective of mode of smoking i. but there has been a corresponding 50% increase in smoking rates in lowincome countries4. By screening smokers. The World Health Organization reported that tobacco smoking killed 100 million people worldwide in the 20th century and warned that it could kill one billion people around the world in the 21st century2. hookah etc. The materials used in the study were a computerized RMS Med-spirometer. measuring tape and Blood Pressure set. • Those with chronic disease or requiring hospital admission or having serious illness 2 weeks prior to the start of the study were excluded. Control For the control group.Sample Size: The study population included 400 male subjects comprising of 200 smokers and 200 non smoker controls aged between 30-60 years. 200 healthy non smokers of almost same age and matching other characteristics were selected. chi square test and t-test of significance. Smoking Index: It is equal to multiplication of the average number of cigarettes/bidis smoked per day and duration (in years) of tobacco smoking10. daily for at least one year. 1 No. body mass index and body surface Review of Global Medicine and Healthcare Research . height. Habit Smoking Index (Frequency x duration) 0 1-100 101-200 more than 200 Non-smokers Light smokers Moderate smokers Heavy smokers The observations of the study were analyzed by statistical methods like percentages. Sampling was done as per the inclusion & exclusion criteria. To evaluate dose and duration response relationship. 11. were considered as smokers9. Inclusion criteria • Individuals with history of smoking cigarettes / bidis. 1 (2010) 278 .Vol. Exclusion criteria • Ex-smokers or past smokers were excluded from the study. weight. Results In the present study it was observed that there was no significant difference in the mean physical parameters like age. quantification of tobacco smoking was performed by calculating smoking index for smokers. weighing machine. FEF25-75% and MVV showed statistically highly significant association between smokers and non-smokers by applying unpaired t-test of significance (p < 0. FEV1/FVC.22%) (Table 7) Review of Global Medicine and Healthcare Research .0%) and heavy smokers (16.0%) based on the criteria of smoking index (Table 3). moderate smokers in 51-60 years (46.0%) (Table 2) Most smokers were light smokers (54. The obstructive lung changes were most common and were observed predominantly in bidi smokers.3 times more risk of having impaired pulmonary functions as compared to non-smokers (Table 6). (72. 51-60 years (75. 1 No. PEFR. The association between smoking and impaired PFT was statistically highly significant. The smokers had 17.0%) followed by both cigarette and bidi (mixed) (24.001) (Table 5).area by calculating mean and standard deviation in smokers and non-smokers (Table 1).0%) and only cigarettes. Most of the smokers smoked only bidi (62.85%). 1 (2010) 279 .66%) and heavy smokers.0%) (Table 4) All Pulmonary function parameters like FVC.Vol. Majority of the light smokers were in the age group of 41-50 years (51.0%) followed by moderate smokers (30. FEV1. (14. 22) 108 (100.14 Table 2: Type of Tobacco Smoking in Smokers.0) Review of Global Medicine and Healthcare Research .67 ± 0.12 64.06 Non-smokers Mean ± 2 S.11 65.66 ±0. (%) 36 (18.Table 1: Physical Characteristics of Smokers and Non-Smokers. 1 (2010) 280 .74 ± 0.66) 24(75.4 ± 8.37 1.80 ± 3.0) 88 (44.0 Table 4: Age Wise Distribution of Grade of Smoking.71 ± 0. 124 48 28 200 % 62. (%) No.0) 76 (38.52 ± 3.0 100.8 23.0 24.0 Table 3: Distribution of Grade of Smoking in Smokers.0 100. Grade of smoker Light smoker Moderate smoker Heavy smoker Total Number of smokers 108 60 32 200 (%) 54.26 ± 10.85) 24 (22. 48. Variables Age (years) Height (m) Weight (Kg) Body Mass Index (BMI) Body surface area (m2) S.4 ± 11.0) 24 (40.33) 0 (0. Age group (years) 31-40 41-50 51-60 Total Light Smoker No. 1 No.0) 8 (25.Vol.0 14.0) 60 (100.0) 28(46. 48.54 1.0 30. Type of smoking Only Bidi Both cigarette & bidi (mixed) Only Cigarette Total No. = Standard Deviation Smokers Mean ± 2 S.D.0) 32 (100. (%) 28 (25.0) Moderate smoker Heavy smoker No. (%) 8 (13.09 1.0) Total No.10 ± 10.20 1.0 16.0) 200 (100.D.92) 56 (51.5 23.D. Burrows et al12 reported that there is quantitative significant relationship between impaired ventilator function and duration and Review of Global Medicine and Healthcare Research . None of individuals smoked tobacco in any form other than bidis or cigarettes.0) In the present study it was observed that there was no significant difference in the mean physical parameters like age.000692 ( HS) 0.1 ± 44.0) 0 (0.06 2.6 ± 33.81 ± 0.22) 0 (0. Table 6: Interpretation of PFT results in smokers and non-smokers.17) 28 (24.98 2.0) 0 (0.0) 4 (1. body mass index and body surface area thereby showing proper matching of smokers and non-smokers (Table 1).54 6. (%) No.0) 8 (2.55) 0 (0.68) 116 (100.0) Both cigarette/ bidi 16(22.0) 116 (58. (Odds’ ratio = 17.98 5.46 2.13) 24(20.74 103. 1 (2010) 281 .02 83.0) 192 (96.0) Total 72 (100.0%) (Table 2) Also the cigarette smokers usually smoked non-filter cigarettes since they are cheap and easily available in rural areas.0) 8 (100.22) 4 (100.0) 400 (100.D 2. (%) 72 (36.0) 200 (100.003808 (HS) 0.22 Non-smokers Mean ± 2 S.001). (62. Pulmonary Function Tests (PFTs) FVC FEV1 FEV1/FVC PEFR FEF25-75% MVV Smokers Mean ± 2 S. Similarly.30 ± 3.86 89.0) 28 (14.66 Significance* p value 0.0) 200 (100. Most smokers were bidi smokers.0) Chi square value = 20.001.59 ± 1. highly significant.00002 (HS) Significance has been calculated by unpaired t test (p < 0.02 86.0) Non-smokers Total No.80 ± 3.0) Only Cigarette 4 (5.13 ± 0.00196 (HS) 0.3) Table 7: Relation of Type of smoking with Pulmonary Function tests Type of smoking PFT interpretation Obstructive Restrictive Only Bidi 52(72.98 ± 1.85%).0) 80 (20.48 ± 1.0) 4 (100.0) Discussion Total Mixed 8 (100.0) 8 (4.0) 0 (0.000034 (HS) 0.0) 4 (2. PFT Results Obstructive Restrictive Mixed Normal Total Smokers No.03242 (S) 0. p < 0.0) 124 (62.44 3. In the present study most smokers were light smokers (Table 3) in the age group of 41-50 years (51.0) 0 (0. weight.0) 200 (100.99 ± 2.49 ± 10.Vol.0) 48 (24.84. height.Table 5: Pulmonary Function Tests among Smokers and Non-Smokers.D** 3.0) 308 (77.93 ± 23. (%) 8 (4. 1 No.0) Normal 64(55. The association between smoking and impaired PFT was statistically highly significant. several researchers like Angelo15 and Mahajan et al16 observed no change in FVC in smokers and non-smokers (Table 5). 1 No. PEFR and other flow rates indicate obstructive lung changes and fall in FVC indicates restrictive lung changes. 24: 71. and Gupta et al14. 1 (2010) 282 . duration and pattern of smoking on the pulmonary functions in smokers. Also a Chest radiograph & other investigations to rule out various pulmonary diseases was not done. The present study reveals the effect of type. Similar. 6. 3. we could not take into consideration the sugarcane harvesters of urban areas. Conclusion The pulmonary function tests were assessed on a computerized spirometer in 400 male subjects comprising. The smokers had 17. Vol. International Journal of Public Health.frequency of smoking (Table 4). observations showing lung function impairment in smokers were reported by Burrows et al12. Study Limitation Pravara Rural Hospital (PRH) being in a Rural area of Loni. the early changes in airflow obstruction may be detected and special emphasis is to be recommended on smoking cessation strategies.Vol. No. The fall in FEV1. By screening smokers. by computerized pulmonary function testing. Partnering for better lung health: Improving tobacco and tuberculosis control. 2. All Pulmonary function parameters showed statistically highly significant association between smokers and non-smokers by applying unpaired t-test of significance (p < 0. Bidi smoking was most common as the study setting was in rural India. Pandya et al13. June 2006. Int J Tuberc Lung Dis 2000. Science Daily. Almost all the pulmonary function parameters were significantly reduced in smokers as compared to non smoker controls and obstructive pulmonary impairment was commonest in smokers. Padmavathy17 in a study concluded that the pulmonary function tests are more affected in bidi smokers than in cigarette smokers (Table 7).3 times more risk of having impaired pulmonary functions as compared to non-smokers (Table 6). Review of Global Medicine and Healthcare Research . However. References 1. 4: 693-7. Yach D. WHO Report: Tobacco Could Kill One Billion by 2100. Also not all the sugarcane harvesters of rural area could be taken into consideration due to paucity of time & finances. 84. Bulletin of the WHO. 495. Aug 2008.001). 200 smokers and 200 non smoker controls. 11: 19-21. 2008. 1998. Gupta P. Angelo MT. Cigarette smoking behavior and consumption characteristics for the Asia. Comparative study of pulmonary function variables in relation to type of smoking. WHO. Vol. Respiratory disorders among workers in a railway workshop. 28:5-30. J Tub. 9.Vol. Maini BK. 11. Physiol & Pharmacol 1984. Indian J Physiol Pharmacol. Indian. 76-101. Pakhale SS. Resp. Physio. 10. World Health Organisation. bidis and other indigenous forms of smoking. World Health Organization. Dis. Zodpey and Suresh N. 52 (2): 193-196. 1984. 42. 3: 361-365. Jr. hydrogen cyanide and benzopyrene. 115.. Ughade. Review. Dhir VS. p-47. 6. Effect of smoking cigarettes on small airways. Dadhani AC. Burrows B. 161.Regional Health Forum. 38. 32: 75-81. 195-205. 17. Jayant K. Mahajan BK. 5. Appl. 7. Review of Global Medicine and Healthcare Research . 1983. 14. 1 (2010) 283 . Khudson R.4. 3: 336-46. Chandwani S. S. Jour. Amer. levels of phenol. Lebowitz M. Geneva. 12: 83. September 2006.D. 16. 1995. Indian J Chest Dis Allied Sci 1990. 27:1-37. Sanjay P. 8. Chemical analysis of smoke of Indian cigarettes. Guidelines for controlling and monitoring the tobacco epidemic. Padmavathy KM.Pacific region. Cardiorespiratory function in healthy smokers and non-smokers. 1977. 1 No. Vol. sex.J. 28: 3. Martha Jeline. IUALTD: The world tobacco situation. Sharma K. Vol. Yu JJ. J. Shopland DR. World tobacco epidemic. Pandya KD. Bhide SV. Physio. Raghunandan V. 1993. Health Situation in South East Asia region 1999. 2nd Edition. Gupta. 14: 7-9. Effect of age. WHO. World Smoking Health 1989. Anonymous. Quantitative relationship between cigarette smoking and ventilatory function. posture and smoking on peak flow rates. Tobacco Smoking and Risk of Agerelated Cataract in Men. Vol. Ind. 15. IUALTD News Bull Tobacco Health 1998. Effect of cigarette smoking smoking on airways. Mahajan SK.K. 12. 13.. And Pharm. WHO South-East Asia Region. Ind. 34. Paul Hamosh. 1973. Silva D. insulin. Aims & Objectives: The objective of this study was to investigate the effect of protease inhibitors (indinavir. Indinavir. So there is every possibility for the combined use of protease inhibitors with gliclazide in chronic diabetics with HIVinfection. After single dose interaction study. 1 No. insulin and glycosylated hemoglobin values. Andhra University. Blood samples were collected in rats from retro orbital puncture to estimate the blood glucose.Vol. beta cell function. Results/Findings: Gliclazide produced biphasic hypoglycemic/antidiabetic activity in normal and diabetic rats with peak activity at 2 h and 8 h. glycosylated hemoglobin. India * Corresponding Author. total hemoglobin and glycosylated hemoglobin.Influence of Protease Inhibitors on the Pharmacodynamics of Gliclazide in Rats Mastan Shaik * Research & Development Cell. Methods/Study Design: Studies in normal and alloxan-induced diabetic rats were conducted with oral dose of gliclazide. insulin sensitivity and percent beta cell function were determined by homeostasis model assessment (HOMA) model. the same group was continued with the daily treatment of interacting drug for the next eight days (multiple dose interaction study) with regular feeding. interacting drug and their combination with adequate washout in between treatments. insulin resistance index. Blood samples were analyzed for blood glucose by GOD/POD method and plasma insulin concentrations were determined by radioimmunoassay method. 1 (2010) 284 . Email: [email protected] Eswar Kumar Kilari Pharmacology Division. Gliclazide is a widely used drug for the treatment of type 2 diabetes. Later after 18 h fasting they were again given the combined treatment on the ninth day. The parameters considered for this study include blood glucose. But there is no report on the safety and effectiveness of the combination. India Pharmacology Division. India Email: ekilari@rediffmail. ritonavir and atazanavir are widely used protease inhibitors for the treatment of HIV-infection. Review of Global Medicine and Healthcare Research . AU College of Pharmaceutical Sciences. ritonavir and atazanavir) on the pharmacodynamics of gliclazide in normal and diabetic rats with respect to safety and effectiveness of the combination. Jawaharlal Nehru Technological University. AU College of Pharmaceutical Sciences Andhra University.com Abstract Background: Type 2 diabetes may occur as a result of HIV-infection and/or its treatment with protease inhibitors. Insulin resistance index. Indinavir and ritonavir significantly elevated the blood glucose. insulin sensitivity index and body weight. insulin. total hemoglobin. 2004). Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels and disturbances in carbohydrate. Gliclazide. 2004). 2006). Keywords: Protease inhibitors.Vol. Diabetes. except increase in body weight in normal and diabetic rats. When given in combination. Review of Global Medicine and Healthcare Research . fat and protein metabolism with micro and macrovascular complications that result in a significant morbidity and mortality (Saely et al. Diabetes mellitus is such metabolic disorder that needs treatment for chronic period and maintenance of normal blood glucose level is very important in this condition. Limitations: Present study is limited to describe the exact mechanism of action(s) behind these interactions and these have to be confirmed by conducting pharmacokinetic interaction studies. The alterations associated with indinavir are more compared to ritonavir treated rats. The drug interaction studies presume much importance especially for drugs which have narrow margin of safety and used for chronic period of time. The number of people suffering from diabetes mellitus worldwide is increasing and estimated to 366 million by the year 2030 (Wild et al. Atazanavir alone has no significant effect on any parameter. 1 No. they are likely to occur in humans. HIV-infection. indinavir significantly reduced the effects of gliclazide in normal and diabetic rats following single and multiple dose treatments of indinavir and it confirms the pharmacodynamic interaction of indinavir with gliclazide. Conclusion: Since the interactions were seen in normal and diabetic rats following single dose and multiple dose administration. 1 (2010) 285 . In combination ritonavir and atazanavir significantly enhanced the effects of gliclazide in rats (normal and diabetic) and it confirms the possibility of pharmacokinetic interaction with gliclazide. Type-1 diabetes is due to decrease in the synthesis of insulin and type-2 diabetes is characterized by hyperglycemia in the context of insulin resistance and relative insulin deficiency. However the present study warrants further studies to find out the relevance of these interactions in other species/human beings and to know the exact mechanism of action(s) behind these interactions. Pharmacokinetics Introduction The study of mechanisms of drug interactions has profound value for the selection of drug concentrations to provide rational therapy.where as the total hemoglobin and body weights were decreased in normal and diabetic rats. since both hyperglycemia and hypoglycemia are unwanted phenomenon (Satyanarayana et al. Pharmacodynamics. Hence care should be taken when the combination is prescribed for their clinical benefit in diabetic patients. also leading to decreased or increased activity of gliclazide. which may need dosage adjustment. Material and Methods Drugs and Chemicals Gliclazide and protease inhibitors (indinavir. 2009). and protease inhibitors (PIs). we investigated the effect of antiretroviral drugs on the pharmacodynamics of gliclazide in animal models with respect to few parameters. Regulation of glucose metabolism is a key aspect of metabolic homeostasis and insulin is the predominant hormone influencing this regulatory system. 2009). Much of concern is due to the recognition of the long-term complications of insulin resistance and hyperglycemia and understood is the context of the growing worldwide epidemic of type 2 diabetes mellitus (Zimmet. Glucose was measured as a metabolic control of insulin action. low incidence of producing severe hypoglycemia. Review of Global Medicine and Healthcare Research . 1 (2010) 286 . So the present study was planned to investigate the effect of protease inhibitors in rats (normal and diabetic) to evaluate the safety and effectiveness of the combination. and other haemobiological effects (Mastan et al. and alterations in body fat distribution (Leow et al. glycosylated hemoglobin and body weight could give more reliable findings in this task. In our previous studies (Mastan et al.Type 2 diabetes may occur as a result of HIV-infection and/or its treatment. among which gliclazide. a second generation sulphonylurea derivative is preferred in therapy because of its antidiabetic activity. The widely used PIs include ritonavir. 2003). especially with PIs (Dube.Vol. The impairment of glucose homeostasis and increase in plasma glucose level are associated with diabetes. alterations in normal glucose homeostasis remain a particularly prevalent and alarming clinical change in affected patients (Hruz. there is no much evidence on the effect of antiretroviral drugs on the activity of gliclazide with respect to multiple parameters. 2000). India) and Aurobindo Pharma Ltd (Hyderabad. in order to have better understanding of the pathological process/mechanisms of insulin resistance to evaluate the safety and effectiveness of the drug combinations. atazanavir and indinavir. 1 No. ritonavir and atazanavir) are the gift samples from Micro Labs (Bangalore. a combination of non-nucleoside reverse transcriptase inhibitors (NNRTIs). 2004). However. insulin sensitivity and β-cell function from fasting glucose and insulin. 2001) and refers to impaired sensitivity to insulin mediated glucose disposal (Reaven. which will substantiate the actual facts of the interactions. So it is of greatest importance to study the glucose-insulin homeostasis. HAART has been associated with a spectrum of metabolic abnormalities including ranging from insulin resistance to impaired glucose tolerance and diabetes mellitus. Among the many metabolic perturbations that occur as a result of HIV-infection and its treatment. Highly active antiretroviral therapy (HAART). Quantifying total hemoglobin. dyslipidemia. 2001). antioxidant property. is widely used to control HIV-infection and the development of AIDS. Insulin plays a key role in the maintenance of glucose homeostasis and provides the major modulator of glucose storage and utilization. 2006). nucleoside reverse transcriptase inhibitors (NRTIs). The homeostatic model assessment (HOMA) is more reliable and validated method to measure insulin resistance. Insulin resistance (IR) is a state where normal or elevated insulin level produces a reduced biological response (Cefalu. Oral hypoglycemic agents are used in the treatment of type-2 diabetes. orally and 4 mg/kg bd. They were maintained under standard laboratory conditions at an ambient temperature of 25 ± 2oC and 50 ± 15% relative humidity with a 12-h light/12h dark cycle. Selection of doses and preparation of oral test solution/suspension In clinical practice..Vol.1N NaOH then made up to the volume with distilled water. India. Shibata et al. weighing between 250-320 g were used in the study. The animal experiments were performed after prior approval of the study protocol by the Institutional Animal Ethics Committee (Reg. Alloxan monohydrate was purchased from LOBA Chemie (Mumbai. Animals Albino rats of either sex of 6 to 8 weeks of age. mg/kg bd. They were fasted for 18 h prior to the experiment and during the experiment they were withdrawn from food and water. wt. wt of gliclazide. All other reagents/chemicals used were of analytical grade. PIs were suspended in CMC for oral administration (Yamaji et al. Glucose kits (Span diagnostics) were purchased from local pharmacy. They were procured from National Institute of Nutrition. 18 and 36. But the dose of gliclazide was selected as 2 mg/kg bd. orally. respectively. The study was conducted in accordance with the guidelines provided by Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA). All the drugs were administered to the respective groups by oral gavage. human oral therapeutic doses of the respective drugs were extrapolated to rat based on body surface area (Lawrence et al. India) and water ad libitum. 516/01/A/CPCSEA). Experimental Design The study consists of three phases. wt. Hyderabad. India). No. Gliclazide solution was prepared by dissolving it in a few drops of 0. Hyderabad. Animals were fed with a commercial pellet diet (Rayan’s Biotechnologies Pvt Ltd. Indinavir.India). 1 (2010) 287 . Phase-I Phase-II Phase-III : dose-effect relationship of gliclazide in normal rats : interaction study of protease inhibitors with gliclazide in normal rats : interaction study of protease inhibitors with gliclazide in diabetic rats Each phase of II and III consists of three groups (N = 6) for the interaction study of 3 respective protease inhibitors with gliclazide (single dose study followed by multiple dose study). to normal and diabetic rats. Review of Global Medicine and Healthcare Research . The same group was administered with gliclazide 2 mg/kg bd. ritonavir and atazanavir were orally administered in the dose of 72. 2002). wt of gliclazide.. 1 No. Dose-effect relationship of gliclazide in rats A group of six normal rats was administered with 1 mg/kg bd. Hence. wt based on the influence of dose-effect relationship of gliclazide on blood glucose in normal rats. 1999. protease inhibitors in therapeutic dose will be administered orally. orally. 1964). One week washout period was maintained between treatments. Rats with blood glucose levels of 200 mg/dl and above were considered as diabetic and selected for the study. Later after 18 h fasting they were again given the combined treatment on the ninth day. The same treatment (single dose interaction study followed by multiple dose interaction study) as described in the study in normal rats was performed with a group of six alloxan-induced diabetic rats.uk ). 1 (2010) 288 .2 (http://www. 1932) and glycosylated hemoglobin (HbA1C) was estimated by the modified method (Nayak et al. i. Blood sampling and determination of biochemical parameters Blood samples were withdrawn from retro orbital plexus (Riley.ox. Interaction study of protease inhibitors with gliclazide in diabetic rats Diabetes was induced in rats by the administration of alloxan monohydrate in two doses. 1960) of each rat at 2 and 8 h.2. Bonora et al. 1982). One week washout period was maintained between treatments. and plasma insulin was measured by Radio Immuno Assay method. 1981. Total hemoglobin was estimated by the cyanomethaemoglobin method (Drabkin. Determination of insulin resistance index and β-cell function The insulin resistance index and β-cell function were assessed by homeostasis model assessment as follows (Matthews et al.Interaction study of protease inhibitors with gliclazide in normal rats Each group of six rats was administered with gliclazide. After this single dose interaction study the same group was continued with the daily treatment of respective interacting drug for the next eight days with regular feeding.Vol. The same group was administered with interacting drug (Indinavir or ritonavir or atazanavir) and the combination of respective interacting drug and gliclazide. Insulin resistance = (FPI × FPG)/22.dtu. After 72 h. 1985. 1 No. 100 mg and 50 mg/kg bd.ac. The blood samples were analyzed for blood glucose by GOD/POD method (Trinder.5) Review of Global Medicine and Healthcare Research . 1969) using commercial glucose kits. orally.5 β-cell function = (20 × FPI)/ (FPG − 3. 1977). Insulin sensitivity was obtained by using the program HOMA Calculator v 2.e. samples were collected from rats by orbital puncture of all surviving rats and the serum was analyzed for glucose levels. wt intraperitoneally for two consecutive days (Heikkila. Bannon. 2000). insulin resistance index and decrease in total hemoglobin. wt of gliclazide was selected based on ideal blood glucose reduction which is about 35%.Where FPI is fasting plasma insulin concentration (µu/ml) and FPG is fasting plasma glucose (mmol/l). Data and statistical analysis Data were expressed as mean ± SEM. Indinavir alone produced significant increase in glucose. 1 No. indinavir and their combination (single dose and multiple doses) were represented in Table 1. 1 (2010) 289 .53%. The gliclazide produced hypoglycemic activity with maximum biphasic reduction of 26. The 2 mg/kg bd. wt and 4 mg/kg bd.67% & 50. respectively (Figure 1).46% at 2 h and 8 h with 1 mg/kg bd.50 ± 1. Gliclazide 1 mg/kg body weight Gliclazide 2 mg/kg body weight Gliclazide 4 mg/kg body weight 60 M np r e tbo dgu o er d ci n e a e c n l o l c s e uto 50 40 30 20 10 0 0 1 2 3 4 6 8 10 12 Time (hr) Figure 1: Dose effect relationship of gliclazide in normal rats (N=6) Effect of indinavir on the activity of gliclazide The levels of biochemical parameters following gliclazide.58% & 40. wt.59 ± 1.28 ± 1.Vol. glycosylated hemoglobin. 38. wt of gliclazide.13% & 28. β-cell function and insulin sensitivity.77 ± 1. insulin. The significance was determined by applying Student’s paired ‘t’ test. Review of Global Medicine and Healthcare Research .65 ± 1.91 ± 2.40% and 46. 2 mg/kg bd. Results Dose-effect relationship of gliclazide in rats Dose-dependent response of gliclazide was observed with the three oral doses. MDA: Multiple dose administration.51* 07.34±3.63±0.22* sensitivity† Total hemoglobin 116.25* 41.04 01.16* (g/dL) Glycosylated 78.09* Insulin (µu/mL) 12.86* 613.36±0.00±0.28±1.96 96.24* 97.67±0.38 19.16 96.52* 07.89±0.Table 1: Effect of indinavir on the activity of gliclazide in normal and diabetic rats (N = 6) Parameter Gliclazide 2h 8h 2h Indinavir 8h Indinavir + Gliclazide (SDA) 2h 8h Indinavir + Gliclazide (MDA) 2h 8h Normal rats Glucose (mg/dL) 53.96±0. Data was expressed as Mean ± SEM.44* 16. 1 (2010) 290 . †Calculated by homeostasis model assessment method.82* 76.84±1.46* 24.00±0.95 135.28* β-cell function† 51.67±0.49±33.33 0.90±0.17±1.64* 110.08 04.38 99.01±0.89 207.85* 47.34±6.87±0.67 57.34±1.14* 86.86±1.38±2.58±0.28±2.34 120.02±0.36±0.34±0.20±0.64±1.46±2.26 98.05 compared to gliclazide control Review of Global Medicine and Healthcare Research .08* 47.67±0.85 25.33±0.48 94.08* β-cell function† 483.44* 23.84 35.64 106.82±0. 1 No.33±8.48* 36.49* 189.30* 97.64±0.05 05.60±0.50* 16.34±1.67* Insulin (µu/mL) 11.34* 214.43* 23.38 88.92 46.34±0.84±0.04±0.26±3.67±0.00±0.05±0.84 71.62 35.32±2.38±0.30* 23.31±3.34 98.30±1.44±0.99 157.33±8.28±1.28±1.46 240.12* 04.54 55.17±1.34* sensitivity† Total hemoglobin 236.32 11.48* hemoglobin (%) Diabetic rats Glucose (mg/dL) 141.22* 21.67 83.34 31.16±1.46±0.07±0.10 03.46±2.50 13.21 224.34* 98.26±0.06 04.64 94.26* 15.57±0.66±2.28* 216.38±2.10* 23.13 08.74 1504.51 41.64* 220.21 86.38 20.33 23.24* 108.44±0.26 11.66 22.24* 88.22±2.66 21.38 76.38±0.64±1.36± 0.22±2.95 398.33±0.28* 38.34±2.52±34.00±0.86±1.01 22.00±1.34 08.28* 202.16 15. 46±3.Vol.80±2.33±1.31* 2600.14±0.34* 86.61 307.97±0.48* Insulin resistance† 03.67±4. *Significant at P < 0.36* 38.58±0.68±3.27* 08.38±2.24* hemoglobin (%) SDA: Single dose administration.42* 69.09* 190.70±91.68 602.35* Insulin 44.61 106.34* 108.32±2.91* 76.23 16.31±23.84±1.97±0.34* Insulin resistance† 01.58±0.27 21.19±0.67±1.49±388.01±42.74±1.67±0.54±1135.34±0.06 11.42±1.24±2.33±2.84±0.16* (g/dL) Glycosylated 84.34 76.83±0.86±2.66±0.82±0.34±2.31±0.91±0.78* 652.34±2.07* 04.35 72.31* Insulin 30.07* 04.04±0.94 258.00±2.43±0.62 37.72±0.70±0. 00±1.95* 130.85 548.01±0.28±1.84±0.34±0.33* sensitivity† Total hemoglobin 120.36±1.67±0.07 07.22±0.43 244.20 18.06 2.03±0.12* 78.20±1.70±0.34±0.46±3.55±3.67* Insulin (µu/mL) 12.13* 24.24 95.29±0.19±2.71±0.22±0.32 94.36±0. MDA: Multiple dose administration.99±0.06 07.09 2.56±0.38* Insulin 46.54± .40±1.46 15.68 80.Vol.55±0.55±0.20 70.59±0.06* (g/dL) Glycosylated 86.09 2.33±1.91±1.26±3.45 54.00±1.24±3. Data was expressed as Mean ± SEM.36±0.34±3.03 274.20 24.61* 620.15±0.67±0.76±1.35±0.00±3.59±68.36 104.24 20.14±0.68 33.64 38.11 2.Table 2: Effect of ritonavir on the activity of gliclazide in normal and diabetic rats (N = 6) Parameter Gliclazide 2h 8h 2h Ritonavir 8h Ritonavir + Gliclazide (SDA) 2h 8h Ritonavir + Gliclazide (MDA) 2h 8h Normal rats Glucose (mg/dL) 53.68* 58.62 54.42±2.94±0.16* (g/dL) Glycosylated 76.20±2.70 25.24 85.42 26.41±2.21 12.38±2.14 07.09 4.24* 38.66 89.99* 555.30±3. †Calculated by homeostasis model assessment method.32* 64.92 491.89 46.08±2.14 246.21±0.34±2.32 ±2.06±0.95* 50.10 10.67±0.46±3.52 190.05 94.25* 132.26 25.65±8.14 279.22±2.48 110.19±0.10 80.84±0.35* 134.22 07.68* Insulin (µu/mL) 11.33±0.32 82.04* 40.63±0.93±2.52 96.00±2.03 † β-cell function 449.28±0.23±0.35 122.85±22.77±0.76±61.14* 76.23 140.00±0.67±1.10±2. *Significant at P < 0.28 44.28 15.23 21.12 18.86* 39.11±0.36±2.42 97.32 78.69±0.42±0.07* 683.2 ±1.26±2.46 56.62±0.20±26.21* 68.16±1.01 4.04 1.52 135.30* 66.13±0.19* Insulin resistance† 1.68±2.62±2.28±1.20* 254.74* sensitivity† Total hemoglobin 238.34±2.01 33.67±1.37 10.41* 250.32±1.24* 21.48* 21.00±0.20* 130.68±3.05±2.16* 258.66±0.26±2.38±3.84±1.00±0.57* 118.93±19.58* 51.61 34.84* 127.10±1.12 197.34 106.57±0.08* Insulin 32.25±3.61±0.67±0.84* 81.64±1.10* 55.28* 58.79±0.31±2.30±0.22* hemoglobin (%) SDA: Single dose administration.81* 21.50* 138.33±1.63±23.84.64±0.33±0.05 compared to gliclazide control Review of Global Medicine and Healthcare Research .02±2.07 † β-cell function 53. 1 No.54±0.22* Insulin resistance† 04.33±0.24* 20.20±2.62±0.06 04.24 12.33* 48. 1 (2010) 291 .41* 117.50* 22.42* hemoglobin (%) Diabetic rats Glucose (mg/dL) 142.24* 132.21 128. 79±0.84* 44.26* 469.96±0.00±0.08 02.25±0.40±0.14±1.73±0.14±1.46 154.04 ±1.83±0.18* Total hemoglobin 234.70±3.18±1.00±0.12* 44.75±0.88±28.36 ±3.12* 76.86* 125.00±0.42 ± 1.86±1.26* 248.12* 74.83* 553.34 ± 2.01 35.43* 24.67±0.67±0.97±0.14* Insulin sensitivity† 44.02±21.26±1.30±2.24 240.16±2.34±2. Data was expressed as Mean ± SEM.10 05.62±0.04±0.28±2.67±5.09±04.50 464.02 02.34±0.31±2.38±0.75±0.84 140.32±0.14±2.16* 42.14 ± 2.16* 58.45* 49.64±27.22* hemoglobin (%) SDA: Single dose administration.38 58.67±1.03 02.22* Insulin sensitivity† 34.31* 18.67±0.10 ± 2.33±0.34* 89.2 ±0.16* 136.15±0.00±0.68 Insulin (µu/mL) 12.06 08.05 06.89±0. MDA: Multiple dose administration.21* Insulin resistance† 01.05 04.58±0.Vol.84±0.14* 64.49±0.10* (g/dL) Glycosylated 88.63* 550.55±0.77* 102.32 96.10 242.64±12.45* 129.14* 78.42 94.00±0.33±1.64 124.24* 58.10* 250.31±2.44±0.04 01.34±4.04 02.39 75.34 94.80 236.10* 58.12±2.09 02.11 05.22 12.36* Total hemoglobin 124.87±0.45 54.98±0.11 05.64±2.34±2.12±123* 142.21* 16.90±0.24 ±1.16±0.01 01.67±1.07 02.10 66.16 240.24 242.96±0.04±1.Table 3: Effect of atazanavir on the activity of gliclazide in normal and diabetic rats (N = 6) Parameter Gliclazide 2h 8h 2h Atazanavir 8h Atazanavir + Gliclazide (SDA) 2h 8h Atazanavir + Gliclazide (MDA) 2h 8h Normal rats Glucose (mg/dL) 53.26 09.09±0.41 263.60±0.14±1.10 08.32±2.24 54.50 527.12* 42.46 42.11 12.14 04.50±0.16±2.02 † β-cell function 446.13 138.16 ±1.23 20.63±0.06 54.28 ±1.62 ± 2.46±2.87 98.26 ±1.33±1.39±0.20 56.33±0.72 ± 2.46±0.39±0.00±2.54±0.42* 47.12 4.24 45.44±17.05 compared to gliclazide control Review of Global Medicine and Healthcare Research .20* Insulin (µu/mL) 11.83±0.73 162.32±0.74 07.41 84.10* (g/dL) Glycosylated 74.02±2.51* † Insulin resistance 04.00±2.85±0.29±20.94±1.32* 62.88* 112.58±2.08±0.34 ± 0.40* 248.18 138.18 β-cell function† 51.16 43.18* 19.17* 20.22 76.52* 131.02±1.25* 60.40* hemoglobin (%) Diabetic rats Glucose (mg/dL) 143.57±0.57±0.57 59.12 58.02 01.11* 23.20* 140.26 ±1.26 ± 1. *Significant at P < 0.36±0.26 40.20±1. 1 No.30 84.25 47.10 78.16 ±2. †Calculated by homeostasis model assessment method.34±2.14±2.16 15. 1 (2010) 292 .24 158. In the present study.05) enhanced the pharmacodynamics of gliclazide in rats (normal diabetic) following single and multiple dose treatments. HIV-infection and diabetes are chronic diseases that significantly affect lifestyle. The incidence of diabetes mellitus in HIVinfected patients has been estimated to range from 1-10% in various studies (Samaras. Drug interactions are usually seen in clinical practice and the mechanisms of interactions are evaluated usually in animal models. We studied the influence of PIs on the pharmacodynamics of gliclazide in normal and diabetic rats. and an additional 16% having impaired glucose tolerance (Samaras. Although animal models can never replace the need for comprehensive studies in human subjects. glycosylated hemoglobin and insulin resistance index and decrease in total hemoglobin. the multiple dose effect of antiretroviral drugs on the gliclazide activity was studied for the influence of the chronic treatment with antiretroviral drugs since both are used for chronic period. This interaction was significantly reflected by increase in glucose. atazanavir and their combination (single dose and multiple doses) were represented in Table 3. their use can Review of Global Medicine and Healthcare Research . When given in combination ritonavir significantly (p<0. Several studies have reported a prevalence of diabetes as 2-7% among HIV-infected patients receiving protease inhibitors (Carr et al. Effect of atazanavir on the activity of gliclazide The levels of biochemical parameters following gliclazide. Effect of ritonavir on the activity of gliclazide The levels of biochemical parameters following gliclazide. insulin.When given in combination indinavir significantly (p<0. insulin. But in our present study we investigated the effect of antiretroviral drugs on the activity of gliclazide with respect to multiple biochemical parameters. 2009) the effect of protease inhibitors on the activity of gliclazide with few parameters in animal models. 2009). ritonavir and their combination (single dose and multiple doses) were represented in Table 2. gliclazide. The normal rat model served to quickly identify the interaction and diabetic rat model served to validate the same response in the actually used condition of the drug. In our study we have studied the effect of widely used PIs on the activity of widely used antidiabetic drug. When they intersect. The reduction in gliclazide effect is more with the single dose treatment of indinavir than the multiple dose treatment. 1 (2010) 293 . The enhancement in gliclazide effect is more with the multiple dose treatment of atazanavir than the single dose treatment.05) altered the pharmacodynamics of gliclazide in both normal diabetic rats following single and multiple dose treatments. Discussion HIV-infected patients are likely to suffer with diabetes mellitus and hence frequently antiretroviral drugs are coa-dministered with oral antidiabetic drugs. 1999).Vol. Atazanavir alone has no significant effect on biochemical parameters. When given in combination atazanavir significantly (p<0. 2009). Ritonavir alone produced significant increase in glucose. Previously we have reported (Mastan et al.05) altered the pharmacodynamics of gliclazide in rats (normal diabetic) following single and multiple dose treatments. glycosylated hemoglobin and insulin resistance and decrease in β-cell function and insulin sensitivity. β-cell function and insulin sensitivity. The enhancement in gliclazide effect is more with the multiple dose treatment of ritonavir than the single dose. 1 No. the treatment required for both diseases can be overwhelming for patients. Diabetes associated glucose intolerance is characterized by an increase in insulin resistance and alterations in insulin clearance. 2001. Gliclazide is known to produce hypoglycemic/ antihyperglycemic activity by pancreatic (stimulating insulin secretion by blocking K+ channels in the pancreatic β cells) and extra pancreatic (increasing tissue uptake of glucose) mechanisms (Mastan. The possible mechanism of this potential pharmacodynamic interaction is due to the opposing effects of gliclazide and indinavir on insulin resistance. In our study indinavir and ritonavir alone produced significant impact on glucose-insulin homeostasis with the contribution of insulin resistance and impaired in β-cell function in normal and diabetic rats. 1976). and it confirmed the presence of potential interaction between gliclazide and indinavir. All these observations are consistent with our previous studies. Diabetes was induced with alloxan monohydrate. Since ritonavir increased blood glucose and insulin levels on its own. insulin release or tissue uptake of glucose.12-15 In combination. 2009). even though ritonavir alone has shown significant alterations in glucose-insulin homeostasis. 2009) and literature (Satyanarayana et al. rather than Review of Global Medicine and Healthcare Research . 1976). the pharmacodynamics of gliclazide was significantly reduced in the presence of indinavir following single and multiple dose treatment in rat (normal and diabetic) model. insulin sensitivity of hepatic and peripheral tissues.provide important insights to understand and to evaluate the potent interactions between drugs. 