Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareTOPICAL VERSUS CONTINUOUS BETAMETHASONE DIPROBIONATE PHONOPHORESIS IN THE TREATMENT OF ATOPIC DERMATITIC PATIENTS
English0108Intsar S. WakedEnglish Abdel Hamid N. DeghidiEnglishPurpose: The purpose of this study was to compare Topical versus Continuous Betamethasone Diprobionate Phonophoresis in the Treatment of Atopic Dermatitic Patients Methods: Forty six patients atopic dermatitis were participated in this study and were randomly assigned to one of two groups. Phonophoresis group received continuous 0.05% betamethasone dipropionate phonophoresis, three sessions per week for 4 weeks, and control group received topical betamethasone dipropionate cream daily. Measurements were carried out by ultrasonography and SCORAD score. Results: results revealed that there was a significant difference between both groups as regard to primary outcomes ( SCORAD score) as well as secondary outcomes ( skin thickness measurements). Conclusion: it was concluded that continuous betamethasone diprobionate phonophoresis is a safe and effective modality more than topical cream for the treatment of atopic dermatitis.
EnglishPhonophoresis, betamethasone dipropionate phonophoresis, SCORAD score, ultrasonography, Atopic dermatitis.INTRODUCTION
Atopic Dermatitis (AD) is a chronic (long-lasting) disease that affects the skin. The word “Dermatitis” means inflammation of the skin. “Atopic” refers to a group of diseases that are hereditary (that is, run in families) and often occur together, including asthma, allergies such as hay fever. In atopic dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling1. Any chronic illness can have major impact on the sufferer's life. Atopic disease have become a major health problem. Its chronic course with extreme pruritus and loss of sleep affects the whole family. AD may have profound effects on the quality of life, social relationships and development. It also interferes with school and physical activities. Treatment may be demanding with frequent hospital attendances2 . Topical corticosteroid such as betamethasone phonophoresis is effective in patients with AD. Although topical corticosteroids have been the mainstay of treatment for the past 40 years, they have local and systemic side effects. Local effects include skin atrophy, telangiectasias, hypopigmentation, rosacea, perioral dermatitis and acne. Systemic side effects include adrenal suppression, cataracts, glaucoma and growth retardation in children. These effects cause anxiety for both patients and clinicians and this is the main reason for patients' poor compliance with treatment3 . The major barrier to the delivery of transcutaneous drugs is the skin. Pharmaceutical companies are continually involved in research to try to find new
ways to enhance the delivery of topical drugs. Although complex chemical enhancers have been integrated into some transdermal delivery systems, physical agents such as electricity and ultrasound (US) are becoming increasingly popular as enhancers. The use of electricity as an enhancer is referred to as iontophoresis, and the use of US as an enhancer is referred to as phonophoresis or sonophoresis4 . Phonophoresis (PH), has been claimed to enhance the percutaneous absorption of certain pharmacological agents such as anti-inflammatory, steroids and local anesthetics from intact skin into the underlying subcutaneous structures by ultrasound, therefore improving their effectiveness. PH offers the potential advantage of delivering a pharmacologic agent in a relatively safe, painless, and easy manner to structures that lie somewhat deep within the body 5 . Phonophoresis (PH) has been studied in vivo with several anti-inflammatory drugs, including hydrocortisone 6 , benzydamine 7 , dexamethasone 8 , and salicylates 9 and with anesthetics, such as lidocaine 10 , with variable results. However, no study in literature review conducted to study the efficacy and safety of betamethasone dipropionate phonophoresis in patients with AD. Therefore, we used 0.05% betamethasone dipropionate cream on daily bases as the reference for comparing and evaluating the efficacy and safety of phonophoresis 0.05% betamethasone dipropionate applied every other day in young adult with AD.