2009). the excess of glucose present in the blood reacts with hemoglobin to form glycosylated hemoglobin (Koening et al. It was reported that during diabetes mellitus. the blood samples were collected by retro-orbital puncture as it was reported to be good method when small samples of blood was required. and these effects were more in diabetic condition. which may be due its biliary excretion and entero hepatic cycling. Since small amount of blood was required for this study. The elevated insulin levels is the face of increased glucose levels suggest an insulin resistant state (Cefalu. as reflected in our study. Ritonavir is a well known potent CYP3A4 inhibitor12 and used to enhance the pharmacokinetic and anti-HIV activity profiles of the concomitantly administered PIs. 1973). but not in a classspecific manner.Vol. So we have conducted the dose effectrelationship study of gliclazide to select the oral dose which produces approximately 35% of blood glucose reduction in rats. Thus it clearly indicates the presence of potential pharmacokinetic interaction at metabolic level between gliclazide and ritonavir. ritonavir and indinavir treated animals shown decreased in body weights further indicating the alteration in metabolic pathways. The results obtained from this study clearly indicate glucoseinsulin homeostasis disorders associated with protease inhibitors are drug specific. In addition. Elevated levels of glycosylated hemoglobin and reduced levels of total hemoglobin observed in indinavir and ritonavir treated rats reveal that these animals resembling the diabetes condition. Gliclazide is known to be metabolized by hepatic microsomal enzymes CYP2C9 primarily and partly by CYP3A4 (Mastan. The level of glycosylated hemoglobin is always monitored as a reliable index of glycemic control in diabetes (Gabbay. Contrast to theoretical expectation and consistent with our previous studies. Rats are known to be more sensitive to gliclazide response. the pharmacodynamics of gliclazide were enhanced by ritonavir following single and multiple dose administration in rats. the increase in the effect of gliclazide on blood glucose might be due to improved blood gliclazide level in the presence of ritonavir. Consistent with our previous studies (Mastan et al. since it was more economical and easily available. gliclazide produced maximum biphasic response (at 2 and 8 h) in rat model when administered alone. But atazanavir alone has not shown any significant impact on these biochemical parameters. The results obtained in our study are consistent with the available literature. 1 (2010) 294 . indicating the potency of these drugs towards exacerbation of existing diabetes mellitus. in our study we have selected 2 and 8 h as blood sampling time points to measure the various biochemical parameters in rats. Reaven. 1 No. 2007). Decreased total hemoglobin content observed in indinavir and ritonavir treated rats might be due to increased formation of glycosylated hemoglobin. 2004). as there is a possibility of pharmacokinetic interaction at metabolic level. Based on this background. Generally total hemoglobin level is much below the normal level in diabetic condition and glycosylated hemoglobin level has been reported to be increased in patients with diabetes mellitus (Paulsen. hyperlipidaemia. Thorisdottir A (1999). Targher G. Peterson CM. pp. Since the interactions of PIs (indinavir. Hruz PW (2006). pp. Gabbay KH (1976). Dube MP (2000). J Biol Chem. Disorders of glucose metabolism in patients infected with human immunodeficiency virus. Clin Infect Dis. Clinical Chemistry. Diagnosis. Homeostasis model assessment closely mirrors the glucose clamp technique in the assessment of insulin sensitivity: studies in subjects with various degrees of glucose tolerance and insulin sensitivity. and natural course of HIV-1 protease-inhibitor-associated lipodystrophy. it has to be confirmed by conducting pharmacokinetic studies in animal models.57-63.13-26.Vol. Hence care should be taken when the combinations are prescribed for their clinical benefit in diabetic patients. atazanavir also enhanced the pharmacodynamcis of glicalzide with respect to glucose-insulin homeostasis. 98. prediction. N Engl J Med. References Bonora E. Jones RL (1976). pp. Spectrophotometric constants for common hemoglobin derivatives in human dog and rabbit blood. pp. they are likely to occur in humans also. and diabetes mellitus: a cohort study. Samaras K.pharmacodynamic interaction. pp. 44. Heikkila RE (1977). 1 No.2093-99. However the present study warrants further studies to find out the relevance of these interactions in other species/human beings and to know the exact mechanism of action(s) behind this interaction(s) if any. pp. N Engl J Med. Review of Global Medicine and Healthcare Research . The prevention of alloxan-induced diabetes in mice by dimethyl sulfoxide.719–33. 295. study of other possible factors and mechanism(s) behind these interactions couldn’t be ruled out. Austin JM (1932). Molecular mechanisms for altered glucose homeostasis in HIV infection. Bannon P (1982). pp. In combination. ritonavir and atazanavir) with gliclazide were seen in normal and diabetic condition. leading to increased/decreased activity of gliclazide. Thus our study has demonstrated the effect of various PIs on the activity of gliclazide with respect to multiple factors of glucose-insulin homeostasis. 95. Am J Infect Dis. pp. Carr A. Eur J Pharmacol. 2009).191-3. as atazanavir inhibited CYP3A4 and CYP2C9mediated drug metabolism leading to raised serum levels of gliclazide (Mastan.443-54. which is consistent with our previous study and confirms the pharmacokinetic interaction at metabolic level. 226. Alberiche M (2000). Koening RL. 28.417-420. Lancet. However. which may need dosage adjustment. Drabkin DL. as metabolic complications arising from HIV-infection and/or antiretroviral therapy are multifactorial and complex. 353. However. Conclusion Our study confirmed that glucose-insulin homeostasis disorders associated with protease inhibitors are drug specific. Correlation of glucose regulation and hemoglobin A1c in diabetes mellitus. Cefalu WT (2001). Effect of pH on the elimination of the labile fraction of glycosylated hemoglobin. Exp Biol Med. 31. 1 (2010) 295 . Glycosylated hemoglobin and diabetic control. Insulin resistance: cellular and clinical concepts. pp. 23. Diabetes Care.1467-75. pp.2183. 2(3).187-92. Journal of Experimental Pharmacology. pp. Homeostasis model assessment: insulin resistance and ß-cell function from fasting plasma glucose and insulin concentrations in man.1961-76. 1 (2010) 296 . 1. Prevalence and pathogenesis of diabetes mellitus in HIV-1 infection treated with combined antiretroviral therapy. Shibata N. Metabolism. 105-13. Diabetologia. Nayak SS. Endocrinol Metab Clin North Am. pp. Hosker JP. Int J Diabetes Mellitus.412–9.751-4. Chaitanya G. J Pharmaceutical Sciences. Mol Cell Biochem.283-03. Influence of atazanavir on the pharmacodynamics and pharmacokinetics of gliclazide in animal models. Influence of non-nucleoside reverse transcriptase inhibitors (efavirenz and nevirapine) on the pharmacodynamic activity of gliclazide in animal models. 88.1016/j. Adaptation of orbital bleeding technique to rapid serial blood studies. Mantzoros CS (2003).269-71. 267–74. Eswar Kumar K (2009). pp. Diabetologia Croatica.101-5. Diabetologia. Bacharach AL. Okamoto H (2002). 109. Mastan SK. 2. pp. 7(1). Eswar Kumar K (2009). Pharmacologyonline. 680-9. Matthews DR. Eswar Kumar K (2009). 28. Mastan SK. different concepts. Int J Integr Biol. Influence of indinavir on the pharmacodynamic activity of gliclazide in rats and rabbits. Marte T (2004). Clinica Chemica Acta. Diabetology & Metabolic Syndrome. Effect of antiretroviral drugs on the pharmacodynamics of gliclazide with respect to glucose-insulin homeostasis in animal models.2009.Lawrence DR. pp.001 Mastan SK. 91. Hemoglobin A1l in childhood diabetes. 1 No. New York: Academic Press. Aczel S. Gao W. A new colorimetric method for the estimation of glycosylated hemoglobin. pp. I Vol. Proc Soc Exp Biol Med. Addy CL. pp. and therapeutic strategies. Influence of nicorandil on the pharmacodynamics and pharmacokinetics of gliclazide in rats and rabbits. 50(5). 38(4).1-11 Mastan SK.16-21. pp. Satyanarayana S.Vol. An Appraisal to the Special Sulphonylurea: Gliclazide. eds.ijdm. Reaven G (2004). 47. Saely CH. J Acquir Immune Defic Syndr. 291. Samaras K (2009). pp. Mastan SK. pp. Reddy KR. Kumar KE (2009). Cardiovascular complications in type 2 diabetes mellitus depends on the coronary angiographic state rather than on the diabetes state. Eswar Kumar K (2009). Kilari EK (2006). Review of Global Medicine and Healthcare Research . 1964. 33. pp. 254-69. pp. pp.145-6. Pattabiraman TN (1981). Riley V (1960). Mastan SK. Eswar Kumar K (2010). Effect of ritonavir on the pharmacodynamics of gliclazide in animal models.499-05. Human immunodeficiency virus/highly active antiretroviral therapy-associated metabolic syndrome: clinical presentation. The metabolic syndrome or the insulin resistance syndrome? Different names. 104. Drug interactions between HIV protease inhibitors based on physiologically-based pharmacokinetic model. Paulsen EP (1973). Rudenski AS (1985). 1:15.10. and different goals. 22. doi: 10. J Clin Endocrinol Metab. Leow MK. Evaluation of drug activities: Pharmacometrics. pp. pathophysiology. Eswar Kumar K. Rajasekhar J. Green R.uk/ Acessed July 2009. 1 (2010) 297 .457-63. Biopharm Drug Dispos. pp. HOMA Calculator. pp.ox. Zimmet P. Roglic A. Wild SG. The Oxford Centre for Diabetes.782-87.. pp. pp. Pharmacokinetic interactions between HIV-protease inhibitors in rats.1047-54. 4. pp. J Diabetes Care. 1 No. Therapy. 27. Alberti KGMM. Yamaji H. 241-7.dtu. Diabetes Trial Unit.ac. 141. Estimated for the year 2000 and projection for 2030. Influence of aqueous extract of fenugreek-seed powder on the pharmacodynamics and pharmacokinetics of gliclazide in rats and rabbits. Takada K (1999). Thomas L. Determination of blood glucose using an oxidaase-peroxidase system with a non carcinogenic chemogen. King H (2004).158-61. 20.Satyanarayana S. J Clin Pathol. Review of Global Medicine and Healthcare Research . Global prevalence of diabetes. 22. Global and Societal implications of the diabetes epidemic.Vol. Rajanna S. Endocrinology & Metabolism. Rajanna B (2007). Available from: http://www. Nature. Trinder P (1969). Shaw J (2001). Matsumura Y. Yashikawa Y. To study and compare the socio-demographic profile of anemic pregnant women in a rural area.Ahmednagar. Majority of the anaemic women (56. To establish an association between anemia & abortion. The study was conducted amongst the rural pregnant women reporting to the Primary Health Centre attached to Rural Medical College as well as the Maternity OPD & Clinics of RMC. religion. income. Maharashtra & the Primary Heath Care Center attached to it. young children and adolescent girls. Loni.25%) were in 20-24 years age group. District. India Email: [email protected] Nadeem Ahmad Department of Community Medicine Rohilkhand Medical College & Hospital. education. Study design: Cross sectional study. 1 No. A total of 100 pregnant women with gestational period between 12-20 weeks were registered for the study. To find out the prevalence of anemia amongst pregnant women of Rural Maharashtra. Objectives 1. caste. age.0 %) of iron deficiency anaemia (Hb <11 gm/dl) was observed. gravida. 2. The study variables included the blood haemoglobin level. 1 (2010) 298 . India Abstract Background: Anaemia affects mainly the women in child bearing age group. India Rubeena Bano Department of Physiology Rohilkhand Medical College and Hospital.Vol. The association of socio-demographic Review of Global Medicine and Healthcare Research . Maharashtra. 3. Results A high prevalence (96. number of abortions and history of abnormal bleeding Statistical analysis: Chi-Square test.Anaemia Prevalence & Socio-demographic Associates amongst Pregnant Women Piyush Kalakoti Rural Medical College Pravara Institute of Medical Sciences. type of family. Loni. and birth interval. Methods Setting: Pravara Rural Hospital. Loni formed the study population. the daily dosage of elemental iron for prophylaxis and therapy has been increased to 100 mg and 200 mg. 2008 were registered for the study.e. present study was carried out to find out the prevalence of anaemia amongst pregnant women and to study the factors associated with anaemia in pregnancy. with wide variations in different regions of the world1. Rural area Introduction The importance of anemia as a major public health problem throughout the world is widely recognized. Apart from the risk to the mother. accounting for 20% of total maternal deaths2. Loni. In the present study purposive sampling technique was applied. In India. According to WHO. Since 1992. it is also responsible for increased incidence of premature births. Materials and Methods The present study was conducted in the Primary Health Center (PHC) & the Maternity Clinics of Rural Medical College. The association of anaemia with adverse maternal outcomes such as puerperal sepsis. 1 No. Conclusion Considering the high-risk status of anaemia in pregnancy. Loni. young children and adolescent girls. Exclusion criteria The women with multiple pregnancies and bleeding disorders were excluded from the study. it was assumed that a sample size of 100 shall be adequate for a preliminary study. Kewwords: Pregnant women. The National Nutritional Anaemia Prophylaxis Programme (NNAPP) was initiated in 1970 during fourth five year plan with the aim to reduce the prevalence of anaemia to 25 percent5. Inclusion criteria A total of 100 pregnant women with 12-20 weeks of gestation. 1 (2010) 299 .characteristics like type of family. Anaemia. Anaemia affects mainly the women in child bearing age group. education and socio-economic status with the anaemic status was not statistically significant. reporting to Maternity ward & PHC attached to RMC. respectively under Child Survival and Safe Motherhood (CSSM) Programme.Vol. Based on the knowledge that about 50% pregnant women in the country are anaemic6. in developing countries. Review of Global Medicine and Healthcare Research . anaemia is the second most common cause of maternal deaths. there is a need to initiate intervention measures at all levels of health care delivery. within three months i. ante-partum haemorrhage. Oct-Dec. the prevalence of anaemia among pregnant women averages 56%. low birth weight babies and high perinatal mortality4. post-partum haemorrhage and maternal mortality is no longer a debatable subject3. The rural pregnant women reporting to the Maternity Ward of RMC. In view of the above. 23. (%) 0 (0.0) 300 Review of Global Medicine and Healthcare Research .83) 34 (35.0) In the present study 96. (%) 1 (25. (%) No. (%) 0 (0. (%) 0 (0.0) 0 (0.62) 21 (21. (%) 2 (9.85) 7 (33.0) 2 (50. (%) 15 (15.0) 1 (25. Statistical tests: Chi-square and related tests were used as applicable.0) 2 (50.16) 96 (96.0) 100 No.5) 96 No. consent form was filled and were interviewed using a pre.0) Total No.0) 5 (5.The pregnant women were informed about the study. (%) 19 (19.0) 56 (56.0) 4 No.25) 19 (19.14% moderate and 21.0) 4 (4. (%) No.0) 1 (1. Results Table I: Age-wise distribution of degree of anaemia Age (in years) Anaemic status Mild Moderate No.0) 0 (0.41) 26 (27.08) 11 (21. Table II: Association of anaemic status with socio-demographic factors Characteristic Type of family Nuclear Joint Extended Total Educational status Illiterate Just literate Primary Middle school High school Senior secondary Graduate & above Total Socio-economic status Class I Anaemia No. Modified BG Prasad classification was used for income classification8.39) 8 (15. (%) <20 6 (26.0) 34 (34.52) 32 (61. 1 (2010) . Majority of anaemic women (56.38) 30 and above 0 (0.16) 3 (3.0) 1 (25.79) 54 (56. (%) 15 (15.0) 100 No. (%) Severe No.08) 9 (9. (%) 0 (0.92) Total 23 (23.Vol.37) 4 (4.9.0) 1 (25.0) 96 No.87) 60 (62.53) 25-29 4 (17.95) 52 (54. (%) 20 (20.0) 1 (25.0) 4 No.87 % severe anaemia.0) 2 (50. 54.0) 62 (62.79) 4 (4. pre-tested schedule.0) 23 (23.structured. 1 No.0% pregnant women were anaemic.15) 20-24 13 (56.0) 4 (4. Haemoglobin estimation was done by Sahli's method. The typing of anaemia was done as per standard peripheral blood smear examination method7.0) Normal No.0) 1 (25.14) Normal haemoglobin Total No.0) 26 (26.0) 10 (10.0) 5 (5.33) 3 (14.25%) were in 20-24 years age group.0) 20 (20.95% had mild.0) 0 (0.52) 9 (42.0) 0 (0.87) Total No.0) 0 (0. (%) 21 (21.0) 100 (100. Anaemia was classified as per the WHO grading criteria6.12) 0 (0.0) 19 (19.28) 21 (21. 05).0%) among pregnant women was observed. There was a trend of low severity of anaemia with high per capita income. Women with gravida >2 more often had severe anaemia.93%) had moderate or severe anaemia.0) 13 (13. e. The association between anaemia and abortion was statistically not significant (p>0.6%)..Vol. (%) 3 (75.33) 47 (48.16) 96 Normal No.0) 0 (0.2%).0% were educated high school and above. Normocytic hypochromic and microcytic hypochromic type of blood picture. which calls for widening the scope of programme for prevention and control of nutritional anaemia.Class II Class III Class IV Class V Total 4 (4.0% pregnant women had no history of abortions however 83. followed by Muslims (6.0) 2 (50. before maximum haemodilution.33% of them were anaemic. Table III: Association of anaemia with number of abortions.05). religion. (Table I). Majority (54.g. As in other studies.05).0) 48 (48. birth interval and number of abortions (Tables I. However.0) 100 The association of socio-demographic characteristics like type of family.79%). The association with anaemic status was statistically not significant (p>0. and only (4.0%). (%) 83 (83. The association with anaemic status was statistically not significant (p>0. In the present study 83.54) 32 (33. the observed status reflects pre-pregnant levels.79%) and 25-29 years (19. of abortions Anaemia No.0) 1 (25.0%) belonged to socio-economic class IV and V. No. caste. 1 (2010) 301 . these trends were statistically not significant.4%) were anaemic and (76.14%) had moderate anaemia. so as to cover adolescent girls also. (%) 80 (83. Most of the anaemic pregnant women were between 20 and 24 years of age (56. type of family. 1 No.0) 0 (0.16%) in 30 years and above.0%).0) 4 Total No.0) 1 (25.Most of women were just literates (34.0) 4 (4. Majority of pregnant women were Hindus (91.1%) and Sikhs (2. Majority (80.0) 15 (15. the severity of anaemia was inversely related to educational status12 and income13. followed by equal distribution in less than 20 years (19.25%). The prevalence of anaemia was not significantly related with age.95) 96 1 (25.0) 100 0 1 2 or more Total The association of anaemia with number of abortions is shown in table 2.5) 4 (4. income.0) 32 (32. II and III).0) 4 5 (5. a characteristic of iron deficiency anemia was observed. Review of Global Medicine and Healthcare Research . The observed very high prevalence of anaemia and its severity in the current study although is similar to earlier studies10.05). In the present study majority of pregnant women belonged to extended or three generation family (62. Since haemoglobin estimation was done at 12-20 weeks of gestation. In the present study a high prevalence of anaemia (96. Only 9.33) 12 (12. All the pregnant women with past history of abnormal bleeding (11. Discussion A total of 100 pregnant women reporting to a rural health care facility were studied.16) 13 (13. education and socioeconomic status with anaemic status is shown in table II. 11. The association with anaemic status was also statistically not significant (p>0. 26(3): 144-54. 1 (2010) 302 . 31: 26-9. Incidence of iron deficiency anaemia in rural population of Kashmir. 1992.e. 1 No. Nirmal Bhawan. Agrawal V. 3. Prevalence of anaemia in pregnancy. Ind Med Gaz. Baksh Ali. Economic Division. religion or number of children as the prevalence was equally high in all groups in this population. Foetal outcome in anaemia during pregnancy. Oxford University Press. Roychaudhary S. 5th edition 1990. Economic Survey 2000-2001. Geneva. 13. World Health Organization. Social classification . J Obstet Gynae Ind. 4. IJPH 1982.Vol. DGHS. 6. Thangaleela T. Shah SNA. Ahmad M et al. Agarwal KN. Prevalence of iron deficiency anaemia in Indian antenatal women especially in rural areas. Targets in National Anaemia prophylaxis Programme for pregnant women. 7. Chakravorty PS. XVIII (2): 60-1. J Obstet Gynae Ind. The prevalence of anaemia in women: a tabulation of available information. 300-3. 10. Indian Paediatr 1988. of India. Ind J Com Med 1993. Conclusion A very high prevalence of anaemia (96. of India. References 1. Anaemia in pregnancy in a rural community of Varanasi. P31. Rush B. 1993. 1989. Ind J Nutr Dietet 1994. Vijayalakshmi P. 42: 743-50. type of family. Maternal and perinatal outcome in severe anaemia. 9. Agarwal DK. Health information of India. Ministry of Finance. 1992. Penington D. Hence the results of the study cannot be generalized. 12. Firkin F. Luwang NC.deGruchy's Clinical Haematology in Medical Practice. Preventing and controlling iron deficiency anaemia through primary health care. 2. It calls for studies on anaemia among adolescent girls and a strategic shift in a programme focussed on pregnant women alone to broaden the coverage so as to include adolescent girls also for control of anaemia. Ind J Prev Soc Med 1980. Rauf A. 5. Roy S. caste. 11:83-8. 11.. Govt. Chesterman C. As normocytic hypochromic and microcytic hypochromic blood pictures were predominant. 2nd Ed. 1995. 8. Sept 1999. Rangnekar AG. WHO. Darbari R. Govt.Study Limitation Not all the pregnant women of the rural area of Loni were taken into consideration. Review of Global Medicine and Healthcare Research . Gupta VM. Tejwani S. 43: 172-6. Geneva: WHO. it indicates deficient iron intake/absorption irrespective of age.need for constant updating. New Delhi. Khanna S.0%) early in pregnancy i. Kumar P. 25: 319-22. 12-20 weeks of gestation is indicative of the status of pre-pregnant levels. fluid resuscitation was initiated. Case Presentation On January 11. After 8 days of hospitalization.com Introduction White phosphorus burn is a special subtype of chemical burns. without signs of inhalation burns. Al Quds University. the patient was relatively well. with extensive necrotic tissue. an 18-year-old male was transferred to the Emergency room (ER) due to exposure to military attack with White Phosphorus shell with multiple scattered patches of full thickness burn surrounded by sloughed tissue. Review of Global Medicine and Healthcare Research . apparent localized injuries weren’t correlated with underlying severe deep destruction (Figure 1).Vol. In the Burn Unit. electrolyte disturbance and ECG changes where he was managed accordingly. a clinical diagnosis of white phosphorus burn was made. irrigation with diluted sodium bicarbonate solution and wet dressing were done. In the operation room. Airway was secured. transferred to ICU for monitoring of vital signs. and discharged without manifestations of systemic complication of white phosphorus burn. Palestine Email: lnb6des@hotmail. 2009. 1 (2010) 303 . distributed in both upper and lower limbs and right shoulder. rarely encountered and is very limited in literature. 1 No. debridement and excision for dead tissues and removing phosphorus particles was accomplished.White Phosphorus Burn: Case Report Loai Nabil Barqouni Medical Student. involving 30% of his body surface area. White smoke was noticed coming up from the wounds which became deeper. Chen SL. Simon GA. early excision and massive debridement of particles was accomplished. Breiterman S. Wexler MR. 17 (3). Wang HJ. (1955). Lee TW. KG. Chen TM. 1991) (Eldad A. Review of Global Medicine and Healthcare Research . The phosphorous burn--a preliminary comparative experimental study of various forms of treatment. Irizarry. Acute management of white phosphorus burn. 2002). 2007). 2002) (Eldad A. Lee CH. 49-55. the management include irrigation by diluted sodium bicarbonate solution at ER. Lee TW.Vol. Chen SG. Wang HJ. L. Wisoki M. 167 (1). Phosphorous burns: evaluation of various modalities for primary treatment. Dai NT. (1991). White Phosphorus. Ben-Bassat H. Dai NT. 83-4. Simon GA.. 1955) (Chou TD. Burn Care Rehabil. CBRNE . Chaouat M. 198-200.. Mil Med. 1 No. 27 (5). D.Incendiary Agents. Wexler MR. associated with extensive full thickness burn injury with delayed wound healing (Irizarry. Ben-Bassat H. Breiterman S. Eldad A.. Cohen H.. . only water have been proved to prevent deaths (KG. Chen SG. 16 (1). Burns. Tung YM. electrolyte disturbance was noticed as a complication. Burns. Lee CH. Chen TM. References Chou TD. In our case. USA. . (Date 12th of January 2009) Discussion White phosphorus is transparent combustible substance (KG. 2001). 1 (2010) 304 .. . (2001). Wisoki M. Tung YM. .. Chaouat M. (2007. Chen SL. whereas. Cohen H. Eldad A. (2002). Aug 22). The management of white phosphorus burns. 492-7. University of Prishtina Republic of Kosovo Email: [email protected] Mas) have really had an impact on patient’s health state. Subjective evaluation of the symptoms of disease was with average of total points 3. with average 16.Vol. Materials and Methods: A female patient N. Laboratory analyses reports (endocrinology and biochemistry) as well as reports from Specialities (endocrinologist. 5-excellent) every month and also manner based on laboratory analyses (hematology and biochemistry) every two months and also based on medical reports every six month.5 mmol/L or 153 mg/dl.The Role of Anthocyanin and Flavonoides in Patient with Diabetes Mellitus . Austria Faton Bytyçi Faculty of Medicine. After stopping to use Cornus Mas. nephrologists and ophthalmologist).com Diellor Rizaj Medical University Graz. 3-good. was noticed. Glucose value has started to fall. Results: Before starting this research we showed Glucose level about 8.3 points average.N. It was found that after starting to use the fruits. Conclusion: This study puts Highlights three dilemmas: Review of Global Medicine and Healthcare Research . 67 years old with Diabetes Mellitus Type II was monitored for about two years. The aim of study was to see if Cranberries (Vaccinium macrocarpon .5 mmol/L or 297 mg/dL.5. 4-very good. 2-fair. Medical reports were showing an aggravation in the condition was with total of 2. an evaluation of Glucose which was slow in the beginning but rapid later. cardiologist. University of Prishtina Republic of Kosovo Abstract Background: Diabetes Mellitus Type 2 also called non-insulin-dependent diabetes mellitus (NIDDM) is a disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. 1 No. 1 (2010) 305 .5 mmol/L or 171 mg/dL. Kutllovci Faculty of Medicine. first slowly and then for about 2 months the value obtained was 9.Type II Arbër H. We used a questionary asking the patient to evaluate the improvement for the disease symptoms with points from 1-5 (1-bad. Cornus Mas Acknowledgements: This study was supported by Hasan Kutllovci MD. kidney and eyes. Institute of Occupational Medicine – Prishtina.and In objective manner based on laboratory analyses (hematology and biochemistry ) every two months and also based on specialistic reports (endocrinologist. Before the beginning of the experiment.5 mmol/L or 153 mg/dl (average). nephrologists and ophthalmologist).medical reports from laboratory(hematologic and biochemistry) and specialistic (endocrinology. 1 No. The values of Glucose from the reports collected before the beginning of the experiment were about 8. Use of any drug containing these two substances Anthocyanin and Flavonoides as an antioxidant with an unknown mechanism will be a goal of therapy for Non Isnulin Diabetes Patients in the future.N.This is why research was oriented in two ways: Patient and Cranberries (Cornus Mas) Patient: The patient was monitored about two years.Specialistic reports showed a great improvement of her health condition including the condition of cardio-vascular system. because her health state improved a lot after using a fruit Cranberries (Cornus Mas) and this was supported by laboratory analyses reports ( endocronlogist and biochemistry) as well as specialistic reports (endocrinologist. After quiting the use of Cranberries (Cornus Mas) an elevation of Glucose which was slow in beginning but rapid later. cardiologist. nephrologists and ophthalmologist) The patient was on Oral Antidiabetic Therapy and on very strict Antidiabetic diet.• • If oral antidiabetic therapy use for oral therapy should be or not to Non Insulin Diabetes Patients. The use of fruit was stopped for one year and the patient condition was again evaluated In subjective manner asking the patient to evaluate the improvement of the diseases symptoms throught questionary every month.. • Keywords: Diabetes Mellitus. 67 years old with Diabetes Type II asked to be an object of study. The aim of study was to see if these fruits Cranberries (Cornus Mas) really had an impact on patient’s health state.was noticed with average 16. nephrology and ophthalmology) done from the moment when a patient started to use the fruit were collected and then the condition of the patient until the moment of research was evaluated.5 mmol/L or 297 mg/dL blood Review of Global Medicine and Healthcare Research . cardiologist. cardiology. Dedication of particular importance to products with natural content in the future by Scientists. 1 (2010) 306 . Republic of Kosova Case Report A female Patient N. Cranberry .Vol. Goh N. Chia T. 5. Folia Med Carcov 41:5–15. 4.Questionary was with total 3. Kong J. Brouillard R.Glucose.3 points average.. Zubik. Scientists zero in on health benefits of berry pigments. Bose. 6. J. S. Sarrafzadegan N. nephrologists and ophthalmologist).5 in average.Maine 3.X. K. Jankowski A. 1 No.Orono.Questionary and Specialistic reports showed an aggravation in the condition was with total of 2. Jankowska B. References 1. The patient was again directed to countinue using the fruits Cranberries (Cornus Mas) and her condition was evaluated in two ways: In subjective manner asking the patient to evaluate the improvement of the diseases symptoms throught questionary every month. kidney and eyes. Arefian A: Anti-oxidant effect of flavonoids on hemoglobin glycosylation. Niedworok J: The effect of anthocyanin dye from grapes on experimental diabetes. M. known with a name Polyphenole with great antioxidant characteristics. Ghassemi N.and In objective manner based on laboratory analyses (hematology and biochemistry ) every two months and also based on specialistic reports (endocrinologist. Naderi GH. F. 2001. Belinda K. Su. Chia L. Retrieved on 2007-07-27. MS and Mary Ellen Camire. After restarting to use the fruit Glucose value had started to fall. (2003). "Analysis and biological activities of anthocyanins". Natural Products Information Center.Specialistic reports were showing an amelioration of cardio-vascular system..Asgary S. 2. Chambers. Fruit: Cranberry (Cornus Mas) is a plant which grows in South Europe but also in Republic of Kosova and it’s name is “The Europian Corneal” Laboratory analyses showed that Cranberries (Cornus Mas) are source of Flavaonoides and Phenolic Ac. 2000 Review of Global Medicine and Healthcare Research .. P. PHD Can Cranberry Supplementation Benefit Adults With Type 2 Diabetes? From the Department of Food Science and Human Nutrition.Agric.. Vinson.Phenol Antioxidant Quantity and Quality in Foods:Fruits. Food Chem. 1999.first slowly and then for about two months the value obtained was 9.A. 1 (2010) 307 .. Boshtam M. Pharm Acta Helv 73:223–226. Gross PM (2007). Anthocyanin lowers the glucose level by increasing the Insulin level in the blood using an unknown mechanism.. cardiologist.They also contain the substance called Anthocyanin which is an important pigment for the color of this fruit.5 mmol/L or 171 mg/dL.University of Maine. Rafie M. Flavonoides accomplish their activity by lowering the oxidation of the lipids and by decreasing the glucolisation of proteins by acting on lowering of glucose and lipid value. L.Vol. J. Are you currenty (check married separated only one): widowed single divorced 4. 1 (2010) 308 . state. zip: ___________________________ Telephone: home ( ) _________. In general._____________ work ( ) _________._____________ Date of birth: ______________ Sex: Female Male Background 1.QUESTIONARY FOR DIABETES MELLITUS Name(Initials): _________________________ Address: _________________________ Today's date: _______________ City. 1 No.Vol. Ethnic origin (check White Albanian only one): Serbian Bosnian Romes Egyptian Other: __________________________ 2. Please indicate below which chronic condition(s) you have: Diabetes type 2 Diabetes type 1 High cholesterol High blood pressure Heart disease Type of heart disease: _________________________________ Lung disease Type of lung disease: _________________________________ Other chronic condition Specify: _________________________________ General Health 1. Please circle the highest year of school completed: 123456 (primary) 7 8 9 10 11 12 (high school) 13 14 15 16 (college/university) 17 18 19 20 21 22 (graduate school) 23+ 3. would you say your health is: (Circle one) Review of Global Medicine and Healthcare Research . ........................................ No Yes Don’t know Review of Global Medicine and Healthcare Research ..................... did you ever have any of the following symptoms… Increased thirst? ................ None of the time A little of the time Some A good Most All of the bit of the of the of the time time time time 1................................................ Were you discouraged by your health problems?...........2 Poor........... 1 No..... Was your health a worry in your life?......5 Very good............................................1 Symptoms How much time during the past month........................ 5 4 3 2 1 0 3.............................................4 Good........ 5 4 3 2 1 0 In the PAST WEEK..........Vol.................................. 5 4 3 2 1 0 2.........3 Fair.5 4 3 2 1 0 4..................... Were you frustrated by your health problems?........... Were you fearful about your future health?...... 1 (2010) 309 .......Excellent...... ................................................................................. No Yes Don’t know Frequent urination at night? Do you have to get up to urinate 3 or more times a night?……….. 1 (2010) No Yes Don’t know 310 ............................................................................................................................. Review of Global Medicine and Healthcare Research ..........................................Dry mouth?.............. No Yes Don’t know Lightheadedness?........................ No Yes Don’t know Night sweats?.......................................................................................................................... even for a short time? ………………………….................................................. 1 No..............................Vol... No Yes Don’t know Abdominal pain?.. No Yes Don’t know Decreased appetite? .................................... No Yes Don’t know Morning headaches?..................... No Yes Don’t know Shakiness or weakness?............... No Yes Don’t know Nightmares?............................................................ No Yes Don’t know Intense hunger?....................................................................... No Yes Don’t know Severely high blood sugar (blood glucose readings of 300 mg or higher?) ……... No Yes Don’t know Times when you passed out fainted or lost consciousness......................... No Yes Don’t know Nausea or vomiting? ...................................................................................... ..... 5 4 3 2 1 3............. On how many days in the last week did you test your blood sugar level? (If you were sick in the last week.... 5 4 3 2 1 Quite Almost Slightly Moderately a bit totally 2... 5 4 3 2 1 Your Glucose Testing 1.. friends. how much.... On days that you test your blood sugar. Has your health interfered with your household chores?.Vol.. neighbors or groups?. 1 No.. Has your health interfered with your errands and shopping?... 1 (2010) 311 ....... Has your health interfered with your hobbies or recreational activities?. Has your health interfered with your normal social activities with family.. 5 4 3 2 1 4... (Circle one) Not at all 1....Daily Activities During the past 4 weeks..................... Do you have a machine to measure your blood sugar (glucose) level? Yes No 2... how many times do you test on average? _______ times Review of Global Medicine and Healthcare Research .. think of the most recent 7 days when you were NOT sick) ________ days 3................. .. _______________ 1....... rowing........ etc. 5 4 3 2 1 4... even if it was not a typical week for you......5 4 3 2 1 Confidence About Doing Things For each of the following questions. 1 No.... please circle the number that corresponds with your confidence that you can do the tasks regularly at the present time. how much total time (for the entire week) did you spend on each of the following? (Please circle one number for each question..... Other aerobic exercise Specify_________________________...Physical Activities During the past week. 5 4 3 2 1 6.......... 5 4 3 2 1 3..... using weights...... 1 (2010) ..Vol.... How confident do you feel that you can eat your meals every 4 to 5 hours every day.... Bicycling (including stationary exercise bikes)........ Other aerobic exercise equipment (Stairmaster..... etc.. skiing machine......)........ Walk for exercise..... 5 4 3 2 1 2.... Stretching or strengthening exercises (range of motion... Swimming or aquatic exercise. 5 4 3 2 1 5.. including breakfast every day? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 Very confident 312 Review of Global Medicine and Healthcare Research ....) less than none 30 min/wk 30-60 min/wk 1-3 hrs per week more than 3 hrs/wk 1..........).. 4 to 5 times a week? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 _______________ 5. How confident do you feel that you know what to do when your blood sugar level goes higher or lower than it should be? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 _______________ 7. How confident do you feel that you can control your diabetes so that it does not interfere with the things you want to do? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 Very confident Very confident Very confident Very confident Very confident Your Diet 1.Vol. How confident do you feel that you can judge when the changes in your illness mean you should visit the doctor? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 _______________ 8. snacks)? confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 Very confident Very confident _______________ 4. How many times last week did you eat breakfast when you got up? ____ times last week 2. How confident do you feel that you can do something to prevent your blood sugar level from dropping when you exercise? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 _______________ 6. How confident do you feel that you canchose theappropriate foods to eat when you are hungry (for example. How confident do you feel that you can follow your diet when you have to prepare or share food with other people who do not have diabetes? Not at all confident | | | | | | | | | | 1 2 3 4 5 6 7 8 9 10 _______________ Not at all 3. 1 (2010) . 1 No._______________ 2. How confident do you feel that you can exercise 15 to 30 minutes. did you eat any of the following foods for breakfast? (Please check all that apply) milk (½ cup) cheese yogurt 313 Review of Global Medicine and Healthcare Research . This morning. .... No Yes Don’t know Please specify the name(s) of the blood pressure pills you took: _______________________ 4... In the past week did you get insulin injections?...... 5 4 3 2 1 0 Review of Global Medicine and Healthcare Research .. or fish beans If you ate anything else...Vol................. how often do you do the following (please circle one number for each question): Never Almost never Sometimes Fairly often Very often Always a. poultry.......... please write here: _____________________________________ Medications 1.... No Yes Don’t know 3................. In the past week did you take pills for cholesterol?... No Yes Don’t know Please specify the name(s) of the cholesterol pills you took:___________________________ Medical Care 1.........eggs meat......... In the past week did you take pills for diabetes?.... 1 (2010) 314 ........... 5 4 3 2 1 0 b.... In the past week did you take pills for high blood pressure?............................. When you visit your doctor............ Ask questions about the things you want to know and things you don’t understand about your treatment... No Yes Don’t know Please specify the name(s) of the diabetes pills you took: ____________________________ 2........... Prepare a list of questions for your doctor...... 1 No....... ...................... When was the last time you had your eyes examined? (example: for glaucoma or any other problem)........... how many times did you visit a physician? Do not include visits while in the hospital or the hospital emergency department __________ visits 3................................... 1 No.........................................c......................................... or other minimum care facility?.......... In the past 6 months. convalescent hospital.............................______________ Month Year 6..................................... how many TIMES were you hospitalized for one night or longer?.................. Discuss any personal problems that may be related to your illness..... 1 (2010) 315 .....__________ times a.............................. How many total NIGHTS did you spend in the hospital in the past 6 months? __________ nights b......... How many times did the doctor or nurse examine your feet in the last 6 months?................. Were any of these hospitalizations at a skilled nursing facility...........Vol......................... In the past 6 months.............. Yes No 5.... In the past 6 months......5 4 3 2 1 0 2...... how many times did you go to a hospital emergency department?...__________ times 4.........___________ times Review of Global Medicine and Healthcare Research . The patient will be under shock .39 Female patients . Most of the following types of fractures can be corrected with application of Ilizarov method a) Open book type pelvic fractures b) Closed book type pelvic fractures c) Vertical shear fractures d) Rotational malalignment of iliac wing e) Multi directional displacements Usually the patient will not be fit for anaesthesia due to poly trauma.3 A . Chennai. Chong Ying Jiun. especially when we require multi directional correction of pelvic bones. Review of Global Medicine and Healthcare Research .42 Male patients . Sarawak . If possible three shanz pins are used on each iliac crest. 1 No.O External fixator set with six shanz pin and connecting elements Ilizarov set consisting two half rings.com Abstract Aim of the study: We aim to use ilizarov method to correct the displacement of fragments in pelvic fractures in patients who are not fit for anaesthesia. East Malaysia Government Kilpauk Medical College @Royapettah Hospital. rancho cubes. associated chest injuries and hypo tension. bolts and nuts As the patient arrives at the emergency department a general assessment is made . Subramaniyam Vasanthapriya. hinges. Choy Yee Yi.Bintulu . Tamil Nadu Email: ilizarov2007@gmail. 1 (2010) 316 . Prem srinivas Hospital Bintulu.In order to save the life of the patient and save time we prefer to apply the shanz pins under local anaesthesia.If decided for application of external fixator. a conventional external fixator is applied over the both iliac crests. it can be performed even at any peripheral centers. long threaded rods.ILIZAROV FOR PELVIC FRACTURES Aruchamy Ramalingam.Vol. As the procedure requires only local anaesthesia. Materials and Methods: Total number of patients . 97000 . Vol. External fixation It is highly advisable to apply the frame with a time frame of 5 to 30 minitues. If not the corrections can be done later. bladder care.DAY 1 – At emergency room – Resuciation. 1 (2010) 317 . 1 No. under image control and without anaesthesia. The advantage of ilizarov method is further corrections can be done gradually. Review of Global Medicine and Healthcare Research . After the application of the frame a minimal correction can be performed if the patient is stable. 1 (2010) 318 . 1 No.Vol.Few days after injury convertion to ilizarov frame Gradual correction of pubic bone and vertical shear under image intensifier Review of Global Medicine and Healthcare Research . 1 No.Vol. 1 (2010) 319 .Gradual correction of sacro iliac joint under image intensifier After correction Review of Global Medicine and Healthcare Research . Knowledge of Ilizarov principle is not an indication • We selected patients whom we felt the correction can be achieved by ilizarov apparatus. 4) Social and cosmetic reasons can make the patient prefer for internal fixation 5) Associated visceral injuries 6) Need of ilizarov trained person ( once the patient is stable with conventional frame the patient can be referred to an Ilizarov surgeon at nearby centers ) Results: • A better selection of patients will give a better result. 1 (2010) 320 .Vol. Review of Global Medicine and Healthcare Research . But the pain subsided spontaneously over a period of 6 months. The remaining patients we subjected for open reduction and internal fixation • All of our patients had a reasonable reduction except for one patient with posterior instability. So it is the surgeon’s duty to achieve maximum possible correction within three weeks.Limitations and Contra indications: This method has the following limitations: 1) Fractures involving iliac crest 2) Complexity of the frame 3) Acceptance by the patient as the frame is bulky and needs uncomfortable postures during the treatment period. We had to do an additional posterior fixation. A delay in this reduction will lead to malunion of fragments. Further management will lead a complicatied osteotomies and blood transfusions. We preferred hybrid fixation for posterior instability as the frame application over the posterior aspect will be uncomfortable for the patient • All our patients were able to walk approximately 6 weeks after surgery • Four of our patients were complaining of vague pain which cannot be localized. 1 No. • No patients had limb length discrepancies Conclusion: As the pelvic bone is a cancellous bone it tends to unite over a period of three weeks. visceral injuries etc. 1 No.Vol. spine injuries.Advantages: • Bloodless surgery • Scarless surgery • No need of Major anaesthesia • No need of major surgical procedures • Incidence of malunion of pelvic bones can be prevented • Can be performed even in under equipped peripheral centers • Multiple corrections can be done as required gradually with the image intensifier • Gradual corrections are usually painless • An early correction of the displaced pelvic bones can be achieved in poly trauma patients and in patients who are having problems for anaesthetic fitness due to chest injury. 1 (2010) 321 . Review of Global Medicine and Healthcare Research . The patient may be viewed by others as weak and lacking motivations. The patient and family may be angry and frustrated that this illness cannot be fixed. emotional and sexual problems. Besides. 95% of the tuberculosis cases and 98% of the tuberculosis deaths occur in developing countries. Annual Report. Haemoptysis (blood tinged sputum) is the most frightening symptom and often leads the patient to seek treatment. there are 15-20 million cases of infectious TB in the world. The immune defects produced by HIV increases the predisposition to tuberculosis. hypoxaemia has been shown to reduce level of testosterone and also suppresses hypothalamicpituitary-testicular axis. India Baba Farid University of Health Sciences. The disease is usually chronic with varying clinical manifestations.Vol. New Delhi).com Introduction Pulmonary Tuberculosis is a specific infectious disease caused by Mycobacterium tuberculosis. (Ibanez et al. Pulmonary TB is the India’s biggest public health concern. Pulmonary Tuberculosis is the most common cause of morbidity and mortality due to single infectious agent in adults and accounts for over a quarter of the avoidable deaths worldwide. can also cause the appearance of social. India Email: klairjagpal@yahoo. 1993-94. usually manifesting as onset of respiratory and constitutional symptoms. According to conservative estimates of World Health Organisation. The interaction of psychic and somatic influences becomes more complex when one considers the etiology and maintenance of symptoms of pulmonary disorders. About 30% of total population is infected with Mycobacterium tuberculosis and 1.Study of Psychiatric Morbidity among Pulmonary Tuberculosis Patients Jagpal Singh Klair Govt. of India. The problem is further complicated by relentless spread of human immunodeficiency virus which causes acquired immunodeficiency syndrome (AIDS) pandemic and the emergence of multi-drug resistant strains. Pulmonary tuberculosis besides the specific clinical manifestations. For example self-destructive or depressive feeling may generate or give momentum to a smoking habit which would increase the incidence of pulmonary tuberculosis. There are about 8 million new cases and 3 million deaths each year due to tuberculosis. Psycological distress may become manifest in disrupted breathing as in the tachypnea seen in anxiety disorders or sighing respirations in the depressed or anxious patients. 1 (2010) 322 . Faridkot. Pulmonary tuberculosis especially the multidrug resistant tuberculosis is characterized by prolonged and distressing symptoms like haemoptysis (Govt. The latter problems appear in advanced lung disease. 1 No.5% of population suffers from radiologically active pulmonary tuberculosis. they may feel helpless. The incidence of tuberculosis in HIV infected patients is about a hundred fold than that in general population (Small. Patiala (Punjab). Dudley et al. DGHS. Medical College. PUNJAB. 1991) and 40% develop active tuberculosis within few months following infection. It had been observed that deterioration of pulmonary function is related to organic erectile dysfunction. Patient may feel guilty if smoking was one of the Review of Global Medicine and Healthcare Research . (1985) observed that when patients and physicians face chronic disease. Physicians may be seen as lacking clinical competence when a patient can’t be cured. 2001) in an interview based study which evaluated the perception of sexual difficulties and changes in communication with patients and their wives showed 67% of patients and 94% of their wives had some type of sexual problems like decreased desire or impotence. The management of pulmonary tuberculosis is further complicated by dual infection of HIV and TB and the emergence of multidrug resistant TB. Review of Literature Research suggest that psychic forces affect the clinical expression of chronic chest diseases in several ways altered awareness of airway resistance. Consequently. Denial. This may perpetuate a cycle of confrontation and avoidance. there is paucity of studies regarding prevalence of psychiatric morbidity in patients of pulmonary tuberculosis. suggestibility to airway constrictions. They may view the patient as unwilling to address issues that they bring up.6% in MDR-TB patients. Though there are a number of studies showing high prevalence of psychiatric morbidity among patients of chest disease like COPD and asthma. such as loss of their job. 2004). repression and isolation frequently are used as coping strategies in these patients.6% in defaulters TB and 25. Psychiatric complications present challenge in the treatment of patient with MDR-TB. (2001) depression and anxiety (as assessed by Intervention Diagnostic Interview) composite among TB patients was 19% in recently diagnosed TB. Review of Global Medicine and Healthcare Research . Number of studies have evaluated have higher prevalence of psychiatric morbidity among patients with chronic chest diseases compared with general population (Karjesh. 2004) showed prevalence of baseline depression and anxiety 52% and 8. 12% and 12% respectively. Pollach. 1998). The incidence of depression.2% among persons with one or more medical conditions (which include lung disease) compared to 17. from etiology to ongoing symptoms and appearance of related respiratory syndrome as well as psychiatric morbidity. or changes in appearance. panic disorders and depression (Kikochi et al. They may feel like a burden to their spouses and families. Patients may fear loss of control or loss of independence.factors resulting in the disease. not recognizing that this strategy is viewed by the patient as necessary for survival. leading to unresolved anger and despair because neither the needs of the patients nor those of the family are met. 1 (2010) 323 . Tuberculosis remains a leading infectious cause of mortality worldwide. Patients may avoid strong emotions to minimize the demands on the lungs. the patients spouse or family may feel that the patient is emotionally distant and unavailable. 1990.5% and 33. co-morbidity with anxiety. Despite the availability of inexpensive and effective antituberculosis medicines. Family members may experience the patients rigid avoidance of affect and conflict as rejection of them. 1 No. anxiety and psychosis required treatment. 1996. 1997). 21. Psychiatric issues impinge on many facets of the cause of chronic respiratory diseases like pulmonary tuberculosis.7% in a cohort of MDR-TB patients. social status.7% and of life time psychiatric disorder was 42. non-adherence to medication by patients due to depression is the principal obstacle in the treatment of tuberculosis. In a study by Ayden et al. Wells (1998) demonstrated the sex and age adjusted prevalence of any psychiatric disorder in the proceeding six months was 24. Spinhoven P Van et al.Vol. While the majority of individuals with depression. cycloserine administration with known neuropsychiatic side effects was successfully continued in all cases (Vega et al. They may have many losses to contend with because of their pulmonary tuberculosis. Wells. anxiety and psychosis during MDR-TB treatment was 13. A recently published study by (Peru.0% respectively for persons with no medical condition. This present study intends to have an insight into prevalence of psychiatric morbidity among Indian patients with pulmonary tuberculosis. with 3/4th of patients in developing countries. Stone C et al 1994. role in family. suppression of affect.3%. 5 patients studied above high school. The majority of subjects knew the name of their disease (87. and less control over their illness. more serious perceived consequences. In this study of the 52 subjects recruited for the study. 9(17. 6(12%) were literate upto high school.8 (16%). above 9). denial of problem (D) was seen more in controls compared to tuberculosis patients. 45 (86.3 years (age range 11-55 years). Bhatia. Imran B Chaudhry. wanted symptomatic relief (40. a self -report instrument was administered to 103 tuberculosis cases and a similar number of age. To evaluate the effect of pulmonary tuberculosis on quality of life. A study was carried out on psychiatric morbidity. In all.Vol. 21 patients (42%) were illiterate. till the course of anti-tuberculosis treatment was completed.7%). and Waquas Waheed (2008) on the relationship between anxiety.Chadha. 39 patients (78%) scored significantly (i.4%) and were satisfied with their treatment (82. Similar study was carried out on illness behaviour of tuberculosis patients undergoing DOTS therapy: a case-control study by (S. 1 (2010) 324 . The sample consisted of 50 patients with the mean age of 28. Raised depression and anxiety scores were associated with an increase in the number of symptoms reported. Material and Methods Review of Global Medicine and Healthcare Research . Aims and Objectives 1.6 (12%). Manoharam. John.Bhasin. affective inhibition (AI) and affective disturbance (AD) more than the controls and the differences between the two groups were statistically significant.5%) had pulmonary tuberculosis. 2.K. 1500. small scale businessmen . 50 (46. There were 38 males (76%) and 12 females (24%). Joseph and Jacob (2001). Only smoking was found to be associated with poor compliance in univanate analysis.2%) and death (59. 26 patients (52%) lived in joint families and 24 patients (48) had a nuclear family.7%) subjects completed their treatment. The tuberculosis patients were receiving treatment from two DOTS centres in East Delhi and the controls were from the same locality. To correlate psychiatric morbidity with gradation of sputum examination.6%). However.7%). 2001) in which Illness Behaviour Questionnaire (IBQ). The average monthly income was Rs. 1 No. To find out psychiatric morbidity in patients of pulmonary tuberculosis. clerical employees .e. skilled workers . On Neuroticism scale. Nadeem Rizvi. feared incapacitation (21. depression and illness perception in tuberculosis patients in Pakistan it was found that out of 108 patients. radiological extent of the disease and socio-economic factors.9%). and R. Sam P Dearman. 32(66.2%) had anxiety. The tuberculosis patients exhibited features pertaining to general hypochondrasis (GH). patients’ perspectives of illness and factors associated with poor medication compliance among the tuberculosis in Vellore.P. Atul Mittal. believed its infectious nature (51. Higher neuroticism showed higher psychosocial dysfunctioning.3%) subjects satisfied the International Classification of Diseases 10 Primary Care Criteria for psychiatric disorders. 3. Depression was the commonest disorder.10 (20%). O. Various occupational groups were Housewives . Mean score was 16. A total of 48 subjects were followed up for 6 months.Aggarwal.6 (12%) and unskilled workers . Bhasin and Dubey (2000) carried out research on Psychosocial dysfunction in tuberculosis patients.3%) were depressed and 51 (47.In another study by Mohammed O Husain. South India by E.(16%).K. The marital status was 26 married (52%) and 24 unmarried (48%). 18 (36%) were studied upto primary class.2). students 12 (24%).6 (±3. sex matched controls to find out the difference in illness behaviour profile of the two groups. The degree of neuroticims correlated significantly with scores on subscales of DAQ. The variables included age. 3. marital status. Review of Global Medicine and Healthcare Research . Sample Size In the present study the patients with Pulmonary Tuberculosis were screened from TB and Chest Hospital. (f) Patients previously diagnosed with psychiatric disorder. treatments received. Govt. 1 No. diagnosis and types of Pulmonary Tuberculosis. 1 (2010) 325 . Patients of Pulmonary Tuberculosis were contacted. symptoms associated with treatment and previous lab investigations were included from the patient's reports in the medical records at the time of clinical assessment. Patiala. education and occupation. Patient exclusion criteria (a) Patient with any history of alcohol or substance abuse. duration since since onset of disease. Patient inclusion criteria (a) Patients of adult age group (18 years and above) (b) Both male and female were examined. The diagnosis and type of Pulmonary Tuberculosis was determined with consultation of Professor of TB and Chest Diseases department. (b) Patient with any other chronic medical illness or epilepsy.16 item number scale as adapted for patients with chronic illness (Burckhardt and colleagues).Vol. domicile. (c) Patients diagnosed and confirmed by histo-pathological examination for lung cancer. (c) Patients having mental retardation. Personal Biodata Proforma (including Medical background data) This proforma included items or variables to study the sociodemographic profile of the patients. The following instruments were applied for the purpose of the study: • • • Symptom check list (SCL)-80 Quality of life (QOL) scale . 2. (d) Those who refused to give informed consent. Clinical diagnosis of psychiatric disorders will be made as per rCD criteria. Information regarding attributes of Pulmonary Tuberculosis like time since diagnosis. (e) Pregnant women diagnosed with chronic chest disease.1. Medical College. Severe The total score obtained by a given patient in the said sub scale was added up. Anxiety subscale (10) 7. Absent 2. Quality of Life Scale (QOLS)-adapted by Burchardt and colleagues for chronic illness The Quality of Life Scale CQOLS) was originally created by American Psychologist John Flanagan in 1970's. the maximum score obtained by any given subject was taken into consideration. The QOLS is now called the "Adapted Quality of Life Scale" or "Flanagan Quality of Life Scale. Phobic anxiety sub scale (7) 6. he/she was placed in category of mild. Review of Global Medicine and Healthcare Research ." In this thesis. he/she was placed in category of moderation he/she scored between 75-100% of the maximum score. if the score was between 25-50% of maximum score. it will be called simply the QOLS and always refer to the 16-item scale as adapted by Burckhardt and colleagues for persons with chronic illness. Depending upon the score.Symptom Check List-80 It consists of 80 items. depending upon the severity of symptom. if the patient scored between 50-75% of the maximum score. he/she was placed in the category of sever. Mild 3. The score one was given when patients complained of a little bit of symptom.Vol. Moderate 4. score four for extremely severe. The severity of symptom in each sub scale was divided into: 1. Additional symptoms subscale (7) The items included in each subscale are listed in the scoring key. These 80 items are further divided into nine subscales namely: 1. Anger hostility subscale (6) 9. Obsessive compulsive neurosis subscale (10) 8. If the score of the given subject was between 0-25% of the maximum score. Interpersonal sensitivity subscale (9) 5. 1 No. Somatization subscale (12) 2. he/she was placed in the category of the absent. Depression subscale (13) 3. Paranoid ideationsubscale (6) 4. Each item had maximum score of four. 1 (2010) 326 . it is used for the purpose of Pulmonary Tuberculosis. Item Scaling A 7 -point delighted terrible scale has been used to measure satisfaction with each item for a broad range of affective responses to QOL items. the means tend to be quite negatively skewed with most patients reporting some degree of satisfaction with most domains of their lives. "mostly satisfied" (5). Use in chronic illness populations. (Andrews and Crandall. It has 16 items rather than the 15 found in the original Flanagan version. to 84 for systemic lupus erythematosus. The QOLS was originally a 15-item instrument that measured 5 "conceptual domains of quality of life": • • • • • Material and physical well being Relationships with other people Social. community and civic activities Personal development and fulfillment Recreation The instrument was expanded to include one more item : "Independence. the ability to do for yourself'. The QOLS scores are summed so that a higher score indicates higher quality of life. The QOLS is a valid instrument for measuring quality of life across patient groups and cultures and is conceptually distinct from health status or other causal indicators of quality of life. including a small group of cancer patients with ostomies. Review of Global Medicine and Healthcare Research . "mostly dissatisfied" (3). 1976). Average total scores for other conditions range from 61 for patients with post-traumatic stress disorder. "mixed" (4). 1 No. 1 (2010) 327 .Measurement by Quality of Life Scale (QOLS) The instrument measures domains that diverse patient groups with chronic illness define as quality of life and has low to moderate correlations with physical health status and disease measures. "unhappy" (2). "terrible" 0). And like many QOL instruments. In the current study. The seven responses were "delighted" (7). has been validated. Average total score for healthy populations is about 90. to 87 for osteoarthritis.g. to 83 for rheumatoid arthritis. "pleased" (6).Vol. This scale can be used with confidence in chronic illness groups. Means for various chronic conditions come from descriptive studies or experimental pretest data e. Scores can range from 16 to 112. Scoring and Interpretation of QOLS The QOLS is scored by adding up the score on each item to yield a total score for the instrument. If more than half of the scale items were incomplete. 10 patients due to diabetes mellitus. Using the inclusion and exclusion criteria of the Pulmonary Tuberculosis. 8 due to ischaemic heart disease. All queries regarding the study were also explained. OBSERVATIONS Table 1: Number Of Patients Number of patients of Pulmonary Tuberculosis screened Patiants Excluded Group A Number of patients of Pulmonary Tuberculosis with psychiatric morbidity Group B Attendants (Control) of Group A patients Number of Attendants (Control) with psychiatric morbidity Prevalence of psychiatric morbidity among patients of Pulmonary Tuberculosis Prevalence of psychiatric morbidity among the Attendants (Control) 124 27 50 50 6 51. Statistical Methods Substitution of missing values on questionnaires scales (QOLS) was made if the patient had responded at least half of the items in a specific subscale. The diagnosis of psychiatric morbidity were made according to clinical description and diagnostic criteria for lCD-l0. the scale score was treated as missing data. written consent was taken and information about the study was provided to the patient. A detailed history of illness was recorded from the patients with the various socio-demographic variables and details of Pulmonary Tuberculosis on Proforma. At the beginning.Vol. Out of these 124 patients 27 patients Review of Global Medicine and Healthcare Research . 50 patients were diagnosed as the patients of Pulmonary Tuberculosis with psychiatric morbidity. 1 No. The missing value was replaced by the mean of completed items in that scale for each patient. The Attendants of these patients serving as control were enrolled in Group B. All the selected cases were screened in detail. 27 patients were excluded from study. Patients who refused to give the informed consent were excluded from the present study. were interviewed and psychiatric symptoms were elicited on the basis of SCL-80 and clinical interviews conducted in consultation with consultant psychiatrist. QOLS were used to assess the Quality of Life (QOL). Out of the total patients screened. 7 due to history of alcohol/substance abuse and 2 patients excluded due to pregnancy. on the basis of which patients were classified. Such patients were enrolled in Group A.55% 12% Table 1 shows that 124 patients with Pulmonary Tuberculosis were screened to get 50 patients of Pulmonary Tuberculosis with psychiatric morbidity (Group A). 1 (2010) 328 .Data Collection All the scales and analyses were administered personally to the subjects. The data collected was subjected to statistical analysis and chi-square and t test were applied to test the statistical significance of the various factors that contributed to psychiatric morbidity. Review of Global Medicine and Healthcare Research . The difference in number of illiterate patients in both groups was significant.85 0.16 4.04* 0. Table 2: Socio-Demograhic Attributes of Patients Socio-demographic attributes Group A Number % Group B Number % Chisq X2 p value Sex Male Female 36 14 41 9 33 13 4 10 40 9 72 28 82 18 66 26 8 20 80 18 64 14 4 32 18 35 15 23 21 6 12 38 7 26 14 3 64 36 70 30 46 42 12 24 76 14 52 28 6 0.55%.97 0.31 0.Vol.15 0.76 0.1 0.39 Marital Status Education Married Unmarried Illiterate Primary Secondary 1.02 0.74 0.63 Domicile Urban Rural Occupation Housewifes 0. domicile and occupation.30 1.09 0. Out of these 50 Attendants (Control).58 0.02 2. 6 had psychiatric morbidity.were excluded initially. 1 (2010) 329 .06 2. 1 No. 50 Attendants of the 50 patients of Pulmonary Tuberculosis with psychiatric morbidity (Group A) were taken as Control (Group B). The patients were almost similar on other variables like marital status. So the prevalence of psychiatric morbidity among the Attendants (Control) is 12%.23 0. Employes Professional 8 2 Table 2 shows that the number of male and female patients in both groups did not differ significantly. So the prevalence of psychiatric morbidity among patients of Pulmonary Tuberculosis is 51.11 0.88 Labourers/Farmers 31 Govt. 28% 72% Male Female Pie diagram showing Distribution of Patients according to Sex in Group A 2. 1 (2010) 330 . 1 No.56% 76.Vol.92% Male Female Pie diagram showing Distribution of Patients according to Sex in Group B 18% 82% Married Unmarried Pie diagram showing Distribution of Patients according to Marital Status in Group A Review of Global Medicine and Healthcare Research . Vol.30% 70% Male Female Pie diagram showing Distribution of Patients according to Marital Status in Group B 8% 26% 66% Illiterate Primary Secondary Pie diagram showing Distribution of Patients according to Education in Group A 12% 46% 42% Illiterate Primary Secondary Pie diagram showing Distribution of Patients according to Education in Group B Review of Global Medicine and Healthcare Research . 1 (2010) 331 . 1 No. 1 No. 1 (2010) 332 .Vol. Employees Labourers/Farmers Professional Pie diagram showing Distribution of Patients according to Occupation in Group A Review of Global Medicine and Healthcare Research .20% 80% Urban Rural Pie diagram showing Distribution of Patients according to Domicile in Group A 2 4% 7 6% Urban Rural Pie diagram showing Distribution of Patients according to Domicile in Group B 14% 4% 18% 64% Housewifes Govt. 8±11. of Patients 20 15 10 5 0 < 30 26 24 Group A Group B 15 13 11 11 30-50 > 50 Bar diagram showing Age of Patients Table 4: Showing Smoking Status Iin Patients of Pulmonary Tuberculosis Review of Global Medicine and Healthcare Research .018.6% 28% 14% 52% Housewifes Govt.018 The table shows age distribution of patients in Group A and Group B. 1 No. Employees Labourers/Farmers Professional Pie diagram showing Distribution of Patients according to Occupation in Group B Table 3: Age of Patient Age Group (in years) < 30 30 – 50 > 50 Range (yrs) Mean ± SD Df ‘t’ & ‘p’ value Significance Group A (n = 50) Number % 11 22 24 48 15 30 24 – 68 42.Vol. The Mean Age of Group A is more than that of Group B but the difference is NS.06±12.163 NS Group B (n = 50) Number % 13 26 26 52 11 22 21 – 59 38. Mean Age (±SD) for Group A was 42.13 and that for Group B was 38. 30 25 No. 1 (2010) 333 .8±11. p=.06±12.402.13 98 1. 001). 30 25 No.Vol.10508 and the difference was highly significant (HS) (p<0. 1 No. Review of Global Medicine and Healthcare Research .2400±21.001**).0002**).67 9.36138 compared with Group B Mean (±SD) 22.001** 0.36138 22. The difference in the number of past smokers in Group A compared with Group B was also highly significant (p=0.2400±21.10508 98 16.002** 0. 1 (2010) 334 .30 0.9400±11. of Patients 20 28 28 Current Smokers Past Smokers Non somkers 13 15 10 5 0 Group A 9 12 10 Group B Bar diagram showing Smoking Status in Patients of Pulmonary Tuberculosis SCL Score < 20 21 – 40 41 – 60 61 – 80 81 – 100 101 – 120 > 120 Range Mean ± SD Table 5: SCL-80 SCORE Group A Group B Number % Number % 28 56 3 6 14 28 8 16 8 16 13 26 19 38 7 14 26 – 116 11 – 54 78.06 X2 P value 0.001 HS df ‘t’ value ‘p’ value Significance The above table shows that the scores as measured on SCL-80 were more in Group A Mean (±SD) 78.242 <0.Group A Group B Chi-sq Current smokers Past smokers Non smokers 28 13 9 12 28 10 10. however there were significantly higher number of current smokers in Group A compared with Group B (p=0.9400±11.80 There was no difference in number of smokers (current and past) and non-smokers in both the groups. 58±2.50±3.61276 50 100 5. 1 No.30±4.18±1. of Patients 20 14 15 10 5 0 0 < 20 21-40 41-60 61-80 81-100 101-120 > 120 3 0 0 0 0 0 8 8 13 7 Bar diagram showing SCL-80 Score Table 6: Scores on Individual SCL-80 Sub Scale SCL Sub Scale Group A Number % 23 46 27 54 19.00238 46 92 4 8 4.12 1.02±2.06 0.33425 50 100 3.51037 49 98 1 2 3.12852 50 100 4.38±1.98659 50 100 5. 1 (2010) 335 .05 0.53 0.37 0.Vol.90±2.14163 46 92 4 8 6.81 0.81 0.00 0.06±13.16738 Level of Chi-sq Significance 27.04±4.54±3.001** 2.27 0.48±7.90±6.70±4.05894 40 80 10 20 6.001** Review of Global Medicine and Healthcare Research .005** 5.91545 41 82 9 18 7.90534 41 82 9 18 9.90±2.20±2.001** Somatization Depression Paranoid I/P Senstivity Phobia Anxiety OCN Anger/ Hostility Additional Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD Absent Present Mean±SD 0-12 13-48 0-13 14-52 0-6 7-24 0-9 10-36 0-7 8-28 0-10 11-40 0-10 11-40 0-6 7-24 0-7 8-24 26.34 0.40594 31 62 19 38 8.73510 43 86 7 14 4.003** 7.63609 50 100 3.0187* 18.16±6.14276 47 94 3 6 5.91286 21 42 29 58 20.5±15.42±1.241 9.005** 7.45665 Group B Number % 48 96 2 4 7.30 25 28 Group A Group B 19 No.56609 50 100 5. 24 20 No. Group A patients had significantly higher mean score for all the parameters except Paranoid and I/P sensitivity subscales as compared to Group B subjects.5000±3.14163 47 94 3 6 6.50 5.14276 47 94 3 6 5.001** Somatization Absent Mild Moderate Severe Mean±SD Depressio Absent n Mild Moderate Severe Mean±SD Paranoid Absent Mild Moderate Severe Mean±SD I/P Absent Senstivity Mild Moderate Severe Mean±SD 0-12 13-24 25-36 37-48 0-13 14-26 27-39 40-52 0-6 7-12 13-18 19-24 0-9 10-18 19-27 28-36 27.05894 Group B Number % 48 96 2 4 7.50 Group A Group B 7.20 3. The difference in the scores of parameters Somatization.48 3. Depression. Phobia.91286 21 42 11 22 11 22 7 14 20.001) and was significant (S) (p<0.3000±4.38 8.4200±1. 1 (2010) 336 .12 1.05) for Anger/Hostility. Anxiety.54 3.241 Review of Global Medicine and Healthcare Research .001** 2.42 5. 1 No.16 5.2000±2.Vol.12852 Chi Sq Level of Signific ance 0.58 Paranoid Phobia OCN Additional Bar diagram showing Mean Scores of Individual SCL-80 Sub scale Table 7: Severity of Symptoms on Individual SCL-80 Sub Scale SCL Sub Scale Group A Number % 23 46 9 18 11 22 7 14 19.06±13. of Patients 16 12 19. OCN and Additional were highly significant (HS) (p<0.56609 50 100 5.34 0.7000±4.37 0.02 7.06 20.72 0.97 28.This table shows that on the basis of SCL-80 scores.04 5.33425 50 100 3.90 6.50±15.90 4.70 4.00238 46 92 4 8 4.90 4.0200±2.30 8 4 0 Somatization 6.18 9. Out of 20 patients (40%) in Group A who satisfied the criteria for depression.1800±1.9000±6.45665 50 100 4.61276 50 100 5.Phobia Absent Mild Moderate Severe Mean±SD Anxiety Absent Mild Moderate Severe Mean±SD OCN Absent Mild Moderate Severe Mean±SD Anger/ Absent Hostility Mild Moderate Severe Mean±SD Additiona Absent l Mild Moderate Severe Mean±SD 0-7 8-14 15-21 22-28 0-10 11-20 21-30 31-40 0-10 11-20 21-30 31-40 0-6 7-12 13-18 19-24 0-7 8-14 15-21 22-28 40 80 7 14 2 4 1 2 6.9000±2. The above table shows significantly severe symptoms on all subscales except Paranoid and I/P senstivity.001**.9000±2. Anxiety.53 0.16738 9.91545 41 82 5 10 3 6 1 2 7.81 0.003** 7.005** 5.90534 41 82 5 10 4 8 9.5800±2. somatisation and phobia.05) for Anger/Hostility. Depression was most common psychiatric diagnosis followed by generalized anxiety disorder.0187* 18.3800±1.51037 49 98 1 2 3.0400±4. Review of Global Medicine and Healthcare Research . Depression. OCN and Additional were highly significant (HS) (p<0.5400±3.81 0. 1 (2010) 337 . There were 9 patients (18%) of generalized anxiety disorder. Phobia. 4 patients (8%) of phobia and 5 patients (10%) were diagnosed having somatisation. 5 patients (10%) were of mild depression.001) and was significant (S) (p<0.98659 50 100 5.4800±7.40594 31 62 7 14 9 18 3 6 8. Table 8: Clinical Diagnosis according to ICD-10 Criteria ICD-10 Diagnosis Depression (F-32) Mild Moderate Severe Generalised anxiety disorder (F-41) Phobia (F-40) Somatization (F-45) Total Number of patients 20 5 12 3 9 %age of patients 40 10 24 6 18 4 5 38 8 10 76 This table shows as per ICD-10 criteria. 1 No.00 0.005** 7.Vol. The difference in the severity of Somatization.1600±6. 12 (24%) were of moderate depression and 3 (6%) were of severe depression.06 0.73510 43 86 5 10 2 4 4.63609 50 100 3. 1 No.106 3.90 ±1.60 ±1.05 (S) <0.05 (S) 0.30 ±1.442 3.87 ±1. food.404 3. visiting.001 (HS) 0.40 ±1.87 ±1.402 4. 51. Conclusions • Among the hospitalized patients Of Pulmonary Tuberculosis in the Chest and Tuberculosis ward.070 2.907 3.080 2.53 ±0.05 (S) .031 <0.383 4. In both Groups A & B the item with highest rate of satisfaction was Close friends and Independence.77 ±0.817 2.479 65.507 3.004 <0.276 Mean SD B 3. siblings & other relatives – communicating.002 <0.037 4.55 % were having psychiatric morbidity as assessed on SCL-80 scale.699 1.67 ±1.137 4.57 ±1.769 3. parties etc.53 ±1. Reading. • The comparison of Group A with B on the basis of SCL-80 scores subscale shows significantly severe symptoms on all subscales except Paranoid and I/P sensitivity sub-scales. getting additional knowledge Understanding yourself – knowing your assests and limitations – knowing what life is about Work job in home Expressing yourself creatively Socializing – meeting other people.094 2.13 ±1. conveniences.001) In Group A the mean value of quality of life is 52.83 ±0.432 3.97 ±1.367 3.973 52.003 <0.013 <0.23 ±1.093 4.53 ±1.05 (S) 0. doing things. financial security Health – being physically fit and vigorous Relationships with parents.448 3.43 ± 13.873 3.095 >0.159 3.383 3. doing for yourself received the lowest satisfaction rate.014 <0. 12% were having psychiatric morbidity.87 ±1.05 (S) <0.406 3.507 4.073 4.036 1.004 <0.97 ±1.43 ±13.05 (S) .23 ± 7.382 3.27 ±0.63 ±1.812 . 