PATIENTS AND METHODS
Subjects This study was carried out on 46 patients with mild to moderate atopic dermatitis. Signed informed consent was obtained from each participant before enrollment in the study. History and clinical examination were done for all subjects and diagnosis of AD was made according to criteria proposed by Hanifin and Rajka, modified diagnostic criteria11 . Reasons for exclusion were patients had severe AD, known sensitivity to the study treatments or eczema confined to the face or nappy area. Patients were excluded if they had received any therapy for AD other than emollients or antihistamines within four weeks before the start of the study. Treatment was stopped when the SCORAD system 12 was below 9 (clinically healed) or ultimately after 4 weeks. All subjects were participated in single blind, randomized, controlled trial. To detect a 50% reduction in SCORAD index scores at the 5% significance level with 80% power, 23 patients per group are required. We recruited a larger number to allow for an estimated 10% withdrawal rate. A computerized random number list was generated and the subject allocation sequence was created from the list. The patients met with the blinded investigators who conducted the assessments. Following their assessments, the patients were assigned into 2 groups of equal number. PH - group received 0.05 % Betamethasone Dipropionate phonophoresis (BDP). Control group received 0.05 % Topical Betamethasone Dipropionate (TBD).
Measurements
All measurements have been recorded by blinded investigators who did not know the assignment groups. Primary outcome measurement included assessment of AD severity using SCORAD. The SCORAD have been collected at baseline (Pre) after 2 and 4 weeks. 2-week follow-up period with basic skin care only served to evaluate the AD and whether a rebound occurred. Secondary outcome included assessment of the thickness using ultrasonography, and safety analysis via measuring cortisol exertion in urine.
Severity of AD using SCORAD
The clinical severity of AD was evaluated by using the SCORAD index that developed by the European Task Force on atopic dermatitis (1993) 13. It defines a score of three parameters: extent, intensity and subjective symptoms. Extent is calculated with the rule of nines. Intensity items are erythema, edema/papulation, oozing/crust, excoriation, lichenification and dryness of non involved skin (0 to 3 points for each item). Subjective symptoms are pruritus and sleep loss for the last 3 days or nights (0 to 10 points for each item). The final score is then calculated according to the following equation: A/5 + 7B + C, where, A represents extent, B represents intensity and C represents subjective symptoms. The SCORAD is considered mild AD is less than 25, moderate lies 25-50 and severe AD is above 50.
Ultrasonography Measurements \
Throughout this study the depth of the lesions was evaluated using a high-resolution ultrasound system dedicated to skin applications 14. A Derma Scan C Ver. 3 (Cortex Technology ApS, Hadsund, Denmark) was used. The system frequency was at 20 MHz and with 10 mm penetration. The size of the probe was 19X33 mm and the scan length 12.1 mm. The principle of ultrasound imaging is based on the ultrasonic wave being partly reflected at the boundary of adjacent structures when traveling through tissue. The strength of this reflection depends on differences in the density of such structures, which leads to an amplitude variation of the reflected signal. Finally, processing of the signal received from multiple ultrasound pulses over an area of the skin forms a two-dimensional image; a so-called B-scan Safety Analysis Three 24-hour urine sample were collected for urinary-free cortisol/creatinine analysis at the beginning (baseline), the last day of the treatment period and at follow up. The 24-hour urine collections were mixed and stored frozen at-200C until they were analyzed in the clinical laboratory department 15 .
Treatment Procedures
Continuous Betamethasone Dipropionate phonphoresis has been conducted through Ultrasound device (Nonius, Sonopuls 434, SN 03- 202 type 1463.900, Enraf, Holland) , three sessions per week for 4 weeks. The patients assumed a comfortable position, then therapist clean and hydrate the body part under treatment. Adjust the US frequency to 1MHz, with intensity 1.5 W/cm2 and the time of treatment was 5 min 16 . For control group: The patients were instructed to apply the ointment to the selected area once daily
Statistical Analysis
Data were expressed as mean ± standard deviation (SD). Student t test was used to assess the difference between the studied parameters in two groups. Paired t test was used to analyze the thickness of the skin within the group. We analyzed severity scores by using a repeated measure analysis of variance. Cortisol excretion between the two groups was compared using the Mann-Whitney U test, and compared in time within each of the two treatment groups using the Wilcoxon test. Analysis was performed using SPSS/PC software (SPSS Inc., Chicago, IL, USA). All p values less than 0.05 were considered to be statistically significant.