1 (2010) 338 .003 <0.285 3.373 4.27 ±1. giving advice Participating in organizations and public affairs Learning – attending school.27 ±1.05 (S) 0. doing for yourself QLY of Life Total 2.001 (HS) <0.05 (NS) .189 4.874 3.143 >0.453 2.961 1.066 >0.483 3.05 (S) .05 (S) <0.224 4.001 (HS) This table shows that quality of life score was highly significant (HS) (p<0.191 2. listening to music.03 ±1.285 >0.05 (NS) 0. helping Having and rearing children Close relationships with spouse or significant other Close friends Helping and encouraging others.522 2.87 ±1.23 ±7.27 ±1. volunteering.276 and in Group B the mean value of quality of life is 65.Table 9: Quality Of Life Scale (QOLS) Scores in Groups of Patients of Pulmonary Tuberculosis Mean SD A 3.167 3.80 ±1.57 ±1.43 ±1.60 ±1.033 <.206 3.001 (HS) 0.377 3. improving understanding.573 3. or observing entertainment Participating in active recreation Independence.137 3.17 ±1. Among the 50 Attendants (Control).05 (NS) 0.769 1.404 3.146.146 Variables T P Value Material comforts home.331 2.096 3.50 ±1.05 (NS) .Vol.47 ±1. The difference in Review of Global Medicine and Healthcare Research . Jacob K. 1 (2010) 339 . New Delhi. Golding JM. 77. NEJM 1991.001) and was significant (S) (p<0. 2001. and Waheed Waquas. Review of Global Medicine and Healthcare Research . Pollack MH. Ibanez M.23(2):77-83. Bhasin S. Gould R. Phobia. Josephand A. Annual Report 1993-94.: illness behaviour of tuberculosis patients undergoing DOTS therapy: a case-control study. Burnam MA.23 ± 7. Kradin R. Husain Mohammed O. depression and illness perception in tuberculosis patients in Pakistan. • Pulmonary Tuberculosis with psychiatric morbidity occurred more frequently among current smokers. 2008. Rizvi Nadeem. John K.48. Ind. 4: 4 doi: 10. Bhasin SK. Otto MW.43 ± 13. Aggarwal O. Dearman Sam P. and Dubey KK. Bhatia MS. Chaudhry Imraan B.: psychiatric morbidity. Gen Hosp.171. treatment of patients with advanced human immunodeficiency virus infection. Psychiatric issues in the management of patients with multidrug resistant tuberculosis.. Tub. Guerra D. Castillo H. Wintont et al.05) for Anger/Hostility.K.. Dudley DL..324:289-94. Prevalence of panic in patients referred for pulmonary function testing at a major medical center. 54. Smith Fawzi MC et al. South India.145(8):946-81. Sexuality in chronic respiratory failure: coincidences and divergences between patiants and primary care gives respire Med 2001.P. Schecter GF. Ind. Ind. Wells KB. Sande Ma et al..Vol. J. OCN and Additional were highly significant (HS) (p<0. Ulusahin A.276 ) in patients with psychiatric morbidity as compared to that of other group of their Attendants (65.14:64-77. Maderal MA et al. Vega P. Anxiety. AchaJ.. Govt. Psychiatry 2001.. Am J Psychiatry 1988.95:975-979. Set. • The quality of life was poorer as shown by a lower mean value of quality of life score (52. Goodman PC. Depression. Med. Mittal Atul. Sweetland A.: the relationship between anxiety. 2001. of India. Sabatino SA et al. Worthington J. Small PM. Aguilar JJ. 1 No.R.K. J. and Chadha R. 2000.146) References Aydin IO.S. somatisation and phobia. Clin Pract Epidemol Ment Health. patients perspectives of illness and factors associated with poor medication compliance among the tuberculosis in Vellore. Sitzman J.1186/1745-0179-4-4. Manoharam E. Depression. Am J Psychiatry 1996.the scores of parameters Somatization. Med 1985. Psychiatric aspects of patients with chronic diseases. Psychiatric disorder in a sample of the general population with and without chronic medical conditions.153(1):110-3. • 76% patients met ICD-10 criteria for diagnosis of psychiatric disorders. DGHS. Most common psychiatric disorder in patients with Pulmonary Tuberculosis was depression followed by generalized anxiety disorder.: Psychosocial dysfunction in tuberculosis patients.81. J Tub. anxiety comorbidity and disability in tuberculosis and chronic obstructive pulmonary disease patients: applicability of GHQ-12..48.8(6):74959. Int J Tuberc Lung Dis 2004. Parasomnias.These are left unnoticed as the neurological evaluation. India Email: drshivam_mittal@yahoo. As sleep disturbances in the form of parasomnias and disturbed sleep rhythm affects the general functionality of the person. The study was prospective questionnaire based including medical history. 68% (study group)v/s 31%(control group) complained of daytime sleepiness and 63% (study group) v/s 44% (control group) reported restless sleep two or more times a week. sleep habits and sleep disturbances. Among 40 participants 32 were males. My study is aimed to measure the long term sleep disturbances in adults who had past history of minor head injury. 74% had learning and concentration difficulties. who had any sleep disturbances before the head injury instance were excluded from the study group. Sleep Disturbances. 20 %( study group) v/s none reported sleep enuresis. MHI may have long-term effects generally termed postconcussive syndrome. It is important to study the co relation between minor head injury and the sleep disturbances. Maharashtra State. Maharashtra State. details of the MHI event. in less-frequent cases. including computed tomography (CT) and magnetic resonance imaging (MRI) scans.Study of Sleep disturbances after Minor Head Injury Mittal Shivam Jawaharlal Nehru Medical College Datta Meghe Institute of Medical Sciences University (DMIMSU) Sawangi (M). electroencephalogram (EEG) is normal or reveals minor transient abnormalities [1]. Wardha. India Abstract Head injuries are very common in a country like India. Keywords: Minor Head Injury. Minor head injury (MHI) is characterized as a brain concussion that can cause a transient loss or impairment of consciousness (for less than 30 minutes). 42% of the study group patients experienced fears of going to sleep.com Waghmare Lalit Department of Physiology Datta Meghe Institute of Medical Sciences University (DMIMSU) Sawangi (M). Somnambulism Introduction Head injuries are very common in a country like India. However. In MHI the Glasgow Coma Scale (GCS) score is 13 or higher [1] . 40 people with no history of MHI participated in the study and were considered as control group. 1 (2010) 340 . or. although considered a benign event. Long term effects. 40 patients who had suffered MHI three years before the study were selected as study group and completed the sleep questionnaire. 37% (study group) v/s none (control group) experienced early morning awakenings.Vol. Parasomnia were also relatively common with 42 %( study group) v/s 20% (control group) reporting sleep talking two or more times a week. 42 % (study group) v/s 5 % (control group) complained of bruxism. General functionality. 63% had significant amnesia regarding the MHI event. 1 No. vomiting. may result in posttraumatic stress disorder Review of Global Medicine and Healthcare Research . Those patients who were ever treated or diagnosed with any psychiatry disorder. Wardha. 62% reported fearful awakenings from sleep and 58% experienced frightening dreams two or more times a week. and a short anterograde or retrograde amnesia. and sleep disturbances. Harada et al. Aims and Objectives The purpose of the study is to characterize subjective sleep abnormalities and general functionality of adults who had experienced Minor Head Injury and complained of sleep disorders at the chronic phase after the injury. and an inability to cope with daily life events. a 909 bedded tertiary teaching hospital of Datta Meghe Institute of Medical Sciences University (NAAC Accredited Grade A).5% of 280 children under 15 years of age in the acute phase after MHI.B. 4]. All of the above-mentioned findings refer to the effects of MHI on sleep in the acute phase.H. Few studies have attempted to objectively measure sleep behavior after MHI. Adolescents and young adults who have undergone MHI may suffer from sleep disorders without necessarily having other symptoms of the postconcussive syndrome or PTSD. sleep habits.). memory and concentration impairments. early morning awakenings. nightmares. details of the MHI event. Subjective evaluation of individuals after MHI revealed complaints of difficulties in initiating and maintaining sleep. They also found more spindle activity in stages 2-3 and increased REM density. Approved from the Institutional Ethical Committee of Datta Meghe Institute of Medical Sciences University.V. Thus the purpose of our study was to characterize subjective sleep abnormalities of adults who had experienced MHI and consequently complained of sleep disorders at the chronic phase after the injury. EEG abnormalities included an increase in slow-wave activity (associated with deep sleep) that had resolved during follow-up examinations. mood disorders. Study Protocol The study was prospective a detailed questionnaire. including medical history. 1 No. Criteria D). decreased daytime performance. Postconcussive syndrome includes headaches. 1 (2010) 341 . and a generally decreased sleep quality [3. There is some overlap with symptoms found in the PTSD. which occur in the event [2]. The longterm effects of MHI on sleep have not yet been studied consistently. [6] found a decrease in spindles and K-complexes during NREM sleep and decreased REM activity. Study Group A list was formed of all admissions above 18 years of age who had been admitted to the hospital between the years 2003 and 2005 for Minor Head Injury (ICD-10 code S06. In the acute phase after head injury in children. and sleep disorders [1]. [7] reported EEG changes in 42. which is a mental disorder consisting of flashbacks. anxiety.0) with a GCS of 13 or Review of Global Medicine and Healthcare Research . There is controversy as to whether MHI can cause PTSD because of the loss of consciousness and the posttraumatic amnesia. Method This is a study conducted in Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital (A.(PTSD). Lenard and Pennigstroff [5] found an increase in stage 2 (“light sleep”) and a decrease in stages 3-4 (“deep sleep”) with no consistent changes in percentage of rapid eye movement (REM) sleep. In contrast. Enomoto et al. The syndrome primarily affects adults and includes two types of sleep disturbances as part of the diagnostic criteria (based on the DSM-IV): re-experiencing events (nightmares.Vol.R. Criteria B) and a hyperarousal state (difficulty initiating and maintaining sleep. 53[1. 1 No. Scores ranged from 0 . They were asked to fill the questionnaire which was in their vernacular language . Each interview and questionnaire completion lasted for at least 30 -45 minutes per participant. Out of these. Others. At the end of the interview and examination the questionnaire was checked for completeness and the interviewer thanked the responder. any emotional stress or any other cause of sleep disturbance were excluded from the study. who left the interview and examination halfway for various reasons.0 version. Statistical Analysis The collected data was depicted in tabular form and interpreted statistically and analyzed. 8 females) to questions regarding the postconcussive syndrome 0 15 10 17 19 35 08 09 1 02 10 06 06 04 02 08 2 06 14 02 02 01 02 14 3 09 04 09 01 00 12 04 4 08 02 06 12 00 16 05 Amnesia of events after the head injury Learning and concentration difficulties Fears before the head injury Fears after the head injury Headaches before the head injury Headaches after the head injury Difficulty sleeping away from home Numbers represent the number of patients who answered in each scoring category.68]. contact details of the patients like address and telephone numbers were derived. Software used is SPSS 14. Rapport was developed with the participants. Patients were explained the purpose of the study and were requested to participate.above on admission to the emergency department . and those who had any past medical history of neurological or psychiatric illness.extremely severe. The collected data was statistically analyzed by using the standard tests to ascertain the clinical relevance of the present study. 1 (2010) 342 .none to 4 . Control group The control group for study was composed of 40 sample of the same age group of above 18 as the control subjects. Those who gave their consent were included in the study. 32 males. Review of Global Medicine and Healthcare Research .The data was collected using a structured interview schedule and experienced evaluators.Vol. Then with the help of local social health worker and volunteers the patients were approached. Results Table 1: Frequency of responses of the study group (n = 40. mean age = 25. Table 2: Questionnaire results of our study group (n = 40. 6 females) to questions regarding their sleep habits and Disorders 0 00 24 04 12 12 32 18 38 40 33 29 15 1 03 16 09 16 10 08 14 02 00 07 11 21 2 09 00 16 12 07 00 04 00 00 00 00 04 3 10 00 06 00 07 00 04 00 00 00 00 00 4 18 00 05 00 04 00 00 00 00 00 00 00 Falling asleep within 20 minutes of “lights out” Early awakenings Difficulty awakening in the morning Daytime sleepiness Restless sleep Somnambulism Somniloquence Bruxism Nocturnal enuresis Fear of going to sleep Fearful awakenings from sleep Frightening dreams Review of Global Medicine and Healthcare Research . mean age = 25. 3 = 5 or more times weekly.53[1. 1 = once monthly or less. 2 = two to four times weekly. 1 (2010) 343 . 4 = every night).Vol. 32 males. Table 3: Questionnaire results of our control group (n =40. 1 No. mean age =23.68].31 [1. 34 males.09]. 8 females) to questions regarding their sleep habits and disorders 0 Falling asleep within 20 minutes of “lights out” Early awakenings Difficulty awakening in the morning Daytime sleepiness Restless sleep Somnambulism Somniloquence Bruxism Nocturnal enuresis Fear of going to sleep Fearful awakenings from sleep Frightening dreams 08 17 05 09 06 34 11 23 32 23 15 07 1 07 08 04 04 09 04 12 11 04 06 09 10 2 09 07 09 10 02 00 11 04 04 03 08 15 3 16 04 12 15 09 02 06 02 00 04 08 06 4 00 04 10 02 14 00 00 00 00 04 00 02 Numbers represent the number of adults who answered in each scoring category (0 = never. Sixty-three percent of the subjects complained of significant amnesia regarding the MHI event but fewer complained about retrograde amnesia or amnesia of events after the head injury. By using Mann Whitney U test statistical significant difference is found in both groups (z=4. The cut-off for most results presented in this part of the questionnaire is two.000) 2.46.82±1. and most subjects reported more fears and headaches since the time of MHI. In the question ‘Falling asleep within 20 minutes of light out’. In the question ‘early morning awakenings’. 2 =two to four times weekly. because of the selection criteria. bruxism. Mean Knowledge score for the question “Falling within 20 minutes off” was 1. which are considered relatively rare. except for three questions that represent parasomnia. 3 =5 or more times weekly.p=0. 1 = once monthly or less.17 in study group and 3.Numbers represent the number of adults who answered in each scoring category (0 = never. there was a higher frequency of sleep disturbances reported in the study group than in the control group.Vol. Tables 2 and 3 present the questionnaire results of the study and control groups. 63 % of the study group fall asleep within 20 minutes of lights out. whereas none of the control group had this complaint. 1 (2010) 344 . and nocturnal enuresis the cut-off was one. 1 No. Results ranging from 2-4 were considered moderate to extremely severe and were therefore significant. Review of Global Medicine and Healthcare Research . Finally. Table 1 lists the responses (ranging from 0 = “none” to 4 = “extremely severe”) of our patients to questions related to the post concussive syndrome.07±0. 58% of the subjects complained of a significant difficulty sleeping away from home. In these three questions regarding somnambulism. respectively.99 in control group. 37 % percent of the study group experienced early morning awakenings. 1. 4 =every night). as compared to 94 % of the control group. As expected. Seventy-four percent of the subjects complained of significant learning and concentration difficulties. 36 in study group and 0.057) 4.90.Mean Knowledge score for the question “Early morning awakenings” was 1.45±1.65.49 in control group. In the question ‘Difficulty awakening in morning’.008) 3. 1 No. 68% in study group and 31% in control group complained of daytime sleepiness. . 1 (2010) 345 .Vol. p=0.97±1.p=0. 80 75 70 65 60 Difficulty awakening in morning ( % ) 69 Study group Control  group 79 Mean Knowledge score for the question “Difficulty awakening in morning” was 2.22±1.31 in study group and 1. Review of Global Medicine and Healthcare Research . 79% in study group and 69% in control group had difficulty waking up in the morning.40±0.14 in control group. By using Mann Whitney U test statistical significant difference is found in both groups (z=2. In the question Daytime sleepiness. By using Mann Whitney U test no statistical significant difference is found in both groups (z=1. By using Mann Whitney U test statistical significant difference is found in both groups (z=3. 6. Mean Knowledge score for the question “Restless Sleep” was 2.Vol.51.52±1.p=0.40±1.00±0.78 in control group. 5. 42% in study group and 20% in control group complained of sleep talking.26 in study group and 1.009). 63% in study group and 44% in control group complained of Restless Sleep.000). 1 No. Review of Global Medicine and Healthcare Research . p=0.35 in control group. 1 (2010) 346 . By using Mann Whitney U test statistical significant difference is found in both groups (z=2.53 in study group and 1. In the question ‘Restless Sleep’.70 60 50 40 30 20 10 0 68 31 Study group Control group Daytime Sleepiness ( % ) Mean Knowledge score for the question “Daytime sleepiness” was 1.60. In the question ‘sleep talking’.92±1. In the question ‘bruxism’.Vol.30±1.865).85±0.04in study group and 0.27±0.20±0. 8. By using Mann Whitney U test statistical significant difference is found in both groups (z=2.p=0. Review of Global Medicine and Healthcare Research .97in control group.40 in control group. In the question ‘sleep enuresis’.Mean Knowledge score for the question “sleep talking” was 0.02. By using Mann Whitney U test no statistical significant difference is found in both groups (z=0. 1 No.17.043).71 in study group and 0. 7. Mean Knowledge score for the question “sleep enuresis” was 1. 20% in study group and no one in control group complained of sleep enuresis.p=0. 42 % in study group and 5 % in control group complained of bruxism. 1 (2010) 347 . 1 No. 42% in study group and 17 % in control group complained of fears of going to sleep.00±0.000). Mean Knowledge score for the question “Somnambulism” was 0.64in study group and 0. In the question ‘fears of going to sleep’. Review of Global Medicine and Healthcare Research . 1 (2010) 348 .p=0.22 in control group. 16% in study group and 20% in control group complained of Somnambulism. By using Mann Whitney U test statistical significant difference is found in both groups (z=2.Mean Knowledge score for the question “bruxism” was 0. By using Mann Whitney U test statistical significant difference is found in both groups (z=3.95.05±0.30±0.62±0. 9.p=0. 10.Vol.00in control group.003). In the question Somnambulism.86 in study group and 0.96. 41 in study group and 0. By using Mann Whitney U test statistical significant difference is found in both groups ( z=2. 12.84. 11.38 in control group. Review of Global Medicine and Healthcare Research . Mean Knowledge score for the question “fearful awakenings from sleep” was 1.22±1.p=0.27±0. 1 (2010) 349 .45 in control group.000). By using Mann Whitney U test statistical significant difference is found in both groups ( z=3.17±0.004). In the question ‘frightening dreams’.Mean Knowledge score for the question “fear going to sleep” was 1.00±1.92. 58 % in study group and 10 % in control group complained of frightening dreams. 62% in study group and 27 % in control group complained of fearful awakenings from sleep. 1 No. In the question ‘fearful awakenings from sleep’.Vol.16in study group and 0.p=0. some of our patients complained of serious difficulties in functioning because of increased daytime somnolence that prevented them from going to school and led to learning and concentration difficulties.27 0. CT scan. health professionals view MHI as transient minor injury that does not cause any permanent damage. EEG.65 0.27 0. patients complained of significant sleep disturbances. Summary of Mean Knowledge score: 6 Mean knowledge score and SD 3.85 0.97 1.45 1. Presently. fears.Vol.3 0. or MRI is usually normal.56.4 1. Whatever the etiology might be. 1 (2010) 350 0.82 2. and patients are commonly discharged from the emergency department with no more than one additional follow-up appointment.2 0.22 1 1.62±0.22 1.62 0.52 4 3 2 2.65±1. By using Mann Whitney U test statistical significant difference is found in both groups ( z=4.p=0. Even so.09 in study group and 0.4 0.17 . 1 No.Mean Knowledge score for the question “frightening dreams’” was 1. most of our patients manage to function quite normally in everyday life. and headaches.000).3 1 0 Q1 0.49 in control group.92 1.62 1 1. Despite their sleep complaints and their disrupted sleep.07 5 1.05 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 0 Q10 Q11 Q12 Question No Study Group Control Group Discussion This study demonstrates that 3 years after a MHI without any important known clinical consequence. Some of the patients had even sought medical care. it is important to recognize that although MHI appears to be a “benign” event with no long-term Review of Global Medicine and Healthcare Research . 31:260-4. Review of Global Medicine and Healthcare Research . [7] Enomoto T. Nose T. Philadelphia: W. Clinical neurology for psychiatrists. 1995:545-8. [3] Parsons LC. Tsukada K. Confounding bias due to other confounding factors causing sleep disturbances. Kumamoto Med J 1976.84:595-9. In: Kaufman DM. 4th ed. [5] Lenard HG. Artiola L. underlying them is a substantial disorder that might influence daily functioning and thus should be addressed and treated properly. Head trauma. should be taken in time to prevent sleep disorder-induced behavioral impairment that may result in learning disabilities and impaired physical and emotional development.Vol. Childs Nerv Syst 1986. Nursing Res 1981. ed. [4] Perlis ML. Alterations in the sleep patterns of infants and young children following acute head injuries. Acta Pediat Scand 1970.29:110-27. Percept Mot Skills 1997. [2] McMillan TM. Saunders Company. 1 No. Recall bias as study based on subjective basis. Curr Opin Neurol 1997. [6] Harada M. Nakamura K. Response rate less (40 cases out of 64 cases) as lack of contact details / mobilisation. 2. Management steps. Sleep-awake patterns following cerebral concussion.2:72-9.effects. Minor head injury.59:565-71. Ono Y. 1 (2010) 351 . Giles DE. Even if the subjective complaints are more impressive than the objective findings. Maki Y. Ver Beek D. Hattori E. Kabashima K. morbidity after MHI can have a serious impact. Pennigstroff H. 3. Minani R. References [1] Kaufman DM. Electroencephalography in minor head injury in children. Sleep complaints in chronic postconcussion syndrome.B. Sleep in brain damaged patients: An all-night study of 105 cases. including psychotherapy. Study Limitations 1.10: 479-83. 38 seropositives heard of Hepatitis B of which 9(16. Andhra Medical College. Socio demographic profile of seropositive blood donors gives epidemiological determinants of susceptibly and risk factor estimation gives dynamics of disease transmission.086 and replacement 9.4. Through simple random sampling 55 Hepatitis B positive blood donors were interviewed for socio demographic characteristics. India Email: findsandeep.24%. which is in Review of Global Medicine and Healthcare Research .74%) replacement donors] tested positive for Hepatitis B and 58 (0. Devi Madhavi Dept. Serological data of blood donors between January 2009 and June 2009. with 30. Seroprevalence of Hepatitis C is 0.2%) belong to low income group. all are literate. Andhra Medical College. Discussion: Seroprevalence of Hepatitis B is 2. Results: Of the 23.Prevalence is more among replacement than voluntary donors. which is in the range of published prevalence data of 1 -13% but less than published average prevalence of 4.a medical hub situated in north coastal Andhra Pradesh( India) catering to people of surrounding three districts with a total population of about 8 million. more in rural than urban donors.5%) naming 4 routes of transmission.591) 502(2. 13(23. 6(10.8% had a family member at home with jaundice. 25(45. 3(5. 10(18. obtained from five blood banks in Visakhapatnam . Evaluating knowledge of Hepatitis B helps streamlining educational methods.Vol.1%) seropositives heard of complications of Hepatitis B.6%) had previous surgeries and 12(21. risk factors and knowledge of Hepatitis B after informed consent.9% from urban and 69.70%) voluntary and 263(2. Visakhapatnam. Aims and Objectives: To determine the prevalence of serological markers of Hepatitis B and Hepatitis C virus among blood donors using Blood bank records.Seroprevalence of Hepatitis B and C among Blood Donors and a Profile of Hepatitis B Seropositive Blood Donors Venkata Sandeep A.4%) know it to be infectious with 3(5. 21. Methodology and Materials: This is a descriptive type of study.3%) are aware of the existence of vaccine for Hepatitis B but only 7(12. serological surveys of blood donors helps in estimating the prevalence of HBV infection among adults in general population.7% in India. 5(9.8%) had a relative at residence with jaundice in the past.12%.1% from rural areas.17%) voluntary and 34(0. Majority of the donors have inadequate knowledge of Hepatitis B disease and vaccination.4%) had previous blood transfusions. 8th semester.of Community Medicine.1% are from rural background with poor sterilisation techniques. risk factors and knowledge of disease and vaccination among Hepatitis B positive blood donors in Visakhapatnam using interviews. MBBS. Screening for HBsAg and Anti HCV anti-bodies was done using enzyme immunoassays (ELISA) and rapid ELISA techniques.677 blood donors (voluntary 14.12%) donors [239(1. Visakhapatnam.7%) took vaccine.9%) seropositives gave history of multiple sexual partners. India Abstract Background: Hepatitis B and C are global health problems. Mean age of Hepatitis B seropositives was 27.35%) replacement donors] tested positive for Hepatitis C.5%) are dependant financially. 23. 26(47.6% seropositives had history of surgeries and 69. 1 No. 1 (2010) 352 .com B.24%) donors [24(0. To know the socio-demographic profile.amc@gmail. C. complications of Hepatitis B and availability of vaccination especially to high risk individuals. Profile Introduction Hepatitis is a term meaning the inflammation of Liver and can be caused by a variety of viruses such as Hepatitis A.68 % of Cirrhosis and 80% of Hepatocellular carcinoma in India is due to Hepatitis B infection5. E and G. placing India in a meso-endemic area(≥2-7%)3. Hepatitis B and C.6. Hepatitis B and Hepatitis C have similar risk factors. Limitations: Recall bias during interviews. Various studies conducted in India show the Hepatitis B surface antigen (HBsAg) carrier rate to range between 1% and 13%.8 About 50% of the cases are asymptomatic and rate of chronification is 75-85%9.accordance with published data of transmission routes as unsterilized needles and horizontal transmission in childhood. Conducting longitudinal studies in general population is demanding and estimating the prevalence of Hepatitis B serological markers in unpaid blood donors offer the most useful means of estimating the prevalence of HBV infection among adults in the general population10. about 2 billion people having serological evidence of infection with Hepatitis B virus (HBV). Evaluating knowledge of Hepatitis B helps streamlining educational methods. Review of Global Medicine and Healthcare Research . i. 1 (2010) 353 . Estimation of Seroprevalence of viral Hepatitis and profile of Hepatitis B positive individuals helps in estimating the burden of disease in society and provides an insight into epidemiological determinants of disease transmission.e. about a million of whom die each year from chronic liver disease1.7 Hepatitis C is caused by Hepatitis C Virus (HCV) and has a prevalence of 3% of world population. Conclusion: The findings suggest prevalence of viral hepatitis among blood donors and risk of susceptibility among recipients. High prevalence in rural areas and poor knowledge of Hepatitis B highlights the need for educating masses of the routes of transmission. 1 No. Risk of chronic hepatitis B after an exposure varies between 90% and 10 % for different age groups4. There is also a need for intimating blood donors if tested positive and proper counselling is required.7%. Vaccination against Hepatitis B is available since 1982 and Chronic Hepatitis B can be managed by giving Interferon alfa 2b or nucleoside and nucleotide analogues like Lamivudine. transmission routes and complications.Vol. hence a need for improving sensitivity of screening techniques. 15-25% of Chronically affected individuals will die due to Hepatitis B disease. Adefovir dipivoxil and Entecavir. Hepatitis B infection is a challenging global health problem with approximately 30% of the world’s population. It is estimated that 400 million of them have chronic HBV infection. Keywords: Prevalence. Materials & Methods Study Type This is a blood bank based descriptive study conducted between 1-1-2009 and 30-6-2009. D. with a national average of 4. No vaccine is available and drug therapies include Interferon alfa 2b and Ribavarin7.2. Blood Donors. Socio demographic profile of seropositive blood donors gives epidemiological determinants of susceptibly and risk factor estimation gives dynamics of disease transmission. B. Raja Blood bank 4-Red Cross Society Blood bank 5-Rotary Blood bank Visakhapatnam is a medical hub situated in north coastal Andhra Pradesh catering to people of surrounding three districts with a total population of about 8 million as a tertiary health care centre. Review of Global Medicine and Healthcare Research . King George Hospital 2-Blood bank.677 blood donors.502(2. All blood donors who were HBsAg positive when tested by ELISA using HBsAg ELISA kit (either second generation or third generation kits) and repeated with Rapid ELISA test were considered as Hepatitis B seropositive individuals. 58 (0. Victoria Government Hospital 3-A. follow up etc.74%) were replacement donors.17%) were voluntary donors and 34(0. 1 No.70%) were voluntary donors and 263(2. privacy and confidentiality was maintained. Stage 1 Preliminary data was collected from the Blood Banks regarding the total number of blood donors with details on voluntary and replacement type of donors. At all stages of study. immunisation history.12%) donors tested positive for hepatitis B of which 239(1.Vol. awareness was created to all blood donors attending blood banks and blood donation camps in Visakhapatnam.General Methods During the study period. Data was analysed using Excel sheet and results are presented in proportions. Stage 2 Through simple random sampling 60 Hepatitis B positive individuals were summoned to Blood Banks to explain their seropositive status and 55 of them volunteered to participate in the study.S. Hepatitis B and Hepatitis C test status of blood donors was obtained from blood bank records. Those blood donors who were Anti HCV anti-bodies positive when tested by ELISA (either second generation or third generation kits) were considered as Hepatitis C seropositive individuals. methods of prevention.086 were voluntary donors and 9. After establishment of rapport with the individual. they were interviewed and a pre tested questionnaire was employed to collect information on socio demographic characteristics. 14. Results Of a total of 23. complications. 1 (2010) 354 . also repeated with Rapid ELISA test. about Hepatitis B and Hepatitis C and the importance of Hepatitis B vaccination using posters at blood banks and lectures at blood donation camps by 1-Blood bank. knowledge of Hepatitis B prior to awareness program etc.35%) were replacement donors. male and female among them. Following the interview the subject was referred to our Institute’s Gastroenterology Department for further evaluation.591 were replacement donors. Informed consent was obtained and a total of around 15 minutes was spent on each individual educating various aspects of Hepatitis B such as modes of spread.24%) donors tested positive for Hepatitis C of which 24(0. exposure to known and potential risk factors. 000 to 10.1%)of them from urban areas and 17 (30. 1 (2010) 355 . 10(18. 1 No.18% EDUCATION FAMILY INCOME UPTO HIGH SCHOOL GRADUATE POST GRADUATE <5.17% Replacement Donors Number 263 34 Prevalence 2.82% 20 18 16 14 12 10 8 6 4 2 0 AGE 11  AGE 21  AGE 31  AGE 41  AGE 51  TO 20 TO 30 TO 40 TO 50 TO 60 AGE GROUPS (YEARS) NUMBER SEROPOSITIVE URBAN A RURAL A Figure 1: Age and Place Distribution of Interviewed Donors Review of Global Medicine and Healthcare Research .000 RUPEES/MONTH 22 23 40% 41.9%) from rural areas.70% 0.000 RUPEES/MONTH 5.74% 0.35% Total Donors Number 502 58 Prevalence 2.000 RUPEES/MONTH >10.12% 0.64% 56.38 (69.Table1: Prevalence of Hepatitis B and Hepatitis C among Voluntary and Replacement donors Voluntary Donors Number HEPATITIS B SEROPOSITIVE HEPATITIS C SEROPOSITIVE 239 24 Prevalence 1. Table 2 : Education and Income of Interviewed donors NUMBER 13 31 11 10 PERCENTAGE 23.4 years (range 18-56 years) with majority.Vol.36% 20% 18.24% Fifty five(55) Hepatitis B seropositive males were interviewed and their mean age was 27. All the subjects were literate and 25(45.5%) were financially dependent on their families.2%) subjects belonged to low income group. 73%) of the interviewed subjects gave prior history of immunisation for Hepatitis B of whom 3(42.72%) 19 (39. Seven (12.23%) of them donated blood previously. VACCIANTED ‐7 (12.45%) of the interviewed subjects had a prior knowledge of their infectious status by a previous screening test but were not advised to discontinue blood donation while 52(94.55%) of them could give at least one route of transmission.45%) of them had previous blood transfusions.1%) were aware of existence of Hepatitis B disease. 48(87.9%) of the subjects were not aware of any consequence of Hepatitis B infection while 26(47.27%) were not previously immunised for Hepatitis B and 29(60.45%) of the subjects knew Hepatitis B was infectious and 8 (14.82%) of them had an acquaintance at residence with jaundice. 18(32.9%) of them never heard of Hepatitis B while 38(69.Three (5.73%) of them gave history of surgeries for various conditions.Vol. On interviewing for potential risk factors and prior exposure risks. 6 (10. it was seen that 17(30.55%) were never knew of their Hepatitis B status though 23(44. On assessment of their knowledge of Hepatitis B prior to awareness program.4%) REASON FOR NOT VACCINATING-NOT AWARE OF THE VACCINE NO Figure 2: Immunization status against Hepatitis B Review of Global Medicine and Healthcare Research . 50(90. Only 9(16.27%) of the subjects were aware of the availability of effective vaccination against Hepatitis B. 6(10.58%) of them considered the vaccine unnecessary for them. 1 No. 1 (2010) 356 . 3(5.85%) were incompletely immunised.42%) of them gave the main reason as being unaware of the vaccine while 19(39.9%) of them donated blood more than five times previously.6%) REASON FOR NOT VACCINATING-NOT FELT NECESSARY TA NOT  29 (60.9%) gave history sexual exposure with multiple partners and 12(21. 9% 16.4% 83.8% 9.4%) PREVIOUSLY UN KNOWN 52 (94.6%) Figure 3: Knowledge of Hepatitis B status prior to Blood donation Table 3: Knowledge of Hepatitis B of Interviewed Donors NUMBER PERCENTAGE a)Heard about Hepatitis B disease YES NO b)Knows Hepatitis B to be infectious YES NO c)Routes of transmission at least 4 routes at least 3 routes at least 2 routes at least 1 route d)Heard of complications of Hepatitis B YES NO e)Aware of vaccination for Hepatitis B YES NO 38 17 9 46 3 2 2 1 5 50 26 29 69.PREVIOUSLY KNOWN 3 (5. 1 (2010) 357 .5% 3.9% 47.1% 90.Vol.1% 30.6% 5. 1 No.6% 1.6% 3.3% 52.7% Review of Global Medicine and Healthcare Research . This study also shows that Seroprevalence of Hepatitis B was more among replacement blood donors at 2.12% is close to 2.82-0.86% among the tribes of Kolli Hill in Tamilnadu to 65. it is as low as 0.38% 8-10% 5% 12% 1-3% India China Pakistan Nepal Egypt Saudi Arabia Turkey Myanmar Indonesia Korea Japan Review of Global Medicine and Healthcare Research .17%.3% 2.9% 5. The Seroprevalence of Hepatitis C among blood donors was 0.9% 32.7% 10. there is variation in different communities seen as ranging from 1.24% and it was more among replacement blood donors at 0.74% compared to voluntary blood donors at 1.97% in Chandigarh6 and 5.5% in Chennai6.12% which is in the range of published general population prevalence data of 1 -13% but less than published average prevalence of 4.2-2.60% among the Jarawas in Andamans12. Table 5: Hepatitis B Seroprevalence among Blood donors of various countries13.70%.8%11 and this study’s Seroprevalence of 2.Vol.2% 0.Prevalence of Hepatitis B in India varies from place to place due to various factors. 1 (2010) 358 .35% compared to voluntary donors at 0.5% 1.92% 4. Studies conducted on blood donors in India gave a Seroprevalence of Hepatitis B in the range of 1.14 Country Hepatitis B Prevalence Among Blood Donors 4.4% 10. 1 No.7% Discussion This study gives the Seroprevalence of Hepatitis B among blood donors as 2.Table 4: Risk Factors among Hepatitis B Positive Blood Donors Risk Factor Number Percentage -Multiple sexual partners -History of Blood transfusion -More than 5 previous Blood donations -History of Surgery/ies 6 3 6 18 10.3% 1.7%3 in India.11% by Mohite et al (1998) and 3% by Kothari et al (2002). and persons with multiple sex partners4.9%20 8. The vaccination coverage even among Indian children is low at around 35% in urban areas. Major routes of transmission are from mother to child (perinatal). The majority 50(90. family members of Hepatitis B individuals.55%) of the counselled subjects could give at least one route of transmission. 46(83.8%11 2. 5. by 29(60.6%21.7% in rural areas25 though Hepatitis B vaccine is included in the immunisation program. 18(32. 