RESULTS
Baseline Characteristics of the Patients Fifty-five patients enrolled in the study. Of these, 46 completed the study and nine dropout (3 patients in the PH -group and 6 in the control group). At baseline, the demographic characteristics, disease severity thickness of lesion and cortisol level were similar in both treatment groups. Table 1 lists the baseline characteristics.\
Results of the Primary Outcome SCOARD
No differences were observed in the SCORAD at the beginning of the study between the groups. Analysis of variance demonstrated significant difference in the mean downward linear trend of SCORAD within each group at 4 weeks compared to baseline and 2 weeks respectively. After 2 week of the treatment, the SCORAD (mean ± SD) significantly decreased in both treatment groups (PH: 17.04 ± 9.72, control: 19.56 ± 5.62). In spite of the marked improvement after 2 week, only 9 patients in the PH -group was scored as clinically healed (SCORAD < 9), and 3 patients was scored as clinically healed in the control group. At the 4 weeks of the treatment, the improvement of AD was more pronounced in the US-group. The mean SCORAD had dropped significantly to 8.08 ± 2.72 for US group compared with 14.26± 6.52 for the control group. There were 27 subjects with a SCORAD of 9 or less (17 in the PH -group and 10 in the control group). Two weeks after discontinuation of active treatment, the mean SCORAD had increased to 13 ± 9 (PH group) and 21 ± 7 (control group
after 4 weeks of treatment for PH and control group was 9.13±1.09 and 12.12±1.38 respectively. These results confirm the effectiveness of ultrasound in enhancing transfer of betamethasone diprobionate so enhancing healing and treatment of atopic dermatitis patients. Numerous studies16-18have since demonstrated that US is generally safe, with no negative long- or short-term side effects, but the mechanisms by which US works as an enhancer are less clearly understood. The simplest explanation for the effectiveness of US as an enhancer of drug delivery is based on its heating effects. Heat increases the kinetic energy of the drug molecules and the proteins, lipids, and carbohydrates in the cell membrane. Temperature changes of approximately 5°C are necessary to cause measurable changes in cell membrane permeability. This level of increase in heating only predictably occurs when the US intensity is 1.5 W/cm 2 or higher 19. Overall, the reviews of the research on the efficacy of phonophoresis are promising. Some of the studies, however, suffered methodological constraints that limit generalizability (eg, no control group, the experimenters were not blinded, the US delivery system was not calibrated, methods of documenting effectiveness were not objective, a small number of subjects were studied, or the topical drug used was not checked to ensure that it transmitted US (transmissivity). All these constraints were avoided in our study. And the transmissivity of betamethasone diprobionate was tested by Cameron MH and Monroe LG 20. Bommannon and colleagues17 concluded that highfrequency US was effective as an enhancer of transcutaneous drugs and could be used safely for short periods of time. When 16-MHz US is used for more extensive periods of time, it is possible that the bubbles of the micronuclei begin to grow, then collapse and self-destruct (cavitation), secondarily enhancing drug penetration. Tyle and Agrawala 21 reviewed the effects of drug delivery by phonophoresis in 1990 and concluded that US effectively enhanced localized and systemic drug delivery. Friberg24 reported that some of the studies that showed increases in drug diffusion with US were correlated with damage to the stratum corneum. This damage was either part of the pathology designated for treatment (eg, psoriasis, dermatitis, and ulcer) or it was an outcome of the US treatment itself or the use of a stationary sound head. Draper and Prentice 22 reported that the thermal effects of ultrasound increase tissue permeability, and the acoustic pressure created by the ultrasound beam drives the medication into the tissue. Naik et al.,23 reported that both the thermal and nonthermal effects of US increase cell permeability. Also Abd El Baky and Waked24 concluded in their study that phonophoresis is an effective method to enhance the delivery of ibuprofen and so enhance the improvement of grip strength. Barbara.,25 documented that both the thermal and nonthermal characteristics of high-frequency sound waves can enhance the diffusion of topically applied drugs. Heating from US increases the kinetic energy of the molecules in the drug and in the cell membrane, dilates points of entry such as the hair follicles and the sweat glands. And increases the circulation to the area sonicated. These physiological changes enhance the opportunity for drug molecules to diffuse through the stratum corneum and be collected by the capillary network in the dermis. In order to assess the safety of the study, Comparing the 24-hour urinary cortisol excretion at the beginning with the excretion at the end of treatment for both groups and the results revealed that there was no significant difference between the beginning and the end of treatment in both groups.