1 No. The main reason given for not being vaccinated. This is due to inconsistent intimation and counselling protocol in our over burdened and under manpowered blood banks.42%) of them was being unaware of the vaccine while 19(39.3-24%19 9. As was seen in this study. Three (5.8-13.33%11 1.6% in urban slums and 2. The remaining 52 subjects never knew of their Hepatitis B positive status though 23(44.45%) of the subjects had prior knowledge of their infective status by previous screening procedures but were unaware of the routes of transmission. 1 (2010) 359 .0001 ml of infected blood capable of transmitting infection and virus can stay active on environmental surfaces for up to 7 days.6%18 8. 48(87.2-2.5-3%15 3.9%) of them never heard of Hepatitis B. clients and staff of institutions for the developmentally disabled. Vaccination though not recommended for all general population. men who have sex with men. They were never counselled or advised for referral. Vaccination coverage among the subjects was also low with only 7(12.73%) of subjects gave history of minor or major interventional surgeries and in India indiscriminate use of interventional procedures and inadequate sterilisation is considered a major mode of transmission.73%) of the interviewed subjects giving a prior history of immunisation for Hepatitis B and 3(42.000 people die each year due to consequences of Hepatitis B infection24.1%) of them being aware of existence of Hepatitis B disease while the rest 17(30. This may be due to nonexistent health education on Hepatitis B compared to HIV in India. contact with an infected person (horizontal).85%) of them did not complete the prescribed doses in schedule.Vol. patients requiring recurrent blood transfusion or haemo dialysis.52%17 23.Table 6: Hepatitis B among various population groups in INDIA Group Blood Donors Pregnant Women Doctors Nurses Eye Donors I V Drug Users Csw Hiv Co Infection Std Clinics Urban Slum Seroprevalence 1.9%) were not aware of any consequence of Hepatitis B infection.23%) of them donated blood previously and was screened for Hepatitis B. Hepatitis B is 100 times more infectious than HIV with 0.27%) of the counselled subjects were not previously immunised for Hepatitis B though many of them were in high risk category. injecting drug users. sexual contact and exposure to infected blood and body fluids2.64%) did not know Hepatitis B was infectious or that it can spread from person to person and only 8 (14. by simple random sampling were males and mostly from urban and semi urban areas.58%) of them considered the vaccine unnecessary for them. Review of Global Medicine and Healthcare Research .3%23 All the 55 Hepatitis B seropositive subjects picked up for interviewing. All the subjects were literate and were from different income groups.22 10. The knowledge of the interviewed sample subjects about Hepatitis B was very poor with only 38(69. though India harbours 30 million carriers and around 100. it is recommended for infants and high risk category such as health care workers.41%16 3. Vol. in addition to routine infant vaccination.73%) of the subjects gave history of jaundice in themselves which is lower than 30-50% expected jaundice rates in infected individuls1. Hepatitis B immunisation can be recommended to mothers at child birth giving first dose immediately after delivery and second. third doses coinciding with child’s first and second immunisation doses as is being suggested in Saudi Arabia26. pregnant women. may be desirable like age-specific cohorts and persons with risk factors for acquiring HBV infection. pp-967-975. injection drug users. most of the infections in India are horizontally acquired in childhood from close contacts2. Conclusion The epidemiology and risk factors of viral hepatitis from a population base should aid in prioritising preventive measures by identifying the at-risk populations. Md. also a proper protocol and machinery for intimating seropositive donors must be introduced. This will allow for the most appropriate use of available resources. Ray Kim. 12(21.9%) of subjects donated blood more than five times previously though professional blood donation is banned in India. Md.45%) of the subjects gave history of previous blood transfusions though individuals with history of transfusions are not routinely accepted for blood donation. hence voluntary blood donation must be encouraged. Mayo Clinic Proc. Natural History of Hepatitis B Virus Infection: An Update for Clinicians. family members of positive individuals. This will eliminate seropositive individuals from blood donation pool. 1 No. most of them were from low socio economic group.. Counselling procedure for seropositives should be improved with properly trained counsellors as is being done in Voluntary Counselling and Testing Centres in India. New technology for screening procedures should be introduced such as third generation ELISA and cassette testing. The routine vaccination of infants rapidly reduces the transmission of HBV but in countries like India substantial disease burden from chronic infections acquired by older children. the appropriate precautions can be implemented to decrease the prevalence of this infection. Six (10.82%) of them had an acquaintance at residence with history of jaundice or succumbed due to an unknown condition associated with jaundice and as was mentioned. homosexual men. improved screening protocol and technology will help in quickening the process. References 1. Public awareness programs and legislations reduced incidence in USA by 89% in a decade24.4% to 0. Pentavalent vaccine recently introduced in India is a welcoming step. adolescents and adults is considerably large hence. thereby increasing illegal professional donors. 7(12. Accordingly. Effective child immunisation program will reduce burden of infection in country but sterile injection practice. China reduced incidence among young children from 9. Review of Global Medicine and Healthcare Research . Surakit Pungpapong. And John J. 1 (2010) 360 . Poterucha. to reduce window period and improve sensitivity thereby making blood safer.9%) of the subjects gave history of sexual exposure with multiple partners which is common mode for adult acquired infection especially in meso endemic and low endemic areas2.9% within 4 years27. education. awareness. dialysis patients. vaccinating infants alone may not substantially lower the incidence of the disease for decades. and catch-up strategies targeted on these older age groups. 6(10. Md (2007). W.3(5.5. 82(8). HIV positive individuals. There is a gross deficit of blood at blood banks in India with only 50% being currently met. Screening should be made compulsory in hyper endemic areas. Lok And Brian J. 24. et al(1995). Lindan CP.31. pp-93-96.Vol.2. Indian J Med Sci. Seroprevalence of Human Immunodeficiency Virus. Indian Journal of Medical Microbiology. Rakesh Aggarwal. 2008. Malathi Sathiyasekaran. Desai S. Mcmahon (2001). Indian Journal of Gastroenterology. R Pushpalatha. 25(2). 9. HCV and HIV among Blood donors in Izmir. S R Naik. Hepatitis B Annual 2004. 4. 22.Hepatitis B. R L Singh. 18. Seroprevalence of Hepatitis B. 6. pp-S21-30. Chronic Hepatitis B. 12. AIDS. I D Gust (1996).K.52. Bhave G. Indian J Ophthalmol . Mohite JB. The Prevalence of HBV. Epidemiology Of Hepatitis B Virus infection In India. 17. 24(2). 53. V. 9. Prevalence of Hepatitis B surface antigen among health care workers. CDC MMWR. 14. S Margarita (2004).Asok Kumar et al (2000). Epidemiology of hepatitis B virus infection in India. 38. 19. 1 (2010) 361 . pp-61-62. India. and condom use among sex workers in Bombay. K. Hajib N Madhavan. WHO. R Tiwari.Hepatitis B Virus Infection In Children In India. Hepatitis B Virus and Hepatitis C Virus among Eye Donors. pp-434-8. I Afsar. Epidemiology of hepatitis B infection in the Western Pacific and South East Asia. pp-S56-S59. pp-132-137. 7. pp-288-289. pp-269-270. Gut. 8. Harjeet Singh. Hudes ES. 1998. S. A G Sener. Wagle U. Abhijit Chowdhury (2004). Turkey. Indian J of Community Medicine. 13. Anna S. 10. Prevalence of HBsAg positivity in staff and patients at MGM medical college and hospital. sexually transmitted diseases. Tripathi SP. Indian J of Microbiology. Gut. WHO/CDS/CSR/LYO/2002. PDevi (2006). Harrisons Principles of Internal Medicine. 38.2. Frequency of infection by Hepatitis B virus and its surface mutants in a northern Indian population. 5. pp-151-152. hepatitis B vaccine into childhood immunization services (2001) 11. Introduction of WHO/V&B/01. Hepatology. 3. Sankaranarayanan (2003). B N Tandon. 1 No. 15. Mumbai. S P Zodpey (2005). S G Yurtsever ( 2008). 26(3). pp-S18-S23. M V Murhekar. B Mahalakshmi. pp-72-91. 17th edition. Hepatitis B Annual 2003. Indian Society of Gastroenterology. Mc Graw Hill. Sita Naik (2003). pp-12251241.AAggarwal. F. 16. S K Acharya and A Tandon (1996). WHO Hepatitis C Factsheet No-164. S Gungor. pp-17-24. Urhekar AD (1999). 34(6). Impact of an intervention on HIV. Review of Global Medicine and Healthcare Research . Hepatitis B virus infection among Indian tribes: need for vaccination program. Hepatitis C and Human Immunodeficiency Viruses Amongst Drug Users in Amritsar. Nigam. pp-01-03. Indian Journal of Medical Sciences. Prevalence of Reproductive Morbidity amongst Males in an Urban Slum of North India. 1 (2010) 362 . Abolfotouh1. Chopra A. Gut. MM Singh. 52(1).20. Hepatitis B Vaccine coverage among children (2000). 38. S Garg. (2009). Shrivastava (2005). Table I. Indian J Dermatol Venereol Leprol. HIV and HbsAg Seroprevalence in commercial sex workers in Raipur (Chhattisgarh) area. 22. (1996). Mostafa A. (2007). pp-17-19. 21. VK Gupta. 23. Mohammed A. 54(8). Vikas Verma. pp-89-90. Hepatitis B Annual 2009. Manisha Jain. (2009). 71(1). Mazen S. Indian J Dermatol Venereol Leprol. 27. 62. Shivaram Prasad Singh. pp-S39-S42. Importance of perinatal versus horizontal transmission of hepatitis B virus infection in China.Vol. pp-70-72. (2008). 32(1). Hepatitis B Eradication Day: It’s Never Too Late. R Malhotra. Alrowaily. pp-11-13. pp-52-53. P. B Mishra. Ferwanah. G B Yao. Seroprevalence of hepatitis viruses in patients infected with the human immunodeficiency virus. HBsAg and sexually transmitted diseases. Preena Bhalla. 1 No. K. Chopra BK. The Saudi Journal of Gastroenterology. Puri KR (1996). 25. K. Y Uppal. Anita Chakravarti. S. 26. 14(2). Review of Global Medicine and Healthcare Research . 24. Indian Journal of Community Medicine. Indian Journal Of Pathology And Microbiology. It also serves to re-affirm the practise of managing the teenage and young adult cancers at multidisciplinary specialist centres to achieve better outcomes. Yet. We present a case of a patient originally diagnosed with Ewing’s Sarcoma at the age of 19 and who was treated successfully.com Nitesh Rohatgi St James's Hospital Leeds. 1 No. but has since had two late recurrences of his disease at 10 and 15 years from diagnosis.com Introduction Ewing's sarcoma is a malignancy of the bones mainly affecting young adults. The histology from this biopsy initially suggested Malignant Haemangiopericytoma but a second opinion advised that a differential of Ewing's Sarcoma family of tumours should be considered. a chest X-Ray at routine follow up revealed a lung mass. with the majority of these cases occurring in the first two years2. During the biopsy he began to haemorrhage and required 35 units of blood before being transferred to a specialist orthopaedic centre for a de-bulking operation. Studies have found that it has the highest survival at 20 years of all the paediatric cancers1. Following the operation he had multi-agent chemotherapy followed by radiotherapy which he tolerated well and had a good response to the treatment. there are case reports of patients who have had late recurrences up to 19 years after the first diagnosis3. and the difficulties in decision-making on the aggressiveness of treatment in a metastatic setting.Vol. Over the coming years our patient continued to do well and was considered effectively cured at five years. Case report This previously fit 19 year old male presented with persistent right hip and leg pain which defied diagnosis for 6 months. surgery and radiotherapy. with a peak incidence in the second decade of life. Yet this case emphasises the lack of data on late recurrence of rare cancers. Recurrence is rare but has a worse prognosis. It has a good prognosis for localized disease when treated aggressively with combination chemotherapy. We present this case to highlight an unusual pattern of recurrence of a rare cancer (Ewing’s sarcoma).Very late recurrence of Ewing's Sarcoma – a worthy challenge Patrick Hamilton Department of Oncology St James's Hospital Leeds. UK Email: paddyhamilton@gmail. 1 (2010) 363 . This Review of Global Medicine and Healthcare Research . A mass was eventually demonstrated in connection with the right iliac bone for which he underwent a biopsy. with long intervals between recurrences. The excellent response to treatment adds a further uniqueness to the case. UK Email: niteshrohatgi@yahoo. 10 years after treatment though. his family and medical staff to continue with the aggressive treatment according to the Euro-Ewing’s 99 protocol. bone and bone marrow.4. is an even rarer phenomenon but not unknown. It is a rare condition affecting approximately 30 patients per year in the UK5.6. pelvis and ribs. 1 (2010) 364 .4. Doxorubicin and Etoposide (VIDE). 1 No. In spite of poor prognosis related to the recurrence and the presentation of his disease. Ifosphamide. For five more years. as in our case. The treatment our patient is undergoing is now causing serious and frequent life threatening neutropenic sepsis.was resected. neuroepithelioma. Review of Global Medicine and Healthcare Research . and hence he continues with a very small potential for cure. The majority of these occur in the first two years although can occur late. Further investigation revealed a mediastinal mass surrounding the pericardium and a recurrence of the effusion. However.2%2. The majority of cases present with localised disease mainly affecting the long bones. the histology of which was compared to the original biopsy and found to be identical. he responded well to the treatment with the mediastinal mass shrinking and pericardial effusion not returning. non-curatively. Recurrence of Ewing's sarcoma is rare but unfortunately does occur. the five year survival for patients with localised disease is approaching 70-75%. A fifth of patients will present with metastases. it was decided after discussion between the patient. The prognosis for patients with a recurrence of Ewing's sarcoma is greatly reduced with a five year survival of only 15. his chemotherapy was combined with Dexrazoxane to protect the heart. despite the addition of GCSF. with a markedly reduced survival rate compared to localised disease3.8% at 5 years. with an overall survival of only 13. This was due to a complicated rectal abscess which required consideration for a colostomy. A pericardial window was performed and histology from the operation showed this was a recurrence of the Ewing's sarcoma. In fact. it can be considered a curable cancer and for this reason it is treated aggressively. He had a resection with no lymph node involvement and post-operative chemotherapy was offered but this was refused by the patient. Treatment of Ewing's sarcoma is dependant on whether the disease is localised or metastatic. Further relapse. One study suggests that the prognosis is further reduced for a second relapse. but in all likelihood. His echocardiogram did not show any acute cardiac toxicity from chemotherapy. our patient again continued to lead a full life until he started to develop worsening breathlessness. his treatment was complicated by recurrent episodes of severe neutropenic sepsis. The current protocol in use is the Euro-Ewing's 99 which involves a multi-agent chemotherapy regime consisting of VIDE which can be combined with surgery and/or radiotherapy. It is histologically similar to the peripheral primitive neuroectodermal tumour. He was found to have a large pericardial effusion from which 2 litres of blood stained fluid was removed. at times requiring ICU admission.Vol. Having received the maximum cumulative dose of Anthracyclines at initial diagnosis. with metastatic disease only 20-25%3. Even with the severe complications our patient suffered. These tumours are collectively known as the Ewing's sarcoma family of tumours4. Discussion Ewing's Sarcoma is a tumour of the bones that was first described by James Ewing in 1921. Yet we do not have robust evidence in favour of stopping this aggressive treatment. He received 6 cycles of combination chemotherapy with Vincristine. with a better prognosis for those patients whose first relapse was later than 2 years post initial treatment7. the main sites being the lungs. Even with this poor prognosis in recurrence of disease and with second relapse. atypical Ewing's sarcoma and Askin tumor. Ann R Coll Surg Engl.Vol. 1654-1659.medscape.htm 6 M Scurr. A Longhi. Our case serves to further highlight the need for long term. I Judson. 1709-20. S Hammond et Late recurrence in pediatric cancer: a report from the Childhood Cancer Survivor Study. 4 5 http://emedicine. 2003 vol. W Leisenring. The complexity of management involved with late recurrence raises the question of whether these patients should only be managed in specialist centres to improve outcomes and again this is an area that needs further research. 2006 pp. 11 (1) pp. AM Cassoni. M De Paolis. even life long follow up for patients with Ewing's sarcoma. 65-72. LA David. 2006 vol. 101 (24) pp. The Oncologist. Very late local recurrence of Ewing's sarcoma – can you ever say 'cured'? A report of two cases and literature review. Review of Global Medicine and Healthcare Research . 2006 vol. al. Therapy and survival after recurrence of Ewing’s tumors: the Rizzoli experience in 195 patients treated with adjuvant and neoadjuvant chemotherapy from 1979 to 1997. LR Meacham. 1 No. 3 SA Hanna.co. References 1 K Wasilewski-Masker. TWR Briggs. AJ Tindall. these late recurrences have been diagnosed when the patient has been considered effectively cured3. S Ferrari. 14 pp.com/article/990378-overview http://www. Y Yasui. Improving Outcomes After Relapse in Ewing's Sarcoma: Analysis of 114 Patients From a Single Institution. 12-15. Sarcoma. 90 (7) pp. D Driver. 2009 vol. PD Gikas. 1 (2010) 365 .patient. SR Cannon. MP Michelagnoli. Annals of Oncology. D Donati. 2008 vol. C Forni et al. JS Whelan. How to Treat the Ewing's Family of Sarcomas in Adult Patients. Cancer Inst.In previous case reports and with our patient. Q Liu. 7 G Bacci. AM Kilby. J Natl 2 AM McTiernan. This case illustrates the lack of data available and therefore reaffirms our belief in the continued treatment in the hope that he responds favourably as he has in the past. 1-9.uk/doctor/Ewing's-Sarcoma. Anti-tuberculous chemotherapy Introduction Although there has been a significant decline in tuberculosis caused by Mycobacterium tuberculosis in wealthy industrialized countries over the past 100 years.1 Extra pulmonary tuberculosis occurs in 20% of patients with pulmonary tuberculosis.Tuberculous Pericarditis – A Case Report and Review of Literature Vishnu Prasad Shenoy Department of Microbiology. Culture. Kasturba Medical College Manipal University. India Abstract Tuberculous pericarditis is a rare. Pericarditis. Department of Cardiology. but life threatening form of extra-pulmonary tuberculosis and accounts for approximately 4% of acute pericarditis and 7% of cardiac tamponade cases. Manipal. The patient responded well to pericardiocentesis and subsequent anti-tuberculous chemotherapy. Acid fast bacilli.Vol. the estimated number of new cases worldwide has increased steadily mainly in the developing world. India Indira Bairy Department of Microbiology. 1 No. Kasturba Medical College Manipal University. Kasturba Medical College Manipal University.com Shashidhar Vishwanath Department of Microbiology. Manipal. Tuberculous pericarditis caused by Mycobacterium tuberculosis accounts for about 1% of all autopsied cases of tuberculosis and 1-2% instances of pulmonary tuberculosis. India Email: vishnuprad. Mortality due to tuberculous pericarditis can reach up to 40%.2 Rapid and accurate diagnosis which is often difficult is essential for effective treatment which prove to be life saving3. Manipal.shenoy@rediffmail. Review of Global Medicine and Healthcare Research . Manipal. Keywords: Tuberculosis. Preliminary diagnosis of tuberculous pericarditis based on his clinical and radiological findings was confirmed with Ziehl-Neelsen’s stain for acid fast bacilli and culture of the pericardial fluid aspirate. Kasturba Medical College Manipal University. High index of suspicion amongst the treating clinicians supplemented with prompt diagnosis and treatment can reduce the high mortality associated with this disease. We here-with report a case of tuberculous pericarditis in a young adult male patient. We report a case of a young adult male patient who presented with a 2 month history of productive cough and breathlessness of recent onset. 1 (2010) 366 . India Padma Kumar R. namely.Vol. glucose – 23 mg/dl. Discussion Tuberculous pericarditis results from retrograde lymphatic spread of M.1 Fever. except for a slight increase in total leucocyte count (11. with which he improved significantly with no recollection of effusion and was discharged from the hospital. Electrocardiogram (ECG) showed sinus tachycardia.4 It is suggested that tuberculous pericardial effusions arise as a result of a hypersensitivity reaction orchestrated by the TH-1 lymphocytes against the protein antigens of tubercle bacillus. In view of his clinical findings and radiological investigations. the patient improved symptomatically with reduced dysnoea. Jugular venous pressure was raised. 1 No. On examination. or elsewhere. and night sweats occur early. 1 (2010) 367 . ethambutol (800 mg) & pyrazinamide (1500 mg) and steroids. dyspnea. the skeletal system.82. The patient was started on Antituberculous chemotherapy (ATT) with four drugs – isoniazid (300 mg).2 Tuberculous pericarditis has a variable clinical presentation and the affected individuals generally lack the typical symptoms and signs of pulmonary tuberculosis.5 Tuberculosis should be considered in the differential diagnosis of all cases of pericardial heart disease without a rapidly self-limited course. peribronchial or mediastinal lymph nodes or by hematogenous spread from primary tuberculous infection from a focus in the lung.Case Report A 25 year old male patient without any prior significant medical illness presented with a history of productive cough with mucoid sputum of 3 months duration and gradually progressive breathlessness since 15 days. Pericardial fluid analysis showed. He had a significant loss of body weight in the past 3 months. Fluid total leucocyte counts were elevated (8700 cells/cu mm). and which is often voluminous and hemodynamically significant. Symptoms of cardiopulmonary origin tend to occur later and include cough. low voltage complexes and diffuse T wave inversions. Later culture of the pericardial fluid in automated system (M-BacT/Alert. tuberculosis from peritracheal. calcific adhesions with clinical constriction in nearly 50 percent of patients. which identified the exudative nature of the fluid. LDH – 5038 U/L and adenosine deaminase (ADA) – 213 U/L. Following which. genitourinary tract. protein 5. His ATT was continued and the steroids tapered.1. and a combination of effusion and constriction. Review of Global Medicine and Healthcare Research .e.73 and pericardial fluid LDH to serum LDH ratio was 6. There was bilateral pedal edema. Routine bacterial culture of the fluid was sterile.1. Other systemic examination revealed no abnormalities.5 Tuberculous pericarditis presents clinically in 3 forms. The patient improved with medications and was asymptomatic on regular follow up. constrictive pericarditis. weight loss.3 g/dl. pericardial effusion. His clinical diagnosis at this stage was pericardial effusion with tamponade.700 cells/cumm) and serum lactate dehydrogenase (LDH) was 739 U/L. rifampicin (450 mg). Biomerieux) detected the growth of Mycobacterium tuberculosis which was confirmed by using DNA probe i. Echocardiography revealed massive pericardial effusion with normal left ventricular function (ejection fraction – 72%). San Diego CA. Accuprobe system (Gen-Probe incorporated. Routine biochemical and hematological investigations were within normal limits. Ziehl-Neelsen’s stain of the fluid was positive for acid fast bacilli (AFB 1+). ethambutol and pyrazinamide. he was afebrile. USA). Anti-tubercular susceptibility testing was done by proportion method and the strain was resistant to isoniazid and streptomycin but sensitive to rifampicin.1.9 g/dl. Pericardial fluid protein to serum protein ratio was 0. pulse rate of 140/min and blood pressure of 116/80 mm Hg. On systemic examination cardiac dullness was obliterated. albumin – 1. pericardiocentesis was done and 300 ml of hemorrhagic fluid was tapped. An adhesive phase follows resolution of the effusion and eventuates in dense. apex was not palpable and a pericardial rub was appreciated.1 The pathological stages of tuberculous pericarditis include a fibrinous pericarditis with caseating necrosis and polymorphonuclear infiltrate which gives rise to an effusive phase with predominantly lymphocytic exudate along with monocytes and foam cells. facilitating hemodynamic recovery.8 Pericardial fluid may be serosanguineous.1 A definitive diagnosis can be obtained by pericardiocentesis under echocardiographic guidance. A regimen consisting of rifampicin.8 Conclusion Tuberculous pericarditis is a potentially lethal condition and should be considered in the evaluation of all cases of pericarditis.6 The most common physical findings are cardiomegaly and fever. Echocardiogram showing a large pericardial effusion with frond-like projections. while Kussmaul's sign (inspiratory swelling of the neck veins) may be seen in patients with constrictive pericarditis. tuberculosis in culture. however PCR has shown a low sensitivity in a study by Peter Cegielski et al. reducing effusion. The ECG is abnormal in virtually all cases of tuberculous pericardial effusion. The chest pain may occasionally mimic angina but usually is described as being dull.orthopnea. definitive diagnosis was done based on demonstration of acid fast bacilli in stained smears from the aspirated effusion and later isolation of M.5 A course of glucocorticoid treatment is useful in the management of acute disease. CT scan and/or MRI of the chest show evidence of pericardial effusion and thickening (>5 mm) and typical mediastinal and tracheobronchial lymphadenopathy (>10 mm. and ethambutol for at least 2 months. and chest pain. and thick “porridge-like” exudate is suggestive of an exudate but not specific for a tuberculous etiology. followed by isoniazid and rifampicin (total of 6 months of therapy) has been shown to be highly effective in treating patients with extrapulmonary TB. pulsus paradoxus. Prompt institution of antituberculosis chemotherapy increases survival dramatically in tuberculous pericarditis. tuberculosis or caseating granulomata found on histological examination of pericardium with consistent clinical circumstances are convincing evidence of a tuberculous etiology. A pericardial friction rub and distant heart sounds are common. Pleural effusion and peripheral edema may be evident. 1 (2010) 368 .1. with a predominance of lymphocytes and monocytes. matting). Review of Global Medicine and Healthcare Research . and hepatomegaly. aching. chest radiograph which may reveal enlarged cardiac shadow in more than 90% of cases. Progression to chronic constrictive pericarditis.7 The diagnostic modalities include.5. Interferon-γ (>200 pg/L) and lysozyme (≥6. isoniazid.2. hypodense centers. or even grossly hemorrhagic. a positive culture of pericardial fluid for M. followed by tachycardia. pyrazinamide. seems unaffected by such therapy. features of active pulmonary TB in 30% of cases and pleural effusion in 40% to 60% of cases. and thus decreasing mortality rates. ankle swelling.1 Also elevated pericardial fluid adenosine deaminase (ADA .6 Evidence of pericarditis in a patient with tuberculosis demonstrated elsewhere in the body and/or a good response to antituberculosis chemotherapy makes a probable diagnosis of tuberculous pericarditis.1 Such changes were seen in the ECG of our patient. and often affected by position and by inspiration. usually in the form of nonspecific ST-T wave changes. 1 No.5 µg/dL) are suggestive of tuberculous pericarditis.1 Demonstration of tubercle bacilli in stained ZeihlNeelsen smear (yield of 0 .Vol.≥35 U/L). complexes <5 mm in limb leads and <10 mm in precordial leads) suggests a large pericardial effusion.42%). In the present case.1 Rapid diagnosis by Polymerase Chain Reaction can be an important diagnostic tool.1 Pericardiectomy may be necessary for recurrent cardiac tamponade.7 when compared with culture and histopathology. The presence of microvoltages (ie.4 Tuberculous pericardial effusions are typically exudative with a high protein content and increased leukocyte count. with sparing of hilar lymph nodes.4 Rapid diagnosis and treatment are crucial in reducing mortality and morbidity from pericardial disease. however. NY: McGraw-Hill. Fauci AS. Kumar S.27:75-77. USA: McGraw. Murray JF eds. Lema LEK et al. New York. Philadelphia. 12th Edition. Mason RJ. 1 (2010) 369 . Indian J Medical Microbiol 2009. Diagnosing tuberculous pericarditis. and Histopathology for Diagnosis of Tuberculous Pericarditis. O’Rourke R. 4th ed. Hurst's The Heart. Circulation 2005. Pennsylvania: Elsevier.References Mayosi BM.Hill. Harrison’s principles of internal medicine. Burgess LJ.112:3608-3616. Doubell A. Comparison of PCR. Mathur M. Kitinya JN. Pulipaka UP. Culture.Vol. Baradkar V.2007. 17th ed. Fowler NO. 1 No. Kasper DL. Q J Med 2006. Wanjari K. Morris AJ. Reuter H. Fuster V. Review of Global Medicine and Healthcare Research . Murray & Nadel's Textbook of Respiratory Medicine. Burgess l.2005. eds. Cegielski JP.266:99-103. Devlin BH. 2008. eds. Tuberculous pericarditis. Tuberculous pericarditis. 35:3254-3257. A case of tuberculous pericardial effusion. Doubell AF. 99:827–839. Vuuren Wv. JAMA 1991. JCM 1997. The glutathione peroxidase (GPx) levels were not significantly different between aorta of diabetes mellitus induced treated rat and untreated diabetic rats. The concentration of plasma VCAM of diabetes mellitus induced rat treated with ALA decreased (60. Conclusion: This study suggested that ALA may be effective in reducing oxidative stress in aorta of STZ induced diabetic rats.. It is also suggested that ALA may reduce VCAM level in diabetic condition.05) compared to untreated diabetic rats. The ascorbic acid levels were increased (434. 1 (2010) 370 . 1 No.92%) significantly (p<0. M. nerve and blood vessels (Ceriello 2000). Kokila. STZ 45mg/kg was injected intravenously to induce diabetes mellitus. *.Vol.05) compared to untreated diabetic rats. The concentration of plasma VCAM of control group treated with ALA also decreased (75. Following of four weeks of force feeding treatment.98%) significantly (p<0. Keywords: Lipoic acid. Budin. Department of Biomedical Science Faculty of Allied Health Sciences Universiti Kebangsaan Malaysia.70%) significantly (p<0. Results: The finding of this study showed that the level of malondealdehyde (MDA) of diabetes mellitus induced rat aorta treated with ALA decreased (32. Studies show that lipid oxidation by free radicals is an essential factor in early atherosclerosis development (Ross 1999).05%) significantly (p<0.05) in aorta of diabetic mellitus treated rats compared to untreated diabetic rats. T.com Abstract Background: Alpha lipoic acid (ALA) is a unique antioxidant and has beneficial effects in fuel metabolism. samples such of aorta and plasma were taken.B. Malaysia * Corresponding Author. Method: A total of 40 (250-280g) Sprague Dawley rats were used and divided into four groups randomly.05) compared to untreated control group.Effect of alpha lipoic acid on oxidative stress and vascular cell adhesion molecule level in diabetes mellitus induced rats Jamaludin. Review of Global Medicine and Healthcare Research . kidney. Oxidative stress plays a vital role in pathogenesis of diabetic complications (Baynes & Thorpe 1999) especially cardiovascular complication. S. Email: jamal3024@yahoo. atherosclerosis Background Diabetes mellitus is an endocrine disease characterized by hyperglycaemia. oxidative stress. The aim of the present study was to investigate the effect of ALA supplementation on biomarker of oxidative stress and vascular cell adhesion molecule (VCAM) level in streptozotocin (STZ) induced diabetes mellitus rats. It causes long term complication involving eye. The diabetic rats were divided into two groups: supplemented with ALA (100mg/kg/day) and non-supplemented with ALA. The non-diabetic rats were also divided into two groups: supplemented with ALA (100mg/kg/day) and non-supplemented with ALA. Blood was kept on ice and centrifuged at 3000 rpm for 15 min at 4°C and the obtained plasma was stored at -50°C until analysis. 1 (2010) 371 . UK). 0. New Zealand) and rats with blood glucose levels >15. the DMTxo and NDMTxo rats were left untreated. USA). the mixture was incubated at 37°C for 3 hours. Meanwhile. After 15 minutes. 2001). For analysis of ascorbic acid. were supplied by The Animal Unit of Universiti Kebangsaan Malaysia. Radicals play a vital role in development of atherosclerosis. strong antioxidant.4 ml of distilled water.0 mmol/l were included in the study. 1945 method and GPx using Paglia & Valentine 1967 method. 1. freshly dissolved in normal saline. ALA (Sigma. and administered after an overnight fast. 1. brussel sprouts and rice bran (Morikawa et al. All animals were maintained on a balanced diet and water without restriction. garden pea. St Louis. 2500rpm. The concentration of ALA from highest to lowest in nonanimal sources are: spinach. The non diabetic rats received saline injection [NDMTxo (n=10) and NDMTx+ (n=10)] and acted as control groups. Aortic homogenate is used to analyze MDA using Stock et al.2 ml of the supernatant was added to 0. ascorbic acid using Lloyd et al. The mixture was vortex-mixed and 2.5 ml of TBA/NAOH was added.5 ml of sample and 2ml of metaphosphoric acid were vortex-mixed and centrifuged for 10 minutes. The mixture was centrifuged at 3000rpm for 10 minutes and the absorption of supernatant was read at 532 nm. Methods Animal preparation 40 Male Spraque Dawley rats. Diabetic rats were divided into two groups which are supplemented with ALA (n= 10) (DMTx+) and not supplemented with ALA (DMTxo) (n=10). For analysis of MDA. The study was approved by Universiti Kebangsaan Malaysia Animal Ethics Committee (UKMAEC) and the guidelines were followed. ALA occurs naturally in the human diet and is found in abundance in animal tissues with high metabolic activity such as heart. liver and kidney. St Louis.ALA is a short chain which has thiol groups (Vessal et al.4 ml DTC and vortex mixed. Then.Vol. Three days following the STZ administration. tomato. broccoli. rats were fasted overnight and blood was collected by cardiac puncture under deep anaesthesia with diethyl ether and descending aorta was quickly excised for homogenization and stored at -70°C. Both antioxidant forms scavenge radicals. 4ml of n-butanol was added to the mixture and vortex-mixed for 3 minutes. and to a lesser extent in fruits and vegetables (Packer et al.5 ml of TCA/HCL was added. 1 No. 2001). Then. 0. The test tubes containing the Review of Global Medicine and Healthcare Research . glucose concentration was measured by a strip operated blood glucose sensor ( Advantage II Roche Diagnostics. USA) was administered orally at a dose of 100 mg/kg/day throughout the feeding period of four weeks. weighing 260-290 grams.1 ml of sample was mixed to 0. Antioxidant Analysis Following four weeks of supplementation. Thus. antioxidant is analyzed to determine the effect of ALA supplementation on oxidative stress in aorta and VCAM of diabetic rats. Diabetes was induced by a single intravenous injection of STZ (45 mg/kg) (Sigma. 1974 method. The mixture was incubated for 30 minutes at 100°C. VCAM plasma was evaluated using Quantikine sVCAM-1 Kit (R&D System. 2003) and can be converted to dehydrolipoic acid (DHLA). 1 No.05. Then.49 ± 20. 0. For analysis of GPx.01).60 ± 4.61 nmol/l protein) was not significantly different compared to NDMTxo (37.01) and NDMTxo (p<0. Statistical analysis Normality test was done.04).02 of sample was added to 0.1 ml hydrogen peroxide solution was added and the absorption was read using spectrophotometer (340nm). Spectrophotometer was used to read the absorption(520nm). One way ANOVA was used to assess statistical significance between the two groups. 1 (2010) 372 . Results: Analysis of MDA level Figure 1: MDA level (mean ± SEM) of each group following four weeks of study a : significant compared to NDMTxo b : significant compared to NDMTx+ c : signifikan compared to DMTxo Figure 1 shows aortic MDA level of each group.93 ± 13.57nmol/l protein) compared to DMTxo (p=0.88 ml of prepared substrate. Analysis of Ascorbic Acid Level Review of Global Medicine and Healthcare Research .01) and NDMTxo (p=0. 2 ml of concentrated sulphuric acid was added and vortex-mixed.mixture were placed into the ice bath for 10 minutes. 0.Vol. All values were expressed as means ± SEM.44 nmol/l protein) compared to NDMTx+ (p<0. DMTx+ was increased significantly compared to NDMTx+ (p<0. However. MDA level is increased significantly in DMTxo (147. MDA level was decreased significantly in DMTx+ (98. Then. Study showed NDMTx+ (19.27 nmol/l protein). The difference is considered to be significant at P< 0.01).65 ± 1. 06 mg/l) was increased significantly compared to DMTxo (p<0. Analysis of GPx Level Figure 3: GPx level (mean ± SEM) of each group following four weeks of study a : significant compared to NDMTxo b : significant compared to NDMTx+ Review of Global Medicine and Healthcare Research .85 ± 0. DMTx+ was not significantly different compared to NDMTxo and NDMTx+. However.Figure 2: Ascorbic acid level (mean ± SEM) of each group following four weeks of study a : significant compared to NDMTxo b : significant compared to NDMTx+ c : significant compared to DMTxo Figure 2 shows aortic ascorbic acid level of each group.12 ± 1.88 ± 1.01).06 mg/l) was not significantly different compared to NDMTxo (9. 1 (2010) 373 .Vol. Study showed ascorbic acid level in NDMTx+ (10. 