CONCLUSION
Finally, according to the results of our study and reports of other investigators in similar studies, It can be concluded that, betamethasone diprobionate phonophoresis is a safe and effective modality more than topical cream for the treatment of atopic dermatitis.
Englishhttp://ijcrr.com/abstract.php?article_id=941http://ijcrr.com/article_html.php?did=941REFERENCES
1. Eldy DJ. What’s new in atopic dermatitis? Br. J. Dermatol.2001;(145): 380-384.
2. Staab D, von Rüden U, Kehrt R, Wahn U. The Impact of Childhood Atopic Dermatitis on Quality of Life of the Family. Dermatology and Psychosomatics 2000;1;(4):173-178.
3. Charman, C.R.: Outcome Measures of Disease Severity in Atopic Eczema. Arch. Dermatol. 2000; (136): 763-769,.
4. Kost J, Levy D, Langer R. Ultrasound as a transdermal enhancer. In: Osborne DW, Amann AH, eds. Topical Drug Delivery Formulations: Volume 42. New York, NY: Marcel Dekker inc; 1990: chap 34(603-632).
5. Srbely,S.: Ultrasound in the management of osteoarthritis: part I: a review of the current literature, JCCA J Can Chiropr Assoc. 2008;; 52(1): 30–37.
6. Kuntz AR, Griffiths CM, Rankin JM, Armstrong CW, McLoughlin TL. Cortisol concentrations in human skeletal muscle tissue after phonophoresis with 10% hydrocortisone gel. J Athl Train. 2006;41:321–324.
7. Benson HA, McElnay JC, Harland R. Use of ultrasound to enhance percutaneous absorption of benzydamine. Phys Ther. 1989;69:113–118.
8. Darrow H, Schulthies S, Draper D, Ricard M, Measom GJ. Serum dexamethasone levels after Decadron phonophoresis. J Athl Train. 1999;34: 338–341.
9. Ciccone CD, Leggin BG, Callamaro JJ. Effects of ultrasound and trolamine salicylate phonophoresis on delayed-onset muscle soreness. Phys Ther. 1991;71:666–678.
10. Benson HAE, McElnay JC, Harland R. Phonophoresis of lignocaine and prilocaine from EMLA cream. Int J Pharm. 1988;44:65– 69.
11. Williams HC, Burney PG, Hay RJ, Archer CB, Shipley MJ,Hunter JJ, et al. The UK working party's diagnostic criteria for atopic dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol 1994;131:383-396.
12. Kunz B, Oranje AP, Labreze L, Stalder JF, Ring J, Taieb A. Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis. Dermatology 1997;195:10-19.
13. European Task Force on Atopic Dermatitis. Severity scoring of atopic dermatitis: the SCORAD index. Dermatology 1993;186:23- 31.
14. Serup J, Keiding J, Fullerton A, Gniadecka M, Gniadecka R. High-frequency ultrasound examination of skin: introduction and guide. In: Serup J, Jemec BE, eds. Handbook of noninvasive methods and the skin. USA: CRC Press, 1995; 239 - 256.
15. Wolkerstorfer A, Strobos MA, Glazenburg EJ, Mulder PG, Oranje AP. Fluticasone propionate 0.05% cream once daily versus clobetasone butyrate 0.05% cream twice daily in children with atopic dermatitis. J Am Acad Dermatol 1998;39:226-31
16. Byl NN, McKenzie AL, Halliday B, Wong T, O’Connell J. The effects of phonophoresis with corticosteroids: a controlled pilot study. J Orthop Sports Phys Ther. 1993;18:590–600.
17. Bommannan D, Okuyama H, Stauffer P, Guy RH. Sonophoresis, I: the use of highfrequency ultrasound to enhance transdermal drug delivery. Pharmceutical Research. 1992; 9:559-564.
18. Bommannan D, Menon GK, Okuyama H, et al. Sonophoresis, II: examination of the mechanisms(s) of ultrasound-enhanced transdermal drug delivery. Pharmaceutical Research. 1992;9:1043-1047.
19. Nyborg WL. Mechanisms. In: Nyborg WL, Ziskin MC, eds. Biological Effects of Ultrasound. New York, NY: Churchill Livingstone Inc; 1985:23-33.
20. -Cameron MH, Monroe LG. Relative transmission of ultrasound by media customarily used for phonophoresis. Phys Ther.1992 ;72:142–148
21. Tyle P, Agrawala P. Drug delivery by phonophoresis. Pharmaceutical Research. 1989;6: 355-361.
22. -Draper, O.O. and Prentice W.E.: Therapeutic ultrasound. In: Draper, O.O. and Prentice, W.E. (ed): Therapeutic modalities for allied health professional. New York, McGraw- Hill, 1st ed. 263-309, 1998.
23. -Naik, A., Kalia, Y.N, and Guy, R.H.: Transdermal drug delivery: overcoming the skin’s barrier function.PSTT:3(9): 318- 326,2000.
24. Abd El Baky A.M and Waked I.S; Nonsteroidal anti-inflammatory phonophoresis versus topical application in improvement of hand grip strength in psoriatic arthritic patients; Journal of American Science, 2011;7(6); 110-114.
25. Barbara, C.: Phonophoresis versus topical application of ketoprofen: comparison between tissue and plasma level. Phys. Ther. August: 349-356, 2003 .
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcarePARA-MEDICAL STUDENTS' PERCEPTIONS REGARDING TREATMENT AND PREVENTION OF ANIMAL BITES FOR PREVENTION OF RABIES
English0912Jahnavi R.English Manjunath M.English Mahendra B. J.English Ananthachari K. R.English Vinay M.English Harish B. R.English Nagaraja G. B.English Subhas B. P.English Anil K. K.EnglishBackground: Rabies continues to be a significant cause of morbidity and mortality worldwide. It is estimated that 55,000 people die annually due to rabies in the world. In India, about 17.4 million animal bites occurs and an estimated 20,000 deaths occur annually due to rabies. Majority of the bites occur among people living in rural areas. Para-medical health workers are important source of information regarding appropriate treatment for animal bite in countries like India where access to qualified doctors is limited. Objectives: 1. To assess the perceptions among paramedical students regarding diseases transmitted due to animal bites 2. The knowledgeabout treatment of animal bites and prevention of Rabies and 3. The knowledge about prevention of animal bites Methodology: This cross- sectional study was conducted in Mandya Institute of Medical Sciences, Mandya in 2013. Para-medical students were administered a pretested, semi- structured questionnaire in the local language (Kannada). A total of 267 students participated in the study. Data was entered and analysed using Microsoft excel. Results: 195 (73.0%) of the para- medical students knew that rabies was transmitted by animal bites and 138 (51.7%) knew about bacterial infections. Only 31 (11.6%) of the students knew the correct and complete post exposure treatment for the prevention of rabies. 218 (81.6%) opined that not chasing the animal was the best way to prevent animal bite and 169 (63.3%) felt that not throwing stones at animal was the best way to prevent animal bite. Conclusion: The knowledge regarding treatment and prevention of animal bites for the prevention of rabies is lacking among the study population.