1 No. Ascorbic level in DMTx+ (9.01).01) and DMTxo (p<0. DMTxo (1.26 ± 1.20mg/l).53 mg/l) showed significant decrease in ascorbic acid level compared to NDMTx+ (p<0. 01) compared to NDMTx+ and was not significantly different compared to NDMTxo. DHLA is a potent sulphdryl reductant as redox potential of DHLA:ALA is as low as -0.Vol. 1 (2010) 374 . The finding shows that ALA successfully acts as antioxidant parallel to previous study which showed that ALA is a potent antioxidant in vivo and in vitro (Packer et al.0028 µmol/min/mg protein ).62 ± 0.04).0036 µmol/min/mg protein) was not significantly different compared to NDMTxo (0.40 ng/ml) was decreased significantly (p<0. DMTx+ was not significantly different from DMTxo.01) compared to NDMTxo (7.027 ± 0. oral administration of ALA has lowered MDA level significantly in DMTx+ compared to DMTxo.13 ± 0. VCAM level in DMTx+ (2. prostaglandin dehydrogenase and alpha ketoglutarate dehydrogenase.42 ± 1. Study showed that VCAM level in NDMTx+ (1. Review of Global Medicine and Healthcare Research . However. Study showed GPx level in NDMTx+ (0.01) compared to NDMTxo and also decreased significantly (p=0. The redox potential helps to neutralize free radical by donating electrons and thus reduces lipid oxidation which will decrease the MDA level.029 ± 0.017 ± 0. 1996).0014 µmol/min/mg protein) decreased significantly compared to NDMTx+ (p=0.0018 µmol/min/mg protein) decreased significantly compared to NDMTx+ (p=0. VCAM level in DMTxo (5.03) and NDMTxo (p=0.Figure 3 shows aortic GPx level of each group.01) and NDMTxo (p=0.04). GPx level in DMTxo (0. Discussion In the present study.83 ± 0. This will also reduce oxidative lipid dissociation and cause decrease in MDA level in diabetic subjects (Hicks et al.89 ng/ml).02 ng/ml) increased significantly (p=0. DMTx+ was not significantly different from NDMTx+. Analisys of Plasma VCAM Figure 4: Plasma VCAM level (mean ± SEM) of each group following four weeks of study a : significant compared to NDMTxo b : significant compared to NDMTx+ c : significant compared to DMTxo Figure 4 shows plasma VCAM level in each group. 1 No.54 ng/ml) has decreased significantly (p<0.017 ± 0. The hypoglycaemic effect will reduce collagen glycation in aorta. Previous study also showed that ALA is able to reduce blood glucose level through glucose metabolism (Erik 2006). Study also showed that GPx level in DMTx+ (0.32V (Roy & Packer 1998). 1988). However.04) compared to DMTxo. acid ascorbic plays an essential role in diabetic condition (Retsky et al. enzymatic cofactors availability (Lu et al. 1989). Vitamin E and C act in concert. MDA.e.2 V). 1992). This may be due to tendency of atherosclerosis development in diabetic subject compared to healthy condition as proposed by Buczynski et al. 1989) may affect the level of enzyme. Because of these synergistic actions. This is due to lower reduction potential of acid ascorbic compared to α-tocopherol (Nakagawa et al. most probably through activity of lipoprotein lipase (Zulkhairi et al. Thus. GPx is used to reduce oxidative pressure in diabetic condition (Cameron et al. ALA mediates dehydroascorbic acid reduction (Xu & Wells 1996). Ascorbic acid is used extensively and preferred compare to α-tocopherol. In addition. DHLA which is secreted into the medium reduces cystine to cysteine. This will prevent suffering of diabetic patient from acid ascorbic deficiency which may lead to impaired collagen synthesis and cause poor vessel support and impaired wound healing (Kumar et al. both of these vitamins have attracted interest as agents that may retard atherosclerosis by reducing the oxidation of LDL (Kumar et al. 1993). Multiple genes (Harris 1992) involve in enzymatic antioxidant activity. Thus. 2002).Vol. Meanwhile. 1993). Cysteine availability is known as the rate-limiting factor in GSH synthesis.Study also showed that ALA supplementation increases lipid and lipoprotein regulation (Heitzer et al. Organ variability. GPx level in this study might be in the compensatory mechanism. diabetes mellitus. Low reduction potential also allows regeneration of α-tocopherol but not the other way around (Buettner 1993). 2001). 1995). 1989). Review of Global Medicine and Healthcare Research .20 V compared to GSH/GSSG which is -0. resulting in enhancement of GSH biosynthesis (Han et al. Decrease in LDL and MDA will also reduce MDA-LDL which mediates proinflammation and proatherogenic processes. DHLA can reduce even oxidized glutathione (GSSG) chemically which is catalyzed by GPx normally (Jocelyn 1967). Although the reduction takes place in the cell. Studies with human cells have provided insights into the mechanism through which ALA increases GSH levels. the acid ascorbic level was increased in DMTx+ significantly compare to DMTxo. In current study. This is due to presence of specific pathway for enzymatic antioxidant such as GPx (Sies 1995). DHLA is able to seep through from cells (Handelman et al. 2008). Ascorbic acid level was decreased significantly in DMTxo compared to NDMTxo. 2001). Hence. Treatment with ALA increases GSH levels in vivo and in vitro. (1993). It may reduce the risk of atherosclerosis (Berliner & Heinecke 1996). GPx level was decreased significantly in DMTxo compared to NDMTxo. ALA regenerates ascorbic acid and indirectly regenerates vitamin E. This shows that ALA is able to regenerate acid ascorbic. 1 No. ascorbic acid and GPx levels in NDMTxo were not significantly different from NDMTx+. hormones and cytotoxin level (White et al. 1994). This shows that ALA acts both in intracellular and extracellular regions (Kagan et al. hypertension and hypercholesterolaemia) rather than in healthy individuals as were examined in the previous study (Heitzer et al. Ascorbic acid is also an antioxidant which prevents lipid peroxidation of ROS (Frei et al. GPx activity is the major intracellular detoxification mechanism of H2O2 and lipid peroxide compare to catalase (Asahi et al. This may due to short treatment period to show any significant increase. 2002). GPx level of DMTxo was not significantly different compared to DMTx+. ALA becomes strong antioxidant when it is reduced to DHLA (E0’ = -3. 1997). 1991). It should be noted that the standard reduced-oxygen (redox) potential of the ALA/DHLA pair is -3. These findings may indicate that favourable vascular effects of ALA are more likely to occur in people with oxidative stress-associated pathologies (i.24V. 1 (2010) 375 . NF.g. 1 (2010) 376 . KT carried out the biochemical analysis and performed the statistical analysis. Authors' contributions: JM and SB conceived of the study. 1997).. Therefore. In the previous study. 1995). NF-kB is believed to play a pivotal role in atherosclerosis (Colin et al. Conclusion ALA may have the potential in reducing cardiovascular complication such as atherosclerosis in diabetes mellitus.κB (nuclear factor κB) has been proposed to be a redox-sensitive transcription factor . 2001). monocytes. 1992).g. Therefore. by inflammatory cytokines is required for the transcriptional activation of endothelial cell adhesion molecules such as VCAM. 1995).. and TNF-a. Competing interests: The authors declare that they have no competing interests. e.Vol. This proves that there is presence of direct effect of ALA on VCAM molecule and not only in pathological condition like diabetes. The data strongly suggest that ALA inhibits TNF-a-induced endothelial activation by affecting the NF kB/IkB signaling pathway at the level of IKK rather than by preventing DNA binding of NF-kB (Suzuki et al. The finding was parallel to previous study whish stated that ALA may elicit cardio protective effect especially in reducing risk of atherosclerosis (Lodge et al. it was found that ALA inhibits NF-kB activation and adhesion molecule expression in human aortic endothelial cells. ALA inhibited IKK activity and nuclear translocation of NF-kB. lymphoid cells. in numerous cell types. the observed anti-inflammatory action of ALA in endothelial cells probably extends to many other important mediators of inflammation in a variety of cells and tissues (Wei-jian Zhang & Frei 2001). In addition. 1998). Thus.ALA decreased VCAM concentrations in DMTx+ significantly compare to DMTxo. modulation of monocyte–endothelial interactions may be an important target for the prevention and treatment of atherosclerosis (Knowles and Maedah 2000). 1995). 2003) and the expression of atherogenic proteins (e. 1997). 1 No. 2002). designed the experiment. vascular hypertrophy (Takaoka et al. Review of Global Medicine and Healthcare Research . Genetic deficiencies of adhesion molecules in mice are associated with decreased atherosclerosis. (Colin et al. ALA effectively inhibits TNF-a-stimulated mRNA and protein synthesis of cellular adhesion molecules (particularly E-selectin and VCAM-1) and consequent monocyte adhesion. e. ALA decreased VCAM level in NDMTx+ significantly compare to NDMTxo. Chelation properties of ALA has been proposed to responsible for inhibition of NF. the formation of advanced glycation end products (Midaoui et al. such as IL-1 and IL-6.κB activation rather than its antioxidant properties (Bowie et al. tissue factor. and endothelial cells. tissue factor and endothelin-1) via inhibition of the inflammatory cytokine nuclear factor kB (Packer et al. carried out the main experiment and drafted the manuscript. Some studies have suggested that ROS play a role in the signalling events leading to NF-kB activation (Schreck et al. It is possible that ALA may improve haemodynamics in diabetic patients by long-term protection against oxidative stress (Midaoui et al. All authors read and approved the final manuscript. It would be expected that ALA also affects NF-kB-dependent expression of many other inflammatory genes.g. Activation of the transcription factor NF-kB. T. 1996. Mohd Taufik Hidayat Baharuldin. Metab.R. 1999. J..C. 498: 16-21. Kraemer.. B.. 3. L. 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Know the clinical manifestations of Para phenylene diamine poisoning.Vol. hair dye. Upper respiratory tract edema. It is not an uncommon suicidal agent in South India. has been used in the preparation of hair dye. Aim & Objectives The aim of the study is to: 1. 1 (2010) 379 .com Swathi Muddasani Siddhartha Medical College.T. India Keywords: Para phenylene diamine. 2. a derivative of paronitroanaline. Tracheotomy.Para Phenylene Diamine Poisoning-Clinical Manifestations & Short Term Prognosis Sri harsha Tella Siddhartha Medical College. E. Seizures. paronitroanaline. Exclusion Certeria (Limitations) Patients who have not shown any confirmation about the ingestion of hair dye poisoning. 1 No. It is commonly used for coloring the hair. Inclusion Certeria Adults ( 18 – 50 Years) who showed the evidence of hair dye poisoning (PPD presence in urine on chromatographic study) Patients who reached the hospital within 12 hours of the in take of the poison and who have not received any treatment from outside hospital. Dialysis. Dyspnea. acute kidney failure Introduction Para phenylene diamine. Know the short term prognosis of the same. India Email: harsha_tella9999@yahoo. Materials & Methods 40 Para phenylene diamine poisoning cases (22 females and 18 males) which came to the Emergency Department of Gandhi Hospital.A. Review of Global Medicine and Healthcare Research . Statistical tests used were Mean . The quantity of dye consumed is 30-100ml. The mean age is 32. CPK values had been raised in these patients. Corticosteroids & local adrenaline spray had seemed to be no role in reducing angiooedema. The quantity of dye consumed by those people who required emergency treacheostomy was 72 (+16.9 (+5.06 mEq/l (+0.Proportions’ and Chi square test with degree of freedom 1(df=1) . 32 people presented with dyspnea (80%) and emergency treacheostomy was needed in 18 (45%). Black colored urine was seen in 12 (30%). The therapies used were stomach wash. local spray of adrenaline.9 (+ 5. 14 people (35%) presented with hypocalcemic tetany.37 mg/dl (+1.725) 5. oliguria & itching.79)] : 20937.65). Dialysis was needed in 8 (20%).82 hours (+1. potassium. together level of azotemia.76) : 2. Airway support. fluid challenge (100%).Patient who are not willing for the study.549).549) Male: Female : Mean volume ingested Mean duration for development of Orofacial oedema Dyspnea : 32 (80%) Upper respiratory tract oedema Creatinine Potassium : : : 18 (45%) 8. seizures were seen in 12 (30%). asphyxia.Vol. corticosteroids. The clinical symptoms dominated were angioedema.65) years 18: 22 : 65.465 (+5869.5) ml. CPK values inducing rhabdomyolysis were significantly associated with higher mortality.26 ml (+ 21. Suspected cases of hair dye poisoning. The mean duration for the development of orofacial edema was 2. Patient characteristics Mean Age : 32.5 CPK values (IU) Tracheostomy was done at dose of Review of Global Medicine and Healthcare Research . 1 (2010) 380 .12) : 72 ml + 16. The amount of toxin.82 hours (+1. 1 No. 10 patients (25%) succumbed out of which 6 (15%) were died on the day of arrival. Statistical analysis was done using Medcalc Results Out of 40 cases 18 were male & 22 were female. potassium levels and this is due to massive rhabdomyolysis & myoglobinuria. 1 (2010) 381 . Emergency tracheostomy was needed in 18 (45%) These causes did not fully respond to antihistamines.76+1. teachers and friends and whoever helped us in completing this paper.67 863. These patients require fluid replacement (7+5 Liters) to prevent acute tubular necrosis(6).6 8. This can be attributed to massive rhabdomyolysis caused by the hair dye.92 1.78 0. 10 patients landed in acute renal failure indicated by raised creatinine. Aknowledgments: We acknowledge our parents.05 0. 1 No. Prognosis also depends on amount of poison ingested. steroids.0025 0.50* 0. present in the hair dye.98 4. The initial line of management for PPD poisoning patients was gastric lavage.05 Dosage Creatinine Potassium CPK 55. 14 patients presented with hypocalcemic tetany with trismus & corporeal spasm & both chvostek’s & trousseau’s signs were positive. black colored urine & oliguria.82 24. itching.11+1087 5. Respiratory support & initial fluid replacement therapy is necessary to improve the prognosis. Factors predicting poor outcome DOSAGE (>74. The clinical features are dominated by cervical and upper respiratory tract edema.12 Dosage Creatinine Potassium CPK 74. Review of Global Medicine and Healthcare Research . This can be attributed to E.A.6 1.67 0.6) CPK (> 34294. Supportive therapy is essential for recovery.92 7.Recovered Mean SD Death Mean SD P value 0.76 5.Vol.12) Creatinine (>8.34 34294.11 18. The commonest cause of death is due to acute respiratory distress caused by cervicofacial & upper respiratory tract edema & acute Kidney failure.T.78 7582.91 10875. adrenaline(7) . fluid replacement (7+5 litres) & securing the air way.D.12 *This indicates the difference is due to chance Discussion Hair dye poisoning is not an uncommon cause of suicidal death in south India.6+18. Black coloured urine was seen in 12 (30%) CPK values were drastically increased in these patients.78)mg/ dl Conclusion Paraphenylene diamine is not a uncommon cause of suicidal death in South India. Review of Global Medicine and Healthcare Research . Homeida M. Lazreq C. Mosadik A. Dakshinamurty KV. Ababou K.Vol. Suliman SM.vali.vani. Dammak H.References 1. Acute Angioedema in paraphenylenediamine poisoning. J Nephrol 2005. causes and complications of hair dye poisoning. Prasad N. Bahloul M. Yadevender reddy-RIMS. Clinical manifestations of systemic paraphenylene diamine intoxication. 1 (2010) 382 . 2. 2: 633-5. Ababou A. Hum Toxicol 1983. Ksibi H. 3. Kallel H.53: 120122. 18:308-11. 53: 181-1824 6. Ashar A. et al. J Pak Med Assoc 2003. Aboud OI.19: 105-7. 7.Ram R. Myocardial rhabdomyolysis following paraphenylene diamine poisoning. 5. 4. Hair Dye ingestion-An uncommon cause of acute kidney injury-Manish sahay. Paraphenylene diamine Ingestion: An uncommon cause of acute kidney injury. Chelly H. Swarnalatha G. Sbihi A. Ann Fr Anesth Reanim 2000. Paraphenylene diamine induced acute tubular necrosis following hair dye ingestion. J Post Graduate Medicine 2007. 1 No. Hamida CB. In 1942 it was seen that sandfly was the vector of this disease.Clinical profile of Kala-azar (Visceral Leishmaniasis) in North Bihar Avaneesh Shukla Sri Krishna Medical College.(1) About 80. but this was not long lasting and VL had a comeback in 1970. splenomegaly or hepatosplenomegaly. 1 (2010) 383 . In 1898 Ronald Ross thought that the peculiarities of Kala-azar were caused by a degree of immunity to malaria parasites. He advised Mercury as its treatment. The parasite is transmitted by the bite of sandfly (Phlebotomus & Lutzomyia). During 1945 to 1955 DDT spraying under National Malaria Eradication program wiped out VL. These days the combination of HIV and VL is also encountered and is a major threat to the already deteriorated health system of this region. Brazil. The disease is endemic in 88 countries. Bangladesh. In July. Nepal and Sudan. J J Clarke wrote an account of kala azar based on information gathered by Mr McNaught. Muzaffarpur. Over 90% of VL cases occur in five countries – India. The department of Medicine and pediatrics are flooded with the patients of VL. wasting. History of Kala-azar in India In 1852 William Twinning in Calcutta reported enlarged spleen along with acute anemia and intermittent fever. In 1930 Dr Brahmachri recommended pentavalent antimonials for the treatment. infecting around two million people each year. This is due to early treatment of the disease. anemia. The term though still in use is now no longer applicable as the disease is not associated with black color of skin.000 cases were reported in northeast India in 1992. as professor of pathology reported via BMJ that VL was a form of trypanosomiasis. If untreated the disease is fatal in one to four months in almost 100% patients. In 1882 Dr.com Introduction Kala-azar or Visceral Leishmaniasis is a zoonotic infection caused by protozoa belonging to genus Leishmania. patients present with fever.Vol. (1) The parasite has two stages – amastigote stage occurs in man & promastigote stage occurs in gut of sandfly.(2) Review of Global Medicine and Healthcare Research . It was in 1903 that William Leishman at Royal Victoria Hospital at Netly. India Email: shukla. The reservoir for VL are human beings where as it is rodents in Africa and foxes in Brazil and canines for Mediterranean and Chinese VL. the civil medical officer at Tura. 1 No.avaneesh@gmail. According to the WHO data in 1997 it is estimated that approximately 12 million people are currently infected and a further 367 million are at risk of acquiring Leishmaniasis in 88 countries. In visceral Leishmaniasis the parasite infects the immune system of the body. Kala-azar is hyper endemic in North Bihar region of India. the professor of physiology also reported the same parasite and this was confirmed by Leveran. 1903 Charles Donovan. We must be sure that there is no bleeding tendency in the patient. pathological and epidemiological findings and co relation of those findings to reflect the condition of VL.This test has a positivity rate of 90 to 95 %. its theme. 1 (2010) 384 . The disadvantage being 5 % cross reactivity with tuberculosis and malaria. My primary aim was to study the clinical profile of the disease. We use Xylocaine for local anesthesia as it’s a painful procedure. It may prove an important tool in epidemiological studies. Precautions must be taken as spleenic aspiration may cause hemorrhage which is very dangerous for the patient.This is easy to do and based on the concept of antigen antibody reaction and is quite sensitive. It was a great learning experience for me. 1 No. Review of Global Medicine and Healthcare Research . Material and Methods Here I will present my findings that are based on observational study of the patients that are admitted in SKMCH. I wished to experience and know research. VL is not a disease but a curse to this area. having the impact at various fronts of development in this poor socio-economic zone of globe.Vol. It’s a leading concern for various governmental and non governmental health organization of the area. This is the best method to demonstrate LD body in a patient. VL is quite prevalent here and I wished to study the patients throughout there stay in the college. I wished to study the data based on clinical. 3) Bone marrow aspiration test. analyze the current situation of Kala-azar in the area. methodology and writing of a report. To confirm the that they had VL we relied on following tests1) rk 39 strip test. It has a positivity rate of 60 to 65 %.Parasites can be demonstrated in the bone marrow of the patients. I did this project in 2nd year of my medical school. Palpable spleen is a must for this test.Aims and Objective The study was done to study. Usually the iliac crest is used for aspiration. 2) Spleen puncture. The dose of Amphotericin B was 1 mg per kg body weight as full dose and 1 mg as a test dose. 1 (2010) 385 . koilonychia. vomiting. respiratory rate.nausea. hypotension. lymph gland enlargement. WBC count. dyspnea. ESR. Various other drugs were given as and when required. Infusion fluids was prepared by dissolving 50 mg of Amphotericin in 10 ml of sterile water and making up to 500 ml with 5% glucose or dextrose to give a final concentration of 100 micrograms of Amphotericin B per ml. Inspection. pallor. Clotting time and weight is recorded. weight and blood pressure. and edema. The mode of administration was intra-venous. percussion and auscultation of abdomen and chest are done. an antifungal drug that was the base of the treatment.Here is a flowchart of the procedure: Susceptible cases Fever Abdominal lump Tests for VL Splenic puncture LD+ Confirmed case VL LD body + LD body Not a case of VL LD body Bone marrow aspiration Patients who test positive are admitted in the indoor ward of the department of medicine. icterus. palpation. Some of the parameters monitored daily were pulse. rashes.Vol. cyanosis. The drug is administered by slow IV infusion in 4 to 5 hours.spleen and liver palpation.pulse. Full history of all the aspects related to the condition is taken. 85% patients had fever with chills after some doses of Amphotericin B. Liposomal form of Amphotericin B is Review of Global Medicine and Healthcare Research . General examination of patients is also done which includes. temperature and respiratory rate. The parameters that were recorded after an interval of 23 days are . X ray of chest is done sometimes when opportunistic infection of Tuberculosis is suspected. which disappeared after 3 or 4 doses. The drug of choice is Amphotericin B. Management of VL in the hospital Pentavalent antimonials are of no use in this area as the resistance towards drugs has increased. RBC count. tachypnea and headache. Bleeding time. Palpable spleen and liver are recorded from the costal margin where the midclavicular line is supposed to pass. decubitus. 1 No. adverse effects noticed were. Differential counts. Temperature was normal during the treatment due to the use of antipyretics.6 gm per dl. Fever with chills was the major complain along with feeling of an abdominal lump on the left side near the costal margin. Leukopenia with relative lymphocytosis was also seen. hemorrhage. hemodilution and hemolysis. Results Patients came from wide spread areas of North Bihar. There was blood transfusion to increase the hemoglobin count. WBC Count WBC count per microlitre 10000 8000 6000 4000 2000 0 1 3 5 7 9 11 13 15 17 19 21 Number of patients Review of Global Medicine and Healthcare Research . 1 No.replacement of bone marrow by parasites. 1 (2010) 386 . The patients having TB or HIV+ were referred to DOTS and ART centre respectively. Almost all the patients had anemia with hemoglobin ranging from 4. There was normochromic and normocytic anemia caused by various factors. The range of lymphocyte % was from 17 to 74% with mean of 42 . There were about 35 patients in Department of Medicine and 25 patients in Department of Pediatrics usually when the study was done. At a particular time nearly 60 patients are admitted in the hospital. The number of patients that were monitored was 21. Period of reporting was as long as six months from the start of fever. The lowest count of WBC was 1400 per dl. The average weight is 41 kgs with range from 22 to 60 kgs. spleenic sequestration.Vol.The average WBC count was 4707 per micro liter. There is marked weakness seen in the patients. Thrombocytopenia contributes to the hemorrhagic tendency observed in some cases.preferred in patients seriously ill.80 to 10. Most of the patients were poor and uneducated. The highest temperature recorded was 105 degree F and the average temperature was 100 degree F before the start of treatment. 1 (2010) 387 . range was 4 to 18 cms.Vol. Review of Global Medicine and Healthcare Research . In most cases there was regression of spleen and liver with a few doses of Amphotericin B.8 cms. The average size of palpable liver was 1.Spleen from left coastal margin Spleen from coastal Margin 20 Size of palpable spleen in cms 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Number of patients WBC Count Cell count per microlitre 10000 8000 6000 4000 2000 0 Lymphocyte count Normal Lymphocyte Count 1 3 5 7 9 11 13 15 17 19 21 Number of patients Hepatosplenomegaly was also recorded. Hepatomegaly was seen in 42 % patients.95: 1. The average size of spleen was 7.2cms. 1 No. The ratio of palpable spleen to liver was 2. Vol. 1 (2010) 388 . They are weak and malnourished as compared to males.(3. Children have more chances of getting infection as – 1) they wear less clothes so they are more exposed to sandfly bite. Females are affected less but they show more morbidity and mortality. so their clinical and pathological condition has deteriorated much when they first report to the hospital.4. (3) Males are also more exposed to sandfly bite then females so they suffer more than females. Review of Global Medicine and Healthcare Research . 1 No.10) They are neglected as compared to males. 2) they have a less developed immune system.History of kala azar in family Patient having opportunistic infection of TB Vomiting and Diarrhoea No serious observable peculiarity Raised JVP Jaundice Had taken SSG before Rashes during treatment Hematemasis during treatment Discussion Children are mostly affected from the disease followed by males and females. There is more likelihood of developing an infection when a person is malnourished. This disease is burden of the area and adds to the loss of life and valuable resources. Some of the patients show continuous high fever. People are still ignorant about the cause and the prevention of the disease. There is decrease in number of WBC is due to increased destruction of cells due to increase trapping by spleen. this was exaggerated by the disease. This is also possible as there is no residual immunity left after the infection. There is a ratio of 2. 1 No. There is marked resistance seen and the disease relapses in a few weeks. but a relative lymphocytosis is seen that shows that the infection is chronic. It leads to more serious complications if there is a combination of HIV+ and Leishmaniasis. HIV may cause the infection of Leishmaniasis to flare up. There can be mild increase in bilirubin levels due to splenomegaly and also due to hepatotoxic nature of Amphotericin B. Summary VL is spreading by leaps and bounds and the situation is grim despite the efforts of government and many organizations. So re infection might be a major cause of relapse.Both HIV+ and Leishmaniasis cause decrease in immunity. 3) Relapse in HIV+ individuals. Bihar has lots of population which is migrant worker and they have more chances to get HIV+ due to the irresponsible behavior of the people. The cases of resistance and HIV combination will be the next trouble which will crop up soon. Cases of relapse were also seen. Most of the cases are resistant to these traditional drugs.9:1. So the goal must be clinical treatment along with parasitological treatment which is possible by the use of Amphotericin B. The efficacy of the anti retroviral drugs and anti Leishmaniasis drugs might be reduced due to drug interaction. Primary health centers are still providing these drugs. Females had an average of 34 kgs which is quite less as compared to the average. There are exaggerated symptoms in HIV+ patients. It is seen that HIV+ individuals are hard to treat. (8) 2) Relapse due to re-infection. 1 (2010) 389 . (7. (6) Size of liver and spleen. The average splenomegaly of females was more then the average of males because disease is more severe in females due to prevalent under nutrition and other co morbid conditions. (3) The average weight of the patients was 44 kgs which is quite low. Cases are difficult to treat and there are frequent relapses.Vol. Review of Global Medicine and Healthcare Research .More increase occurs in spleen as compared to liver. We must find a way to resolve the crisis so that the area can develop and attain the health which is basic human right of every human being. The relative lymphocytosis and total WBC count is more severe in females as compared to males. Usually there is some difference in the weight between male and females.9) Leishmaniasis accompanied with TB and HIV+ cases . I grouped them into three1) Due to treatment by Sodium Stibogluconate or Sodium antimony gluconate. Spleen is a soft structure without any capsule so it increases more than liver.(5) as there is damage to renal cells by Amphotericin B during treatment. Reduced erythropoiesis due to bone marrow replacement by the parasite and due to reduced level of erythropoietin. They have low immunity and are become easy prey to the infections. 20(3):40-3. 3) Mymensingh Med J. 1999. 9) J Ayub Med Coll Abbottabad.17(1):46-50. 1 (2010) 390 .77(5):371-4. 1999 Aug.Vol. 5) Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi.69(8):4709-18. 2) Medical history. 2008 Jul-Sep.27(2):180-1. 2009 Apr. 8) J Infect Dis. 2001 Aug.Acknowledgements: I wish to express my regards for: 1) Indian Council of Medical Research – The project was done as a short term studentship of ICMR.20(3):40-3. 1 No. Review of Global Medicine and Healthcare Research . 10) Bull World Health Organ.12(2):159-63. 2008 Jul-Sep. 4) Infect Immun.180(2):564-7. References 1) Round table conference on Kala-azar.1983 27:203-213. 7) Ann Trop Paediatr. 6) J Ayub Med Coll Abbottabad. 2) My guide – Dr Kamlesh Tewary who guided me throughout and Dr Vijay Kumar Singh who guided me in indoor wards and in compilation. 2008 Jan. 1992. India Email: [email protected] Swathi Muddasani Siddhartha Medical College. 1 No.Vol. Aims & Objective: The aims of the study are to 1. IgM. It is diagnosed positive IgM titers &/or four told raise in IgG titer. A hemorrhagic variant with a bleeding dyscrasia presents with petechial dermatitis. 1 (2010) . Inclusion Criteria • Patients who have positive Dengue serology by ELISA. It is most commonly encountered in Southeast Asia & Africa. spleenomegalae. Introduction Dengue fever is an acute flavivirus infection that presents with fever & myalgia. DENGUE HEMORRAHGIC FEVER. Exclusion Criteria • Suspected Dengue cases 391 Review of Global Medicine and Healthcare Research . India College grant number SMC G ICD-10S100 Keywords: Dengue fever. Materials & Methods 90 (54 females & 36 males) Dengue serology positive cases by ELISA that have had admitted at Gandhi Hospital & Sir Ronald Ross institute of Communicable & Tropical Diseases. Know the clinical correlation between the raised IgM &IgG titers and decreased platelet count. 2. it is commonly known as break bone fever. IgG. PRP transfusion.Dengue Hemorrahgic Fever – Correlation of IgG & IgM Values & platelet count Sri harsha Tella Siddhartha Medical College. platelet count. Know the short term prognosis of the patient who has both IgM & IgG raised titers. flavivirus. Vol.2 Lakh + 25.000/mm3(Least identified was 5.000 + 15.2 lakh + 25. This can be attributed to the exaggerated immune response to the second viral infection and damaging their own platelets. Loss of appetite. Patients who are having co-infection with other organisms ( Ex: positive for both plasmodium & Dengue ) Statistical tests used were Mean .000/mm3±15.000 cells/ mm3). myalgia and decreased platelet count.000/mm3±15. • • • • • • • • Patients with positive IgM & IgG have platelet 20.000/mm3 Positive IgM antibodies with No spleenomegalae & IgG negative is seen in 8& in theses platelet count longed between 1. as selected. This is due to sequestration effect of spleen as spleen is the reservoir of platelets. Results All the patients.Proportions’ and Chi square test with degree of freedom 1(df=1) .000 cells/mm3. vomiting. Patients with IgM & IgG positive needed 4±2 PRP transfusions. 24 of the patients with platelet count 20.000/mm3±15.000/mm3 showed bleeding manifestations in the form of epistaxis & patechiae.000 cells/mm3). 1 (2010) 392 . No of deaths with IgM & IgG positive – 3 Discussion Dengue fever.3%) & in these platelet count ranged between 80.000/mm3. an acute flavivirus infection presents with fever. Review of Global Medicine and Healthcare Research . Patients with both IgM & IgG positive titres have massive decrease in platelet count (20. DHF is a severe form of dengue fever caused by infection with more than one dengue virus.000/mm3) Positive IgM & spleenomegalae in 30 (33. are having IgM positive titers. 1 No. Patients with only IgM positive have platelet count of 1.7%) (20.000/mm3) count ranged between- Positive IgM &IgG is seen in 42 (46. Patients with positive IgM titers with spleenomegalae have moderate decrease in platelet counts (80.• • • Patients who are not willing for the study. 6 patients have had intracranial bleeding (evidenced on CT scan) & had seizures clinically.000/mm3±15. Statistical analysis was done using Medcalc.000+ 20. epigastric pain & tenderness in right coastal margin DHF is diagnosed by positive IgM titres & or four fold raise in IgG titre. Vol.93 + 1.10 >01.10 >01.000 20.000 + 20.68 + 1.000 + 15.13) Review of Global Medicine and Healthcare Research .10 Negative Equivocal Positive The patients with both IgM & IgG positive required 4+2 platelet rich plasma transfusions an steroids can also be given in order to reduce the exaggerated immune response.34 Mean IgG Value 0.000 Reference range for diagnosis IgM Values (By ELISA) Negative Equivocal Positive IgG values : : : : : : < 0.90 – 1. Factors predicting the platelet value* Mean IgM Value 3.69 + 1. 1 No.90 – 1.000 +15.Patient factors Number of cases Spleeno megale Platelet count (cells /mm3) IgM IgG Out come 24 24 30 Positive Positive Positive Negative Negative Positive Negative Positive Negative 1.000 cells/mm3 Platelet count ranged Between 80.98 + 0.000 80.83 + 1.32 Mean IgG Value 1. Three patients succumbed due to intracranial bleed as evidence on C.05(estimated=3.9 0.12 + 0.9 0.2 lakh+25.32 * Platelet count ranged Between 20. 1 (2010) 393 .T.52 Mean IgM Value 3.000 Good prognosis Good prognosis Epistaxis Petiechae IC bleed in 2 Epistaxis Petiechae IC bleed in 2 12 Positive Positive Positive 20. Scan.000 +15.observed=4.10 < 0.84.000 +20.000 cells/mm3 Platelet count ranged Between 1.2 lakh + 25.28 Mean IgG Value 4.78 Mean IgM Value 3.000 cells/mm3 P VALUE= 0. McGraw Hill. Biological sciences / the Royal Society 255 (1342): 81–9. Retrieved 2009-02-26. One patient succumbed due to intracranial bleed. 1 No. http://www. 2009-02-03. This can be attributed to sequestration effect of spleen. 5. Cases with IgM positive & spleenomegalae have moderate decrease in platelet count. CDC Traveler's Health: Yellow Book. Retrieved 2008-10-05 3. Sherri’s Medical Microbiology (4th ed. Review of Global Medicine and Healthcare Research .cdc.).uk/2/hi/americas/7866908. Retrieved 2008-10-05 6. Dengue Fever. Prevention of Specific Infectious Diseases". May RM (January 1994). October 9. "Superinfection and the evolution of parasite virulence". References 1.org/openurl.gov/NCIDOD/dvbid/dengue/dengue-hcp.royalsociety. CDC.Vol. ISBN 0838585299. Dengue epidemic threatens India's capital 9. 2. 4.co. 1999. Proceedings. Nowak MA. Dengue Fever Fact Sheet. Ryan KJ. pp. CDC Division of Vector-Borne Infectious Diseases (DVBID). 7. Steroids can be tried in the management along with PRP transfusion aspirin and other NSAIDS are to be avoided in there patients as they exaggerate the bleeding manifestation. 2007-10-22. PMID 8153140.bbc. "Chapter 4. http://www. Dengue Fever – Information Sheet. http://journals.1098/rspb. BBC. "Dengue fever: essential data". "Dengue fever outbreak in Bolivia".com/Biological/Pathogens/DENV. doi:10. Retrieved on 2007-11-30. World Health Organization. 2006. 8.asp?genre=article&issn=09628452&volume=255&issue=1342&spage=81. Ray CG (editors) (2004).cbwinfo.Conclusion Cases with both IgG & IgM positive titers have massive decrease in platelet count & this may be due to exaggerated immune response. "Dengue & DHF: Information for Health Care Practitioners".html#0009.0012. http://news. 1 (2010) 394 .1994.stm. 592.htm. M Department Of Pediatrics IRT Perundurai Medical College. IRT Perundurai Medical College Perundurai. India Mohan D. Serum iron profile was also studied for evaluation. group III – oral iron with vitamin E. Lipid peroxides and Lipid hydroperoxides were measured as the indices of oxidative stress before initiation. 1 No. Thindal. Methods: All the children attending the pediatrics OPD in IRT PMCH during JULY/AUGUST 2008 were randomly screened for anemia by clinical and haemoglobin evaluation. group I – oral iron only. Perundurai. India Abstract Background: Increased oxidative stress with free radical generation in iron deficiency anemia (IDA).Though iron supplementation is a common clinical practice in children it is not conventional to coprescribe anti-oxidants in children. thirtieth day (II follow up) after oral iron therapy. India Janakarajan V.com Natesh Prabu R Department Of Pediatrics IRT Perundurai Medical College. IRT Perundurai Medical College Perundurai. children were started with oral iron supplementation in three different groups. Nutritional status of the study population was recorded by a twenty four hour recall survey method. Erode. India Sabitha N Department of Nutrition and Dietetics Vellalar College for women.Role of Oxidative Stress and Antioxidants in Children with IDA Parasuram Melarcode Krishnamoorthy Department Of Pediatrics. They were in the age group of ten months to sixteen years. Studies in this regard are scanty in children. Review of Global Medicine and Healthcare Research . 1 (2010) 395 . group II – oral iron with vitamin C. Erode. Objective: The co-prescription of antioxidants with iron supplementation in IDA to counter the oxidative stress is a well studied and established fact in adults . Erode. Erode.N Department Of Biochemistry. tenth day (I follow up). 21 children whose parents gave consent for participation in the study were included for evaluation. India Balasubramanian Natesan Department Of Pediatrics IRT Perundurai Medical College.Vol. its aggravation at therapeutic doses of iron and reduction of oxidative stress by antioxidant supplementation are well studied in adults. India Email: parasumk@yahoo. After deworming. Therefore a study was undertaken to evaluate the oxidative stress in IDA in children and the effect of antioxidants during iron supplementation and to evolve an optimal suitable therapeutic strategy to minimize oxidative stress and there by adverse clinical effects. 1 No. Iron therapy Full Text: http://www.Results: There was no significant difference in serum iron profile response to oral iron therapy between the groups.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research .com/ijcrimph/ijcrimph-v02-n01-01. There was no significant difference between oral iron alone and oral iron with antioxidants in terms of clinical and biochemical response. Oxidative stress indices showed a decreasing trend in all the groups with no significant difference among the groups. Oxidative Stress. Key Words: IDA. Conclusion: Unlike in adults. 1 (2010) 396 . oxidative stress in iron deficiency anemia is not aggravated by oral iron supplementation in children. Lipid hydroperoxides seems to be an early indicator of oxidative stress. Children.iomcworld. There were no clinical adverse effects of oral iron supplementation in all the groups.Vol. 1 No.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . On the scale for sources of stress. Subjects and Methods: A cross-sectional study covered 426 law students selected through a stratified cluster sampling method.Vol.iomcworld. including 15 items on sources of stress (stressors). The questionnaire covered four categories.2%. anxiety and depression. We conducted this study to identify the prevalence and predictors of perceived stress among law students in Mansoura University. Egypt Abdel-Hady El-Gilany Department of Community Medicine Faculty of Medicine. Additional studies are needed to improve our understanding of the causes and consequences of law students' stress. Egypt Email: ahgilany@hotmail. Mansoura University. 80% experienced personal troubles and two thirds of the sample had relationship. Stress. Faculty of Medicine Mansoura University. 59. Mansoura. 1 (2010) 397 . Conclusions: It appears that the law students have a high level of perceived stress and majority of it is generated from personal factors and less from the academic or environmental factors. respectively. anxiety and depression were reported by 42. Egypt.Perceived stress among tomorrow’s attorneys in Mansoura.com/ijcrimph/ijcrimph-v02-n01-01. Mansoura.2%.com Mostafa Amr Department of Psychiatry. Egypt Abstract Background and Objectives: Few data are available on the level and sources of stress among law students in the Middle East generally and in Egypt specifically. Key Words: Law students. Anxiety. Depression Full Text: http://www. Perceived stress scale and Hospital anxiety and depression scale were used to measure stress. Results: A high level of perceived stress. academic and environmental problems.2% and 18. 1 (2010) 398 .written informed consent was obtained from the patient/legal guardian both in English and local language. The data thus collected was tabulated with reference to some important parameters of the study. Methodology: Cross-sectional study with simple random sampling technique was conducted at K. After they were tested they were found to be positive and were included in the study.R. KOH test.Vol. There was significant increase in the cases of non infectious lesions on HAART population (88% against 40% in Review of Global Medicine and Healthcare Research .) hospital. CD4 cell count etc. with special reference to age. India Mallikarjun Department of Skin and STD Bangalore Medical College and Research Institute. Appropriate lab investigations were done i. Before involving the patients in the study . Mean duration of HAART initiated life is 6months. But the cases of bacterial and fungal infections were almost equal in both categories. Aims: To conduct a clinical study of mucocutaneous manifestations in HIV-positive patients visiting Skin and STD Dept. Mysore Medical College and Research Institute. roseola like rash in the acute seroconversion illness to end-stage. Results: Among the opportunistic infections and other infectious lesions (HAART and non-HAART put together). India Email: kpkantha@gmail. base line investigations like Hemoglobin. The study involved 350 HIV positive patients aged between 16-60y of which 175 were on HAART presenting with some mucocutaneous manifestations and 175 were not on HAART consisting of patients who presented with a symptom of one of the mucocutaneous lesions. HIV status. India Aparna Mysore Medical College and Research Institute. It was analysed using the software SPSS 11. 1 No. VDRL test. highest was viral(56%) followed by fungal (42%). and to compare the pattern of dermatological lesions between patients on HAART and patients not on HAART. extensive Kaposi sarcoma. They did not know if they were HIV infected. So here is an attempt to find out the spectrum of dermatological lesions in HIV infected. They were procured from the Anti Retroviral Centre of our hospital. Peripheral Blood Smear. their association with the CD4+ cell count.com Sunith Vijayakumar Mysore Medical College and Research Institute. India between August 2007 and October2008.e. of Krishna Rajendra(K. Certain studies showed dermatological lesions are indicators of the immune status of the patient. bacterial(22%) and least being infestation. Viral infections were less on HAART initiated (32%) as compared to non HAART (80%). Mysore Medical College and Research Institute.A hospital based cross sectional study of mucocutaneous manifestations in the HIV infected Kadyada Puttaiah Srikanth Mysore Medical College and Research Institute. gender and risk factors.R.4 version.Hospital. India Abstract Background: HIV infection produces a panorama of mucocutaneous manifestations ranging from macular. But prevalence of bacterial and fungal infections showed no change [p=0.023]. 1 No.64 standard error of estimate and pvalue <0.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research .763(NS) and p=0.com/ijcrimph/ijcrimph-v02-n03-02. The study was comparable to many Indian and foreign studies. Mucocutaneous manifestations. p<0. immunodeficiency virus.05].non HAART. When opportunistic manifestations among non-HAART were considered. One case of pityriasis rosea in non HAART. Herpes simplex Human Full Text: http://www. 1 (2010) 399 .iomcworld.034) due to drug eruptions and pruritic papular eruption.134.31) with 0. Key Words: Highly active anti-retro viral therapy. Opportunistic infections. oral candidiasis was the leading manifestation seen among the 28% of the study group with mean CD4 count of 150cells/cu. there was significant reduction in the prevalence of dermatological viral infection in CAT 2 [under HAART-chi square=5. Majority of the lesions were seen at the cell counts less than 200cells/cu. followed by molluscum contagiosum.mm. resistant to treatment was diagnosed. Conclusions: In correlation with CD4 cell count.827(NS) respectively]. mucocutaneous manifestations increased with decreased CD4 cell count [Regression Coefficient (-0. p<0.mm. When dermatological lesions of patient who are on HAART was compared with that of non-HAART.Vol. condyloma accuminatum-20% and herpes zoster-16%.This may be due to poor socioeconomic status and poor hygiene. Oral candidiasis.24%. radiological manifestations. A total of 108 patients were included.34 (range 12-81 years). Yangon General Hospital. Macroscopic findings.48%). radiological findings.0 %) and signs of consolidation (11. UCSI University. two billion people are infected with mycobacteria tuberculosis and are at risk of developing the disease.A Study on Tuberculous Pleural Effusion Zay Soe School of Medicine. significant weight loss (72.1%). Myanmar.6%).6% and 1.5 %).60 ± 16. 74 males and 34 females were included. Haemoptysis was present in only 7.9%) had positive AFB smear in pleural fluid. hematological and serum biochemical profiles were recorded. UCSI University.4%). At least two pieces of pleural tissue were taken and one piece of each sample of pleural tissue was cultured for mycobacteria and the rest was sent for histological examination. radiological findings.com Wunna Hla Shwe School of Medicine. The rest had straw color aspirates. 53.7% of them had fever during admission. Their mean age was 42. Associated radiological pulmonary parenchymal lesions were noted in 28 patients (25.5%). Review of Global Medicine and Healthcare Research . Malaysia Email: zaysoe13@gmail. cervical lymph nodes were palpable in 14. Culture of pleural effusion and pleural biopsy reports for AFB were positive in 5. Malaysia Abstract Background: Nearly one third of the global population i. Thorough history taking and physical examinations. UCSI University.8%) and 2 (1. Pleural effusion is one of the common complications of pulmonary tuberculosis. cytological. 1 No. and night sweat (78.6%).8% and had clubbing of fingers in 5. hematological and biochemical profiles of serum and positivity rate of microbiological procedures and blind pleural biopsies in these patients. cough (81.7 %). 1 (2010) 400 .e.6%. microbiological and biochemical analysis of pleural fluid were analyzed. Only 2 patients (1.1 %).Vol. 15. biochemical and hematological profiles of serum and pleural fluid were analyzed. 7 patients revealed blood stained pleural fluid (6. collapse (15. biochemical. Malaysia Soe Moe School of Medicine. Common presentations were breathlessness (82.3 %) were diagnosed on first biopsy procedure and 15 (13. In this study. fever (80.9 %). of study period from January 2004 through January 2005. Only one patient (0. loss of appetite (74.2%) and chest pain (67. Only 39. pleural rub (13. Regarding the physical signs. Results: A total of 108 patients. Objectives: To report our experience of 108 patients with tuberculous pleural effusion and discuss the clinical features. cytological and microbiological analysis of pleural fluid. Pleural aspiration and biopsy were also performed.9%) had bilateral pleural involvement. They also had respiratory physical signs other than pleural effusion which include crepitation (31. the positivity rate of microbiological procedures and blind pleural biopsies.9 %) of patients needed second and third session of procedures respectively.7%).7% were cachexic.9% respectively. the clinical features.3% of TB patients produced sputum in their history.4% of the patients. 91 patients (84. Methods: This study was a hospital based descriptive cross sectional study performed at Chest Medical Ward. htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . Pleural effusion.Mean Pleural fluid and serum protein ratio was 0.64. Conclusion: Analysis of pleural fluid can have an important contribution for investigation of patients with pleural effusion.86 ± 15.39 ± 170.16.iomcworld.69 ± 0. Pleural fluid LDH was high in most cases with a mean ± SD was 726.com/ijcrimph/ijcrimph-v02-n03-01.17. percentage positivity of microbiological examinations on pleural fluid does not reach the degree required for a single diagnostic investigation for tuberculosis.24 ± 383. Total and differential white cell counts of peripheral blood film were within normal limits. The main WBC subset was lymphocytes (mean 91. Pleural biopsy will be useful as an ultimate procedure in cases with diagnostic problem as it is a procedure which can give a definitive tissue diagnosis.4 mm/1st hour. Light’s criteria Full Text: http://www. The mean ratio of pleural fluid and serum LDH was 1. Although highly specific. Key Words: Tuberculosis. 1 (2010) 401 .76). The Light’s criteria are fulfilled in all cases.56 ± 1. Mean ESR was high 77.96% of total WBC population) and polymorph was detected only 6. Pleural biopsy. Serum LDH also was high (507. 1 No.88 % (mean ± SD).Vol. India Abstract Background: The incidence of Breast Cancer is increasing. Bangalore & Thiruvananthapuram. India Suma Nair Department of Community Medicine Kasturba Medical College. The cases were enrolled in the order of their admission into the hospital during a four month study period. India Email: [email protected]%) of the disease when treatment options are limited and cure a distant probability. In fact in India.Vol. there are inherent factors that aid in the late presentation of breast cancer patients to a hospital. Results: Most (46%) of the cases belonged to the 45 – 54 age group and only 8% were over the age of 60. Identifying these factors holds great promise in reducing the incidence. Manipal University. Nearly 88% of the cases approached more than one Review of Global Medicine and Healthcare Research . Objectives: To study the socio-demographic and risk factors of breast cancer patients presenting to a tertiary care hospital and to determine the stage at presentation and factors contributing to delayed presentation. Despite a high literacy status (80%).Risk factors for breast cancer among women attending a tertiary care hospital in southern India Prince Antonio Harrison Kasturba Medical College. Nearly all the cases (98.05] showed a significant risk association. First delivery at age > 30 years [OR = 2.05] showed a beneficial effect. India Binu VS Department of Statistics Kasturba Medical College. 1 No. Cases and controls were personally interviewed by the investigator using a structured questionnaire and the data pertaining to treatment and diagnostic modalities were collected from the medical records. Methods: This was a one is to four matched case control study with a sample of 315 individuals. it is considered the leading Cancer among women in certain metros such as Mumbai. For each identified case an age matched control was recruited from the hospital. morbidity and mortality due to this disease. Moreover. 1 (2010) 402 .321 (0. The risk factors responsible for the causation of breast cancer may be population specific. Manipal University. Manipal University. Manipal University.com Kavitha Srinivasan Kasturba Medical College.106 – 0. women in this study had poor awareness pertaining to breast cancer (63%). particularly in previously low incidence areas such as Asia.27 (1.05) p < 0.971) p < 0. Manipal.02 – 5. Menarche <11 years [OR = 0.4%) had accidently identified the breast lump and none of them had ever performed a breast self examination or undergone any screening procedure. India MS Vidyasagar Department of Radiotherapy Kasturba Medical College. Considerable proportions of the cases were detected in stage III (46%) or stage IV (36. Risk factors.primary care practitioner prior to being referred to a cancer detection center. women in this study were more literate and employed as compared to many in other parts of India. 1 (2010) 403 .iomcworld. Delay in referral of cases was another significant finding which is of concern and needs to be addressed pragmatically. Various factors that affect delayed presentation such as fear of diagnosis and affordability were not studied. Key Words: Breast cancer. Conclusion: The risk factor for breast cancer determined by our study was first delivery over the age of 30. Screening Full Text: http://www. generalisability of these findings could be limited. 1 No.com/ijcrimph/ijcrimph-v02-n04-04. thereby delaying the process of diagnosis.Vol. Stage at diagnosis. Breast self examination.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . Besides. Considering the low awareness levels of the participants and nonexistent screening practices a targeted intervention to tackle this problem seems to be the need of the hour. Study Limitations: Since the controls were hospital based. 7% of abdominal trauma patients. Statistical significance was set at P<0. Although urgent surgery continues to be the standard for hemodynamically compromised patients with hepatic trauma.5%) had hepatic trauma with male predominance 68(81%).287 trauma patients referred to the main hospitals of seven cities with different geographic patterns was done in Iran.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . 1 No.com/ijcrimph/ijcrimph-v02-n04-03. The most type of trauma was blunt and the main cause was motor vehicle crashes. School of Medicine Tehran University of Medical Sciences (TUMS). We determined the incidence. Thirty patients (35. Eighty-four patients with hepatic trauma during the 1-year period ending March 2000 included in this Cross-Sectional study. There was no mortality in the patients managed non-surgically.05. Key Words: Liver trauma. etiology and management of the patients suffering liver injury.Vol. A marked change toward a more conservative approach in the treatment of abdominal trauma has been noted during the last decades. There was no significant difference in hospital stay between patients operated and managed non-operatively.iomcworld. Sina Hospital Tehran University of Medical Sciences (TUMS). Iran Email: laal. but liver damage is the most common cause of death after abdominal injury. Results: Out of 16287 trauma patients 84 (0. Material and Method: A study including 16. Analysis was done using SPSS 18. Modern treatment of liver trauma is increasingly non-operative. Non-operative management is a safe approach for the patients of liver trauma with stable hemodynamic. This study concluded non-operative management of hepatic injuries is associated with a low overall morbidity and does not result in increases in length of stay. Iran Marjan Laal Sina Trauma and Research Center. Non-operative Full Text: http://www. Conclusion: In this study hepatic trauma was in 3. there has been a paradigm shift in the management of patients who have stable hemodynamic. 1 (2010) 404 . Purpose: To find the epidemiology.marjan@gmail. Management.Liver Trauma: Operative and Non-operative Management Moosa Zargar Sina Trauma and Research Center Department of surgery.7%) managed non-operatively.com Abstract Background: The liver is the second most commonly injured organ in abdominal trauma. etiologies and managements of liver trauma in a population based study in Iran. Manipal University. Smear status by QBC.0% respectively.0%. India Email: ibairy@yahoo. 1 (2010) 405 . India Chetan Manohar Department of Pathology Kasturba Medical College. India Indira Bairy Department of Microbiology Kasturba Medical College. Manipal University. falciparum accounting for 32(45. vivax 37(52. positive predictive value and negative predictive value of 90. Falcivax test showed sensitivtiy. Further these antigens are obtained using recombinant techniques. Manipal. with their own initiative and meeting the inclusion criteria are included in the study. The technique is capable of accurate and reliable identification when performed by skilled microscopists using defined protocols. Manipal University. Aim of the study: The aim of the study is to evaluate Falcivax (Immunochromatographic Strip) test for the diagnosis of Malaria and to compare with Quantitative Buffy Coat (QBC). Tests were run in batches of 8 samples at a time for Falcivax.Vol. Review of Global Medicine and Healthcare Research . The current MRDDs are based on antigen capture immunoassay methodologies using immunochromatographic strip (ICS) technology. Manipal University.Evaluation of Falcivax against Quantitative Buffy Coat (QBC) for the Diagnosis of Malaria Bimala Gurung Department of Microbiology Kasturba Medical College. The newer generations of MRDDs are using more antigens like Merozoite protein 2 and circumsporozoite proteins. specificity. 100. In comparison with the study control – QBC in the detection of malaria. India. 1 No.7%) and P.9%). This study was done for the evaluation of two commercially available immunossays against QBC for the diagnosis of Malaria. Materials & methods: A total of 100 patients attending outpatient department of Kasturba Hospital.com Jagadishchandra Department of Microbiology Kasturba Medical College.0% and 81. The problems associated with implementing and sustaining a level of skilled microscopy appropriate for clinical diagnosis have particularly prompted the development of malaria rapid diagnostic devices (MRDDs). 2ml of blood was collected by venipuncture into tubes (Vacutainer blood collection system) containing EDTA as anticoagulant from all patients. clinical features and relevant laboratory data of each sample was noted down. India Abstract Introduction: Microscopic detection of appropriately stained blood smear for the diagnosis of Malaria has been the standard diagnostic technique for identifying malaria infections for more than a century.0%. Results: Out of 100 patients 70 tested positive for malaria by QBC with P. 100. 1 (2010) 406 . 1 No. Hence QBC still continues to be better option than MRDDs for detection of plasmodium infection in health care facilities with all expertise.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . Quantitative Buffy Coat Full Text: http://www. Immunochromatographic method.Conclusion: Falcivax showed a reduced sensitivity compared to the QBC. Falcivax. Key Words: Malaria.Vol.iomcworld.com/ijcrimph/ijcrimph-v02-n05-02. Results: The mean age at Menopause was 49. 1 No. Pakistan Nusrat Nisar Department of Obstetrics & Gynecology Liaquat University of Medical and Health Sciences.com Nisar Ahmed Sohoo National Programme for Family Planning and Primary Health Care Matiary. the mean scores of menopause rating Scale were high in all domains.Vol. psychological. Pakistan. Hyderabad Division from November 2007 to October 2008. Data was entered and analyzed by SPSS version 15.38±14. Objective: To investigate the severity of menopausal symptoms associated with menopausal status and to determine the quality of life of menopausal women from rural Sindh. 1 (2010) 407 . perimenopause and post menopause status (P=<0.001). psychological. 3062 women were selected by multistage random sampling method within the age range of 40-70 years. The psychological symptoms were more severe for women in perimenopause and post menopause status while the scores for urogenital symptoms were found to be higher in perimenopause women (P=<0. 25. the significant difference was found in the mean somatic scores of women in Premenopause. Pakistan Abstract Background: Menopause is the time in women’s life when her ovaries stops producing Estrogen and Progesterone. Pakistan Email: nushopk2001@hotmail. Along with collection of socio-demographic data the Menopause rating Scale (MRS) and WHO Quality of life Brief (WHO QOL Brief) Questionnaire translated in Sindhi Language were filled for each individual subject. Material and Methods: This cross-sectional survey was conducted in 19 Union Councils of Matiary district. Assessment of quality of life during menopause deserves special attention as with increase in the life expectancy women lives about one third of their lives with hormone deficient state.29 years.053 households of these Union Councils. Sindh.Severity of Menopausal symptoms and the quality of life at different status of Menopause: a community based survey from rural Sindh. Among 5. social and environmental domains of WHO QOL questionnaire were found significantly impaired for all women at different status of menopause. Studies on menopause and quality of life of menopausal women are scarce and none is conducted before among rural women of Sindh Province. The mean scores of all the domains of Menopause rating Review of Global Medicine and Healthcare Research . vasomotor and sexual symptoms that affect the overall quality of life of women. the deficiency of these hormones elicit various somatic. The mean scores for the physical. Conclusion: To best of our knowledge this is the first attempt to provide data on menopause and quality of life of women from rural Sindh.082 population dwelling in 1509 villages and 56.001). Key Words: Menopause. The severity of menopausal symptoms decreases the quality of life in everyday life of these rural women.Vol. Menopause Rating Scale (MRS).com/ijcrimph/ijcrimph-v02-n05-01.scale were significantly high in Peri and postmenopausal women from rural Sindh. Quality of life. 1 No.iomcworld. Severity of symptoms. 1 (2010) 408 .htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . WHOQOL Full Text: http://www. migration of valved stent. the fact that the procedures are less invasive in comparison to open heart surgery. Study Limitations: Percutaneous valve replacement is a relatively new treatment modality. Results and Findings: Percutaneous valve replacement procedures offer substantial advantages to patients. few publications exist for consideration. Turkey Abstract Background: Percutaneous valve replacement is a relatively new treatment modality that is rapidly growing in application.com Gamze Gezgen Hacettepe University Faculty of Medicine. that needed to be taken into consideration and the selection of patients for the procedure needs improvement. Although these techniques have difficulties such as paravalvular leakage difficulty in deployment. Keywords: Percutaneous Valve Replacement Mitral Aortic Full Text: http://www. referenced and discussed them from articles that were obtained through Pubmed. percutaneous valve replacement is currently one of the most researched and actively debated subjects in interventional cardiology. Conclusion: With 12 different kinds of valves available for use. However.healthmedjournal. use of percutaneous catheter-based techniques as balloon valvuloplasty has been a good therapeutic option. In patients with mitral and aortic stenosis. migration of valved stent.com (HealthMED Journal) Review of Global Medicine and Healthcare Research . there are complications such as paravalvular leakage difficulty in deployment. percutaneous aortic valve replacement was demonstrated in the 1990s in vitro. Methods/Study Design: We enumerated the pros and cons from different perspectives. and improvement in patient selection. we expect to see an increase in percutaneous valve replacements worldwide.Vol. 1 No. Turkey Baki Gezgen Department of Molecular Biology and Genetics Istanbul Kultur University. The reducing of surgical risks. In this study we are aiming to review the current state and evaluate the pros and cons of this new treatment modality. Aim&Objectives: Percutaneous treatment of valve diseases has been an alternative to open surgery since the early 1980's. Turkey Email: emirroach@yahoo. and that rehabilitation times are shorter are positive aspects [2]. Later on.Percutaneous Valve Replacement: Where do we stand? Where are we going? Emir Charles Roach Hacettepe University Faculty of Medicine. followed by successful in vivo applications. 1 (2010) 409 . Hamedan. Several studies have shown conflicting variations for inflammatory cytokines and other biologic markers in RAU.24 pg/ml and 9. Iran Hamed Mortazavi Department of Oral Medicine. Interleukin-6. Hamedan. Aim: The aim of the present study was to determine the level of IL-8 and IL-6 in the serum of patients with RAU. Dental School Hamedan University of Medical Sciences. Dental School Hamedan University of Medical Sciences.Evaluation of serum levels of interleukin-6 and interleukin-8 in patients with recurrent aphthous ulcerations Behnoush Bakhtiari Dental School. Hamedan.01). Iran Abstract Introduction: Recurrent aphthous ulcers (RAU) are one of the most common ulcers in oral cavity. The cytokines levels were measured in serum by ELISA.Vol. Conclusion: The results of our study showed that serum levels of IL-8 and IL-6 were significantly higher in patients compared to controls.com Pejman Bakianian Vaziri Dept of Oral Medicine.09 pg/ml).com (HealthMED Journal) Review of Global Medicine and Healthcare Research . Iran Mehrdad Hajilooi Research Center of Dental School Hamedan University of Medical Sciences. Recurrent aphthous ulcers Full Text: http://www. Iran Email: beh_bakht@yahoo. respectively. Results: The mean value of IL-8 and IL-6 in patients (52.39) was 10 and 4 fold higher than control group (5.01 pg/ml and 2. Hamedan. Materials and method: In this case – control study. The SPSS software was used to analyze the results. 1 (2010) 410 . serum levels of IL-8 and IL-6 levels were measured in patients with RAU (n=40) and in healthy control subjects (n=40). Keywords: Interleukin-8. 1 No.healthmedjournal. The difference was statistically significant (t-test p=0. Hamedan University of Medical Sciences. com (HealthMED Journal) Review of Global Medicine and Healthcare Research . A Case-control Study Behnoush Bakhtiari Dental School. clinical and radiographical examination was carried out and blood samples were collected.Serum Interleukin-6 as a Serologic Marker of Chronic Periapical Lesions. Data were subjected to SPSS software and t-test was used for statistical analysis. Hamedan. Dental School Hamedan University of Medical Sciences. Iran Mehrdad Hajilooi Research Center of Dental School Hamedan University of Medical Sciences. Serum interleukin-6 was measured by ELISA method. Iran Email: beh_bakht@yahoo. Hamedan.001). 1 (2010) 411 .com Hamed Mortazavi Department of Oral Medicine. Hamedan. Results: Serum interleukin-6 concentration was significantly higher in patients group in comparison with healthy controls (P<0. After informed consent was obtained. Iran Shahrzad Nazari Department of Endodontics. Conclusion: The results of present study indicate that interleukin-6 produced in periapical lesions may serve as a marker of pathologic inflammatory activities in chronic periapical lesions. Keywords: Cytokine. Hamedan University of Medical Sciences. Chronic infection could affect general health by increasing production of cytokines such as interleukin-6 that probably play some roles in pathogenesis of pulpal and periapical diseases. Iran Abstract Background and aims: Chronic periapical disease with pulp origin is an inflammatory disorder caused by bacterial infection. Interleukin-6. Periapical lesions Full Text: http://www. 1 No. The aim of present study was a comparative evaluation of serum interleukin-6 in patients with periapical lesions and healthy controls.healthmedjournal. Cytokines such as interleukin-6 have important role in pathogenesis of inflammatory diseases. Dental School Hamedan University of Medical Sciences.Vol. Materials and Methods: This analytical case-control study included 40 patients suffering from chronic periapical lesions and 40 healthy persons without any oral diseases. Hamedan. Ministry of Defence. Institute of Nuclear Medicine and Allied Scieces Defence R&D Organization. microemulsion. Faculty of Pharmacy Jamia Hamdard (Hamdard University). New Delhi. non productive absorption. thus increasing the pre-corneal residence time of the delivery system and enhancing ocular bioavailability. solution. lower the risk of sightthreatening complications such as corneal ulceration. India Abstract Background: Hyperacute bacterial conjunctivitis is a severe. Jamia Hamdard (Hamdard University). currently being used topically to treat Review of Global Medicine and Healthcare Research . India Asgar Ali Department of Pharmaceutics.person spread.com M. India R. Aqil Department of Pharmaceutics. and eliminate the risk of more widespread extraocular disease. Institute of Nuclear Medicine and Allied Scieces Defence R&D Organization. microparticles. Flouroquinolones are one of the promising groups of antibiotics.Vol. such as hydrogels. ocular efficacy is closely related to ocular drug bioavailability. INDIA Email: himanshu18in@yahoo. transient residence time in cul-de-sac and the relative impermeability of the drugs to corneal epithelial membrane. A variety of ocular drug delivery system. Faculty of Pharmacy Jamia Hamdard (Hamdard University). nanoparticles. Khar Department of Pharmaceutics. changes to the gel phase.e. Ministry of Defence. suspension and ointments) is due mainly to the precorneal loss factor that include rapid tear turnover. India Aseem Bhatnagar Department of Nuclear Medicine. upon exposure to physiological conditions (pH. Faculty of Pharmacy. temperature. Bacterial conjunctivitis requires treatment with antibiotics for 5 to 7 days that may result in poor patient compliance with conventional dosage forms due to greater frequency of drug administration (2 drops every 2-3 hrs). K. sight threatening ocular infection that warrants immediate ophthalmic work-up and management. Poor ocular bioavailability of drugs (< 1%) from conventional eye drops (i. 1 (2010) 412 . ionic activation). reduce person-to. In situ hydrogel system can be formulated as a liquid dosage form suitable to be administered by instillation into the eye which.Novel in Situ Gel System for Effective Treatment of Bacterial Conjunctivitis Himanshu Gupta Department of Pharmaceutics. which may be enhanced by increasing corneal drug penetration and prolonging precorneal drug residence time. 1 No. liposomes and collagen shields have been designed and investigated for improved ocular bioavailability. Treatment to bacterial conjunctivitis is provided to shorten the course of disease. In general. India Gaurav Mittal Department of Nuclear Medicine. Faculty of Pharmacy Jamia Hamdard (Hamdard University). Gelation pH and gelation tempaerature of the formulation was found to be ~ 7.2). whereas developed formulation cleared at a very slow rate (p<0. the viscosity of the formulation should be increased due to physiological condition of eye i. It has a wider antibacterial spectrum. Methods/Study Design: Different placebo formulation were prepared and tested for best combination. Aims & Objectives: The purpose of our work was to develop and evaluate an ocular drug delivery system of a flouroquinolone antibacterial agent. 1 (2010) 413 . Application is under consideration of Human ethical committee for approval. Precorneal residence time was studied on albino rabbits by gamma scintigraphy after radiolabelling of sparfloxacin by Tc-99m.33 up to 24 h The developed in situ gel was found to be stable for longer duration of time imparting a shelf life of 2 years to the product. Conclusion: The developed in situ gel formulation gives extended release with better tolerability and prolonged retention at corneal site as compare to marketed formulation. tempaerature (pluronic F-127) and ion-activated (gellan gum) in situ gelation. based on the concept of pH (Chitosan). It is suitable for sustained ocular drug delivery and can go up to the clinical evaluation and application. In vitro release from developed formulation in simulated tear fluid. HET-CAM assay further proves the non irritant property of developed in situ gel. The formulation so developed should be in liquid form at formulation condition.5% w/v Chitosan. 9% w/v pluronic F-127 and 0.e. temperature (~32 C) and ion (calcium ion etc present in tear buffer). Curve fitting of in-vitro release data of optimized formulation was compared with different release model to select best fitting model using PCP Disso V 3.05) and remained at corneal surface for longer duration as no radioactivity was observed in systemic circulation. gamma scintigraphy Table 1: Physicochemical properties of the developed in situ gel formulation Review of Global Medicine and Healthcare Research . in situ gel. Results/Findings: A combination of 0. but when it will drop in to the eyes. Formulation was non-irritant up to 8 h (mean score 0) while the mean score was found to be 0.1). Stability studies were carried out as per ICH (International Conference on Harmonization) guidelines to determine the shelf life of the developed formulation. The optimized formulations were subjected to Microbiological assay which was carried out against Pseudomonas aeruginosa using cup-plate method.conjunctivitis and corneal ulcers. Limitations: Clinical trial was not done yet. Microbial assay shows clear zone of inhibition. and has the least chance of developing resistance compared with antibiotics of other groups. Formulation which gave the best result was considered the optimized formulation and subjected to rheological studies and in vitro release studies. Ocular tolerance of developed formulation was also studied by HET-CAM method. Marketed drug formulation cleared very rapidly from the corneal region and reached to systemic circulation through nasolachrymal drainage system.25% of gellan gum was found appropriate for in situ gel formulation. The observation of acquired gamma camera images showed good retention over the entire precorneal area for developed formulation as compared to marketed formulation (Fig. The best fit kinetic model was matrix model. pH 7. as significant radioactivity was recorded in kidney and bladder after 2h of ocular administration. conjuctivitis. sparfloxacin. better ocular penetration. 1 No. Key words: Ophthalmics.4 showed an extended release profile of sparfloxacin. suggesting non-fickian diffusion process. better bioavailability. Thus this will increase precorneal residence time of the drug with no compromise with vision and therapeutic efficacy of formulation.2 and 32ºC respectively (Table 1). And reveals prolong microbial efficacy of developed in situ gel as compared to marketed eye drops.0 software.Vol. pH (~ 7. (n=5) 6.Vol.1 296-301 mOsmol 7. 1 No.2) Values are expressed as mean ± S. Static whole body image after 2 h of drug administration in albino rabbits(a) marketed formulation (b) developed in situ gel system Review of Global Medicine and Healthcare Research .0-7. 1.337 40±5 cps 450±10 cps Fig.332-1.0-6.2 1.0) Viscosity (at pH 7.D.Parameter Inference Clarity Clear solution pH Osmolarity Gelation pH Refractive Index Viscosity (at pH 6. 1 (2010) 414 . 6% in all aneurysms in DSA (ACoA-100%. CTA is nowadays the best choice of diagnostic tool for detection rate in AcoA and MCA bifurcation aneurysms. 1 (2010) 415 . p=0.118. Poland Corresponding author’s Email: urbanski. Results: Comparison of demographic data. Aims: The aim of our study was to evaluate the diagnostic value of CTA in comparison with DSA and with surgical findings for the detection of intracranial aneurysms (IA) in patients with symptoms or signs indicating the presence of an aneurysm. who underwent open aneurysm repair or preservative treatment between January 2006 and December 2008. CT angiography. MCA-60%.59 day. However some locations of IA still may remain problematic.63 day. median age 53±16.bartlomiej@gmail. for the diagnostic confirmation (mean time 0. Marta Zebala.15).com Abstract Backgroung: CT angiography (CTA) has been used for the early diagnosis of ruptured intracranial aneurysms whereas digital subtraction angiography (DSA) is the accepted diagnostic procedure for the assessment of intracranial aneurysms and for the preoperative treatment planning of patients suffering from subarachnoid hemorrhage (SAH). 9 patients (2 men. Eighteen cases were selected.27±0. Lukasz Rejman Department of Neurosurgery of the 2nd Faculty of Medicine Medical University of Warsaw. The reported rate of negative angiography in SAH ranges from 10 to 20%. It is correlated with the accuracy of CTA and DSA in detection of IA.Computer tomography angiography and digital subtraction angiography as two valuable methods in the early diagnosis and treatment of intracranial aneurysms . However. median age 46±8 years) were treated using neurosurgical intervention and 9 patients (6 men. which were appropriately 91% in all aneurysms in CTA (ACoA-67%. CTA can be used not only as the first diagnostic tool. 1 No. Stanislaw Szlufik.Vol. but also as a control for diagnostic procedure when DSA was used firstly but the localization of aneurysm was not found or the location of SAH is unsure. Keywords: cerebral aneurysms.9 years) were qualified to preservative therapy. PCoA-100%).44±0. DSA is not the most valuable diagnostic method in all cases of aneurysms. but as the second tool. that more frequently firstly used is CTA (mean time 0. From the group. preoperative aneurysm anatomic features revealed no significant differences. Overall rate of diagnostic use of CTA and DSA in time after starting the verification of aneurysm diagnosis showed. as diagnosed with the use of both CTA and DSA for the detection of aneurysms. besides microaneurysms. digital subtraction angiography Review of Global Medicine and Healthcare Research . whereas DSA is also used. MCA-100%. p>0. PCoA-100%) and 63. But sensitivity in smaller aneurysms can be improved with optimization of the technique. Conclusions: We conclude that cerebral CTA is equally sensitive to DSA in the detection of intracranial aneurysms. Material and Methods: A retrospective analysis was performed of 328 patients with the diagnosis of subarachnoid haemorrhage.a comparative study Bartlomiej Urbanski. The data were evaluated with the use of statistical analysis.15). p>0. smaller than 2mm. Moreover. Poland Corresponding author’s Email: urbanski. operative and embolization reports and imaging of 328 patients with the diagnosis of SAH. patients who underwent coil embolization. Keywords: cerebral aneurysms. basillar artery (6. however both regimens have inherent risks. Patients were divided into 2 groups: group A. Stanislaw Szlufik.7) and 9 male between ages 24 and 70 years (mean 52. The aneurysm location were middle cerebral artery (45. Marta Zebala. surgical clipping Review of Global Medicine and Healthcare Research . controversy still surrounds especially the management of poor-grade subarachnoid hemorrhage (SAH) that historically fared poorly and often were excluded from aggressive treatment.com Abstract Backgroung: Both endovascular coil embolization and surgical clipping are now firmly established as treatment options for the management of cerebral aneurysms.2%). 1 No.1% were GOS 4 after the operation. This is especially important in patients within these grades due to their potential for obtaining higher functional and physical recoveries.Vol. In group B 50% were GOS 3 and 50% were GOS 4.4% in group A and 25% in group B. Results: 33 aneurysms were treated. Lukasz Rejman Department of Neurosurgery of the 2nd Faculty of Medicine Medical University of Warsaw. Short-term outcome was measured with Glasgow Outcome Scale (GOS). anterior communicating artery (24. sex. subarachnoid hemorrhage. coil embolization. endovascular embolization has evolved worldwide. 43. The mortality rate after 14 days in group A was 47.1%).1%).1%). localization of aneurysm. The diameter of the aneurysms ranged from 2 to 47 mm with mean 8. 27 patients were selected as cases with IV and V grade WFNS SAH. Conclusion: The results of this study demonstrate that endovascular treatment is associated with better outcome in patients with ruptured intracranial aneurysms with WFNS grades IV and V. The following data were evaluated: age. Clinical status of the patients was assessed using World Federation of Neurological Surgeons (WFNS) grade and Glasgow Coma Scale (GCS). In this group in 25% patients conditions had worsen. The standard treatment for several decades has been surgical clipping of the neck of the aneurysm.5% were GOS 3 and 26. patients who underwent clipping. The periprocedural technical complication rate was 17. who underwent aneurysm treatment at single center between January 2006 and December 2008. In group A 30. group B. Aims: The aim of our study was to evaluate both treatment techniques in poor-grade patients. 1 (2010) 416 .8% and 25% in group B. These group consisted of 18 female between the ages 30 and 71 years (mean 52.8 mm.5%). morphological parameters of aneurysms found in CTA and DSA. In this group in 52.Comparison of clipping vs coiling as methods of treatment in poor-grade subarachnoid hemorrhage  Bartlomiej Urbanski. vertebral artery (3%) and posterior communicating artery (3%). Methods: We retrospectively reviewed the charts.2% patients conditions had worsen during one to fourteen [email protected]). pericallosal artery (6.4% were GOS 2. In recent years. internal carotid artery (12. Coil embolizations were unsuccessful due to vasospasms and atherosclerosis. Methods: 1213 adult patients. Patients were randomly assigned to receive ondansetron 8 mg or granisetron 3mg or palonosetron 0. Main treatment related side effects were constipation and elevation of liver enzymes which was comparable for all the 3 drugs. remains a matter of debate. 1 (2010) 417 . Conclusion: When administered with dexamethasone before chemotherapy. But the best drug of the different serotonin antagonists. The observation period started with the initiation of chemotherapy (0 h) and continued for 24 h after completion of the chemotherapy for acute emesis and up to Day 5 for delayed nausea and vomiting. 1 No. India Email: [email protected]%) in the ondansetron group and 210 of 254 patients (82. 41 patients (64%) had complete response in the palonosetron group compared with 133 patients (56. Results: For highly emetogenic regimens. cost wise ondansetron may be preferred in highly emetogenic regimens. 52 of 64 patients (81.com Saugat Dey Bankura Sammilani Medical College. During the delayed phase.1%) in the ondansetron group and 114 patients (61. During the delayed phase. 2007 to September 30.Vol. For moderately emetogenic regimens. which is present in any developing country. Study Limitations: The study has fewer numbers of patients taking palonosetron due to financial limitations of the patients.8%) in granisetron group. 63 patients (67.75 mg (single dose).5%) had complete response during the acute phase in palonosetron group compared with 291 of 379 patients (76. when used along with equal dose of dexamethasone. India Abstract Background: Chemotherapy Induced Nausea and Vomiting (CINV) is a major problem for all cancer patients. which is both efficacious and economic. along with 16 mg of intravenous dexamethasone on Day 1 and 4mg on Day 2 and 3.Comparing Different Antiemetic Regimens for Chemotherapy Induced Nausea and Vomiting  Sayantani Ghosh Bankura Sammilani Medical College. randomized controlled trial in order to obtain the most potent and cost effective drug.7%) had complete response in the palonosetron group compared with 216 patients (57%) in the ondansetron group and 162 patients (63. 30 min before receiving chemotherapy. granisetron and palonosetron. in moderately to highly emetogenic chemotherapy by a double blind.2%) in granisetron group.4%) in the ondansetron group and 130 of 186 patients (69. 5-hydroxytryptamine 3 (5-HT3)-receptor antagonists or serotonin antagonists used along with dexamethasone is the most widely used antiemetic regimen in chemotherapy. although palonosetron requires only a single dosing. granisetron outshines ondansetron and is further outshined by palonosetron in both acute and delayed emesis and thus the decision should be taken as per patient profile.9%) in granisetron group.6%) in granisetron group. Although we have compared Review of Global Medicine and Healthcare Research . However in moderately emetogenic regimens. 86 of 93 patients (92. 487 on highly and 726 on moderately emetogenic chemotherapy. although palonosetron is found to be more efficacious. Aims & Objectives: To compare the relative efficacies and safeties of ondansetron. admitted in various departments of a teaching hospital in India from November 05. 2009 were included in the study.2%) had complete response during the acute phase in palonosetron group compared with 181 of 237 patients (76. palonosetron.the cost and availability of the 3 drugs.com/ijcrimph/ijcrimph-v02-n05-03. dexamethasone. ondansetron.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)) Review of Global Medicine and Healthcare Research . Keywords: Chemotherapy induced nausea and vomiting. Full Text: http://www. 1 (2010) 418 . granisetron.iomcworld. a detailed cost analysis could not be done due to paucity of resources. 1 No.Vol. 5-HT3 receptor antagonist. Aim of the work: Investigation of biochemical and ultrastructural changes of the diabetic hearts and effect of supplementation with alpha-lipoic acid (ALA). abnormal mitochondria with heterogonous electron dense matrix and disrupted mitochondrial membranes. malondialdehyde (MDA). Faculty of Medicine Mansoura University. cholesterol and hepatic tissue glucose -6-phosphatase enzyme (G-6-Pase) activity in addition to a significant decrease in heart tissue glutathione (GSH). dilated sarcoplasmic reticulum. Egypt Email: [email protected] of Alpha-Lipoic Acid on Streptozotocin Induced Diabetic Cardiomyopathy in Adult Male Albino Rats: A Biochemiacal and Microscopical Study  Samar A. Egypt Shireen A. biochemicals   Review of Global Medicine and Healthcare Research . Egypt Hala Abdel-Malek Departments of Clinical Pharmacology. Ultrastructurally. with collagen deposition. diabetic hearts showed poorly organized myofibrils and sarcomeres. Mazroa Departments of Histology. Diabetes was induced in groups II and III by streptozotocin drug. 1 (2010) 419 . The animals were sacrificed after16 weeks. These patients may suffer from diabetic cardiomyopathy. In diabetic (group-III) animals. The hearts and sera were prepared for biochemical and microscopical studies. Results: Diabetic (group-II) animals showed significant increase in sera of glucose. ALA. Faculty of Medicine Mansoura University. Keywords: Diabetic cardiomyopathy. 1 No. Asker Departments of Histology. Materials and Methods: Thirty adult male albino rats were divided into: group I control. structural and ultrastructural changes. ALA ameliorated biochemical.Vol. group II diabetic and group III diabetic rats receiving ALA. Faculty of Medicine Mansoura University. cardiac muscle fibers appeared swollen with areas devoid of fibers. Alpha-lipoic acid. Conclusion: The supplementation of ALA in diabetic rats had a possible protective effect against the risk of the progression of cardiovascular diseases during diabetes.com Abstract Background: Cardiovascular disease is responsible for 80%of deaths among diabetic patients. ultrastructural. disrupted Z lines. Structurally. 185 were abstainers. long-term memory and attention were used in every phase of the experiment. Tests on short-term. Minsk. third phase – with text № 2 (physiology of autonomic nervous system and also answered subsequently on the questions that followed it). The errors made on various tests/tasks increased with decrease in the blood glucose concentration (r= – 0. STAI. even in episodic moderate doses (28ml/person with 1-2 times frequency per month) is accompanied by long-term glucose homeostasis Review of Global Medicine and Healthcare Research . including the initial level. second phase . The Intellectual Capacity on various tests/tasks positively correlated with the blood glucose level and in the 2-3 phases of the experiment and according to the results of the academic performances (r= +0. as well as to the values of the abstainers.A Novel Psychophysiological Model of the Effect of Alcohol Use on Academic Performance Menizibeya O.0 times higher number of errors on various tests/tasks than the non-alcohol users (p<0. Pereverzev Department of Normal Physiology Belarusian State Medical University.83. p<0.5 hours on fasting. Minsk.05). Selection criteria were based on a screening survey conducted among students in Minsk. Blood glucose level was measured at 2 hours intervals. The t-test was employed for statistical analysis of results. Academic Performance questionnaires. Methods / Study Design: The study involved 13 male volunteers (8 moderate alcohol users and 5 non-alcohol users) – medical students and took 6. CAGE. 1052 – moderate drinkers.com Elena V. p<0. Results / Findings: The moderate drinkers had significantly lower glucose concentration after 4-6 hours. 1 No. Belarus Email: [email protected]). Conclusion: This is the first study to show that alcohol use. Alcohol users had 12. precisely a decrease in the effectiveness of active attention and a faster development of fatigue after 4-6 hours of mental work in alcohol users. Belarus Vladimir A. 1 (2010) 420 . compared to abstainers was statistically proven. MAST. Out of 1499 students. Aims & Objectives: To produce a model of students’ alcohol use based on glucose homeostasis control and cognitive functions. Significant increase in VPC among abstainers was also observed (p<0. 262 – problem drinkers. Belarus Abstract Background: The blood glucose concentration might determine the degree of academic performance.05. Pereverzeva Department of Internal Medicine Belarusian State Medical University. Belarus. Minsk. Disturbances in cognitive functions.5–40.01).01). Decrease in the glucose concentration leads to a lowering of cognitive functions. The experiment was divided into three phases: first phase – the students were administered AUDIT.Vol. Welcome Belarusian State Medical University. The probability value for significance was set at p<0. compared to their initial concentration.the students worked with text № 1 (physiology of bone tissue and subsequently answered on the questions that followed it). disorders. glucose homeostasis. These disorders in glucose homeostasis. cognitive functions. Keywords: Psychophysiological model. alcohol use. leading to cognitive function disturbances and a decrease in the effectiveness of mental activities. 1 (2010) 421 . cognitive functions were retained after 7-10 days of moderate alcohol use and might be the reason for the low academic performances among students who use alcoholic beverages.iomcworld. 1 No. students Full Text: http://www.com/ijcrimph/ijcrimph-v02-n06-01.Vol. academic performance.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH))   Review of Global Medicine and Healthcare Research . Imarisio Department of Genetics. University of Cambridge.htm (International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH))   Review of Global Medicine and Healthcare Research . increasing its capacity to aggregate.Vol. defective autophagy is involved in the pathology of neurodegenerative diseases 2. These were the phenotypes of the mRFP and EGFP. After inserting the marker into the vector the construct was then tested using Drosophila embryonic cell cultures and analysis by fluorescence microscopy. monomeric red fluorescent protein (mRFP) and a green fluorescent protein (EGFP) 3. expression of the two colours red and green were seen. and has already been used in mammalian cells. showing that the construct was being expressed correctly. however. This system is based on the production of a fusion protein of LC3 tagged with two fluorescent markers. Methods/Study Design: We attempted this by placing the LC3 marker into a Drosophila vector ФC31 pUAST attB. Email: sr508@imperial. LC3 is a protein incorporated uniquely into the membrane of an autophagosome. and is widely accepted as a marker of autophagy. The intensity of these colours changed when the levels of autophagy were varied using bafilomycin and rapamycin. One of the major ways soluble monomer. autophagy. which is the apparatus of autophagy. a robust quantitative analysis still needs to be undertaken. 1 (2010) 422 .com/ijcrimph/ijcrimph-v02-n06-02.uk Abstract Background: Huntington’s disease is an autosomal dominant disease where the huntingtin protein is expanded by polyglutamines. Conclusion: For this construct to be used as a useful marker for autophagy. Keywords: Huntington’s. Dr S. Results/Findings: When the construct was tested in Drosophila embryonic cells. This results in a toxic gain of function of the protein 1. Dose response curves would also produce important data in trying to ascertain what level of calibration is needed to effectively use this transgenic marker. transgenesis Full Text: http://www. 1 No. Furthermore. Aims & Objectives: The aim of this project is to use this system in vivo targeting the mRFP-EGFPrLC3 construct into the Drosophila genome by site specific integration.ac. oligomers and aggregations can be degraded is by macroautophagy (from here after referred to as autophagy).iomcworld. only a small qualitative difference was seen. UK * Corresponding Author. A relatively new assay has been developed by Kimura where the different stages and activity of autophagy can be more closely studied.Developing a transgenic marker to research Huntington’s disease in Drosophila melanogaster Simon Rodney *. Prepregnancy BMI categorized into four major groups recommended by Institute of medicine and WHO guidelines for Asian and Pacific populations. Pakistan Email: jduhs@duhs. Pakistan Email: mustafeelaser@yahoo. Pakistan Email: Nutrition_bmu@hotmail. Email: Mahjabeen. Review of Global Medicine and Healthcare Research . 1 No. Karachi.khan@duhs. Data were analyzed using SPSS windows version 15. Karachi. This communication describes the modern changes in obesity during pregnancy especially in deprived society Objectives: To determine the influence of maternal Prepregnancy body mass index (BMI) and total weight gain during pregnancy on perinatal outcome in a low resource Pakistani community. All pregnancies were followed for weight gain for Perinatal outcome.com Abstract Background Maternal weight and weight gain during pregnancy are related to fetal weight and outcome as they are surrogates for maternal nutrition and health.com Zahid Mira Research Department Dow University of Health Sciences. Karachi.Implications of Weight Gain during Pregnancy in Pakistan Mahjabeen Khan * Department of Obstetrics and Gynecology and Research Dow university of Health Sciences. Pakistan Duration: from June 2007 to June 2008 Methodology: A total of 1039 women were assessed for nutritional status (BMIKg/m2 and waist measurements in centimeters) before conception and/or in early first trimester pregnancy before 10th weeks of pregnancy.edu.pk Syed Mustafeel Aser Quadri Institute of Environmental studies University of Karachi. Obesity is associated with major risks of adverse pregnancy outcome in deprived population. Pakistan * Corresponding Author.pk Peter Baillie Department of Clinical Nutrition Baqai Medical University. 1 (2010) 423 . Statistical tests chi square test was used to compare means and calculation of P values. Study design: Population based prospective cohort study Setting: Periurban area of three union councils (UCs) in Gadap Town. Prepregnant body mass index and total weight gain during pregnancy are important determinants of birth weight.Vol. Mean ±SD for numerical and proportions for categorical data was obtained.edu. Mean estimated weight gain from conception was 6.6%) and above 2500 gms 680(82.The average weight gain during pregnancy in the first trimester was 1. Waist measurement.Results: Total numbers of deliveries were 1039 observed during the study period.400.90 Kg per week. Obesity and pregnancy.5 Kg±4. Perinatal outcome.4%).Most of the mothers delivered alive babies701 (67.50 ±.4%).4%). 1 (2010) 424 .Vol. Low birth weight   Review of Global Medicine and Healthcare Research .5%) and reproductive failure was abortion 209(20%) and Perinatal mortality 129(12.6%) and Perinatal mortality 213(30. The Prepregnancy Waist measurement at categories (≤80≥Cms) on Perinatal outcome revealed live488 (69.06 Kg. Total weight gain during second and third trimester ranged between0. Study Limitations: The study had logistic limitations of collecting data for whole length of pregnancy therefore three to five observations were collected from each index pregnancy included in the study. weight gain during pregnancy.2.Low birth weight <2500 gms were 145(17. 1 No. Keywords: Prepregnancy Body Mass Index. Conclusion: The implication of these findings are that BMI can no longer be used as a measure of over nutrition leading to increased fetal size in deprived populations and that the mechanisms of fetal death are different in deprived situations where fetal precedence does not apply. total palsy. Over the last 15 years. Five functions were tested: shoulder abduction. For the former four functions. Al-Kahtani FS College of Medicine. as one goes down from Group 1 to 4. the first visit to our clinic before three weeks of age. wrist extension and the overall hand function. King Saud University. Al-Harbi MS. C6. by which time lesions due to simple conduction block have begun to recover. A hypothesis was made that newborns with extended Erb's palsy (Narakas Group II) may be subclassified into two groups according to this "early recovery of wrist extension. Over the past 15 years. Newborns were classified into five groups as shown in Table 2.Vol.0001 by Chi-square test). Al-Zahrani AY *. cephalic presentation. extended Erb's. Good spontaneous recovery of hand function was defined Review of Global Medicine and Healthcare Research .Narakas Classification of Obstetric Brachial Plexus Palsy Revisited  Al-Qattan MM. elbow flexion. the hypothesis was found to be true: patients with extended Erb's and "early recovery of wrist extension" have a highly significant higher percentages of good spontaneous recovery of limb function than those with extended Erb's and "no early recovery of wrist extension" (P<0. The percentage of "good spontaneous recovery" of the motor function of the limb was documented and compared between the groups. Al-Mutairi AM. A hypothesis was put that patients with extended Erb's may be subclassified into two groups according to this "early recovery of wrist extension". C7 injury) was more likely if they recovered active wrist extension against gravity before two months of age. the overall prognosis for spontaneous recovery gets worse and hence the likelihood for primary surgery gets higher and this was confirmed by Bisinella and Birch (2003). Narakas (1987) classified babies with obstetric brachial plexus palsy (OBBP) into four groups (Table 1). and total palsy with a Horner. However. the senior author (MMA) has noted that good spontaneous recovery in newborns with extended Erb's (Group 2) was more likely if they recovered active wrist extension against gravity before two months of age. Birch recommended that the classification should be applied after about two weeks (post-delivery). He also recommended that the classification should not be used as indication for primary exploration of the brachial plexus. shoulder external rotation. it was noted at our obstetric palsy clinic that good spontaneous recovery in newborns with extended Erb's palsy (C5. 1 (2010) 425 . El-Sayed AA. Saudi Arabia * Corresponding Author. and a minimum follow-up period of 36 months. The following study was designed to test this hypothesis." In a retrospective study of 581 cases with strict inclusion criteria. Birch (2002) considered the classification an important contribution to the clinical analysis of OBBP and stated that it deserves to be better known and more widely used. Inclusion criteria were as follows: vaginal delivery.com Abstract Background Narakas classified babies with obstetric palsy into 4 groups: upper Erb's. Al-Mutairi SA. 1 No. regular attendance at clinic visits. "good spontaneous recovery" was defined as full spontaneous recovery or spontaneous recovery of greater than half range of motion compared to the contralateral normal limb. Email: ahmad96@hotmail. Patients and Methods A retrospective review of the data from our OBBP clinic over the last 15 years was done. It is important to realize that breech babies were not included in the current study because they present a unique group with unusually high percentage of upper root avulsion (Al-Qattan. n = 279 (48%). we perform primary brachial plexus exploration for Erb's and total palsies if there is no active elbow flexion against gravity by 4 and 3 months of age.. Ubachs et al. Similarly. All patients who underwent primary brachial plexus surgery in our series were found intra-operatively to have root rupture or avulsion which also confirmed that recovery would have been poor without surgery. 1996). Group IV. respectively by Chi-square test). 1995).034 and 0.Vol.0001) in all functions tested indicating that Group II have a better chance for good spontaneous recovery of all affected functions. The explanation of these findings may be withdrawn from forces applied to the brachial plexus during delivery. 2003. and the differences reached statistical significance in shoulder abduction and shoulder external rotation (P=0. 1 (2010) 426 . the following events occur concurrently: hyperextension of the neck of the foetus. Results A total of 581 cases of OBBP were included in the study and were classified as follows: Group I. The percentages of good spontaneous recovery in each group at each function tested are shown in Table 3. a comparison between Groups III and IV showed worse percentages of Group III in all functions except shoulder external rotation. The percentages of good spontaneous recovery were compared using the Chi-square test. 1996. spontaneous recovery was documented prior to any surgical procedure to improve function.” In fact. and Group V. 1995). and statistical significance was reached for elbow flexion (P=0. the presence of pseudomeningocele on CT myelogram or MRI may give an idea regarding root avulsion despite the false positive/negative occurrences (Clarke and Curtis. In all patients. n = 44 (8%).002 by Chi-square test). n = 138 (24%). n = 61 (10%). Using the Chi-square test. 1 No. In our center. Finally. elongation of the spinal cord and direct downtraction on the shoulders. these studies may only reach a high level of accuracy with an experienced operator (Smith. The senior author is frequently asked about the expected prognosis by the anxious parents as well as by the referring obstetrician fearing medico-legal litigation. respectively.as the recovery of a good grip and the absence of intrinsic minus posture.. Discussion Narakas classification of OBBP is useful in clinical practice because it provides an overall view of the expected prognosis soon after birth of the affected newborn. We do not do these tests in our center because they require general anaesthesia or heavy sedation in the newborn and the radiological findings will have no impact on the decision for primary exploration of the brachial plexus. Group III. Geutjens et al. n = 59 (10%). An unexpected finding was the comparison between Groups I and II which showed better percentages of good spontaneous recovery in Group II. This is explained by the fact that during difficult delivery of the “after-coming head” of breech babies. those with “early recovery” have a better outcome at the shoulder and elbow when compared to the upper Erb’s group and those with "late or no recovery" have a worse outcome in most upper limb functions when compared with total palsy and no Horner. The results of our study proved that the hypothesis is true: patients with extended Erb’s palsy may be subclassified into two groups according to “early recovery of wrist extension. This puts the transmitted force directly on the upper nerve roots at their fixed entry in the intervertebral foramina leading to upper root avulsion (Sunderland’s central Review of Global Medicine and Healthcare Research . the worst spontaneous recovery was in shoulder external rotation in all five groups.048. the difference between Groups II and III was highly significant (P<0. Neurophysiological studies are difficult to interpret in the newborn because of the well known “collateral sprouting” and hence. Furthermore. Group II. Obstetric brachial plexus palsy." Further force will then cause a stretch injury and finally extraforaminal rupture of the upper three roots. This percentage will then be intermediate between the percentages of the "upper Erb's" group and the group with "total Erb's and no Horner". In: Lamb DW (Ed). In: Sunderland S (Ed). p 461. Edinburgh 1987. Amar-Khodja S. p 147. 21:145-8. Curtis CG. 1991). Obstetric brachial plexus lesions: A study of 74 children registered with the British Paediatric Surveillance Unit (March 1998-March 1999). Invited Editorial: Obstetric brachial plexus palsy. Churchill Livingstone. 1998. Arch Pediatr Adolesc Med. Birch R. Bisinella GL. Obstetric paralysis: its etiology. Kay SPJ. Scheker LR (Eds). Obstetric brachial plexus palsy associated with breech delivery. 28:40-5. 1996. clinical aspects and treatment. Sunderland. J Hand Surg Br. 1998) have noted that internal rotation contracture of the shoulder is the most common secondary deformity in older children with OBBP. several authors (Al-Qattan. Obstetric antecedents of surgically treated obstetric brachial plexus injuries. but also establish the fact that spontaneous recovery of external rotation of the shoulder is the worst among all affected limb functions in all types of OBBP (Table 3). 28:483-6. Br J Obstet Gynecol. Hand Clin. Smith SJM. Sunderland S. Ubachs JMH. 1996. J Bone Joint Surg Br. Obstetric brachial plexus injuries.avulsion mechanism. the anterior shoulder of the baby is ‘stuck’ at the symphysis pubis of the mother and lateral forces on the head lead to widening of the head-shoulder angle. Birch. Sloof ACJ. 1988. forcible separation of the head and shoulder puts the upper two cords under tension and they "stand out like violin strings. If we combine both groups. Indications and results of brachial plexus surgery in obstetric palsy. Classification of secondary shoulder deformities in obstetric brachial plexus palsy. 1 No. 2003. Razabon R. Br J Plast Surg. Geutjens G. 1995. Gilbert et al. 1991. 2000. Narakas AO. 2003. A different pattern of injury. pp 116-135. Group II (with early recovery of wrist extension) may have been mostly a "stretch" injury with better prognosis while Group III (with late or no recovery of wrist extension) were probably a "rupture" injury with worse prognosis. Helsen K. 1988). Review of Global Medicine and Healthcare Research . These experimental findings could provide an explanation to our results. Traction nerve injury. In: Gupta A. 19:91-105. As described by Sever (1916) in his experimental studies on infant cadavers. Mosby: Edinburgh 2000. Ann Palst Surg. Our results not only confirm this observation. 27:3-12. Obstetric brachial palsy. The role of neurophysiological investigation in traumatic brachial plexus injuries in adults and children. 102:813-7. Nerve injuries and their repair. Gilbert A. Kay. Birch R. Kay SPJ. 2003. The Growing Hand. 1 (2010) 427 . Orthop Clin North Am. All cases included in the current study had cephalic presentation and upper root avulsion is known to be extremely rare in these newborns (Gilbert et al. J Hand Surg Br. J Hand Surg Br. 11:56380. 12:541-78. References Al-Qattan MM. Gilbert A. Al-Qattan MM. Obstetric brachial plexus palsy associated with breech delivery.Vol. Peeters LLH. Finally. In cephalic babies with traumatic delivery. The paralysed hand. the percentage of good spontaneous recovery for elbow flexion would be 72% (74 out of 103 cases with C5/C6/C7 injury). 2002. Edinburth. 1916. J Hand Surg Br. Sever JW. An approach to obstetrical brachial plexus injuries. 51:43-50. Churchill Livingston. Clarke HM. 2003. 1995. 78:303-6. with a report of four hundred and seventy cases. 1988. Birch R. 51:257-64. A functional hand may be seen in many patients. C6. The worst outcome. C7 3 Total palsy with no Horner syndrome C5. severe defects throughout the limb are expected.Table 1: Narakas classification of obstetric palsy Group 1 Name Upper Erb's Roots Injured C5. C6 Site of Weakness/Paralysis Shoulder abduction/external rotation. C7. C6. III Extended Erb's with no early recovery of wrist extension IV Total palsy with no Horner V Total palsy with Horner Review of Global Medicine and Healthcare Research . 1 No. There is no Horner syndrome. Active wrist extension against gravity does not recover on follow-up within the first two months after birth. C5/C6/C7 injury as per the first examination 2-3 weeks after birth. Active wrist extension against gravity recovers on follow-up within the first two months after birth. C5/C6/C7/C8/T1 injury as per the first examination 2-3 weeks after birth. T1 Complete flaccid paralysis 4 Total palsy with Horner syndrome C5.Vol. Good spontaneous recovery of the shoulder and elbow in 30-50% of cases. Good spontaneous recovery in about 60% of cases. 2 Extended Erb's C5. C5/C6/C7 injury as per the first examination 2-3 weeks after birth. Same as group IV but with a Horner syndrome present at the initial examination. T1 Complete flaccid paralysis with Horner syndrome Table 2: Classification of newborns with OBBP in the current study Group I II Name Upper Erb's Extended Erb's with early recovery of wrist extension Criteria C5/C6 injury as per the first examination 2-3 weeks after birth. elbow flexion As above with drop wrist Likely Outcome Good spontaneous recovery in over 80% of cases. Without surgery. 1 (2010) 428 . C6. C8. C7. C8. 1%) 17 (27.5%) Definitions of the groups are shown in Table 2. %) Good spontaneous recovery of wrist extension (n. 1 No.5%) 5 (11. Review of Global Medicine and Healthcare Research .9%) 16 (36.4%) 9 (6.6%) 246 (88.6%) 45 (76.6%) 31 (52. %) Good spontaneous recovery of shoulder external rotation (n. %) 169 (60. %) Good spontaneous recovery of hand function (n.2%) 28 (20. %) Good spontaneous recovery of elbow flexion (n.3%) 8 (13.Vol.5%) 22 (36.Table 3: The percentages of good spontaneous recovery in the five groups of OBBP in the current study Group I (n = 279) Group II (n = 59) Group III (n = 44) Group IV (n = 138) Group V (n = 61) Function tested Good spontaneous recovery of shoulder abduction (n.5%) 100 (72.1%) 105 (37.7%) 18 (29.2%) 54 (91.5%) 20 (45. 1 (2010) 429 .5%) 1 (1.3%) 8 (18.9%) Not applicable Not applicable 56 (94.4%) 56 (40.6%) Not applicable Not applicable 63 (45. Counseling and awareness regarding the presence of macrosomia was given. 1 No.5 Kg in last trimesters Exclusion criteria: Women not consenting Twin pregnancy Review of Global Medicine and Healthcare Research .pk Introduction There has been no test to predict fetal macrosomia with certainity. There is a need for macrocosmic infants screening.Outcome of Macrosomic Infants in a Lowsocioeconomic Groups Mahjabeen Khan Department of Obstetrics and Gynecology and Research Dow University of Health Sciences. Objective To estimate the incidence and obstetric outcome of fetal macrosomia in both diabetic and non diabetic mothers Patients and Methods Baseline information was collected in the form of a questionnaire.Vol. Obstetrics outcome in terms of birth weight. Pakistan. Study Design: Community-based prospective cohort study Study Setting: The study was conducted at 3 union councils of Gadap Town Karachi. Study duration: From May 2008-April 2008 Study population: All prospective mothers including diabetes and non diabetics with estimated weight greater than 3.khan@duhs. This study will provide information about: incidence of macrosomia in a rural community. Perinatal mortality associated with fetal macrosomia is documented in some studies of few countries. Fetal macrosomia is missed during pregnancy and labour. 1 (2010) 430 . There have been maternal and fetal complications contributing in high maternal and fetal mortality and morbidity. mode of delivery. Rationale The incidence and risk of macrosomia in our population is unknown. Prepregnancy weight was taken in the initial visit at home or hospital and total weight gain at delivery. morbidity were collected and analyzed. Pakistan Email: Mahjabeen. Karachi. National planning & implementation for macrosomia in developing countries. The route of delivery with suspected macrosomia is still controversial.edu. Vol. 1 (2010) 431 . 1: Proportion of Macrosomiac Infants in Diabetics and Non Diabetics Patients Review of Global Medicine and Healthcare Research . 9.Results The incidence rate of macrosomia in my study was 7% per year. Fig.The obstetric outcome of fetal macrosomia in both diabetic and non diabetic mothers have been shown in graph I and Tables I & II.7 Kg is the mean difference between Prepregnancy weight and total weight gain in both groups. 1 No. 90 Mean 26.3%) 155(67.77%) 34(5.38 -0. 1 No.5 Total 249(70. Review of Global Medicine and Healthcare Research .93 7.I.37 0.90 1.24 73.40 7.74%) Cesarean Delivery 14(3.63 -2.85 -0.87 Standard Deviation 5.Vol.53 Diabetics Patients Standard Deviation 5.26 1.24%) 144(24.08 2.16 28.52 1.19 2.09 28.01 5.08 1. Based on these results it is recommended that fetal macrosomia screening should be an integral part of antenatal care.10 0.41 37. 1 (2010) 432 . for difference of Mean Upper Bound Lower Bound -0.76 7.98%) 404(69.41%) Instrumental Delivery 91(25.7%) 53(23.76 63.02 0.14 7.69 73.95%) 20(8.18 -2.09 1.29 Conclusion Incidence of fetal macrosomia in our study population was 7 %.88 37.69 2.95 2.57 1.29 6.12 64.5 More than 3.14 95% C.Table I: Weight of Baby * Mode of Delivery Mode of Delivery Weight of Baby SVD Less than 3.84%) Total 354(100%) 228(100%) 582(100%) Table II: Demographic Characteristics of Study Population Non Diabetics Patients Demographic Characteristics of Study Population Mean Maternal Age Parity BMI Pre-Pregnancy Weight Total Weight Gain Gestational Age 26.