EnglishPerceptions, animal bite, para medical studentsINTRODUCTION
Rabies continues to be a significant cause of morbidity and mortality worldwide. Globally, it is estimated that 55,000 people die annually from rabies.1 In India, about 17.4 million animal bites occur and an estimated 20,000 deaths occur annually due to rabies. Majority of the bites occur among people living in rural areas.2 Studies reveal that dogs account for 76 to 94% of animal bite injuries. Of the millions of people bitten by animals in developed countries, about 20% seek medical care.1Rabies is a significant health concern following dog, cat and other animal bites. There are many myths and false beliefs regarding treatment of animal bites especially among the rural population. 2 The medical officers, health workers and para medical personnel are important in delivering health care services.3 Currently in rural India, the doctor population ratio is low4 . Due to the paucity of doctors, paramedical health workers are an important source of information regarding appropriate treatment for animal bite which consists of early cleansing of the wound, antiseptic application, rabies immunoglobulin, rabies vaccine, tetanus vaccine and antibiotics. The current study tries to find out the para medical students’ perception regarding post exposure treatment for prevention of rabies and methods to avoid animal bite. OBJECTIVES The present study was conducted with following objectives 1. To assess the perceptions of para-medical students regarding diseases transmitted due to animal bites, 2. To assess the knowledge of the para-medical students regarding treatment of animal bites and prevention of Rabies and 3. To assess the knowledge of the para-medical students regarding prevention of animal bites
METHODOLOGY
The present study was conducted at Mandya Institute of Medical Sciences, Mandya in 2013 after getting approval from institutional ethical committee. All the para-medical students who consented to participate in the study were administered a pre-tested, semi-structured questionnaire in the local language (Kannada). Of the total 332 students, 267 students participated in the study and 65 were absent during the study. Data was analysed using Microsoft excel software.
RESULTS
267 para-medical students were administered the questionnaire. They included diploma students of various courses (laboratory technicians, health inspectors, medical records technician, x-ray technicians). 114 (42.6%) belonged to the first year, 110 (41.2%) were second year students. and 43 (16.2%) were in the third year. 56 (20.8%) were males and 211 (79.2%) were females. 231 (86.5%) were residents of rural areas and 36 (13.5%) were from families below poverty line (possession of BPL card). All the 267 students opined that animal bite may lead to injury / wound which may need medical attention. Regarding transmission of diseases by animal bite, 195 (73.0%) knew rabies could be transmitted by animal bites and 138 (51.7%) knew about bacterial infections after animal bites. Some of them had wrong perceptions about diseases caused due to animal bite, 18 (6.7%) thought that animal bites can lead to madness. (Table 1) 97 (36.4%) knew that some of the diseases caused due to animal bite could be fatal. 121 (45.3%) thought that washing the bite wound with water would suffice to prevent rabies. 84 (31.4%) knew that the bite wound should be washed thoroughly with soap and water as soon as possible after the bite. 47 (17.6%) mentioned the application of antiseptics like povidone iodine or cetrimide, 15 (05.7%) did not know about wound toilet. 38 (14.2%) believed that, irritants should be applied to the bite wound. The various irritants stated were turmeric - 14 (05.2%), jackfruit sap – 12 (04.5%) and chilli powder- 09 (03.4%). 03 (01.1%) mentioned that copper coin has to be tied to the wound. This is a matter of concern as this is contrary to the advice to be given and such wrong advice could be a cause for treatment failure. 117 (43.9%) felt that bandaging the wound should be avoided. 56 (21.0%) opined that bandage should be applied depending on the severity of the wound. 49 (18.3%) thought that a bandage is a must and 45 (16.8%) did not know whether it was necessary. 04 (1.5%) opined that a tourniquet has to be tied above the bite wound. Avoidance of suture was opined by 163 (61.1%), however 104 (38.9%) said that the wound should be sutured depending on the severity of the wound. 153 (41.4%) felt the need for antibiotics. 77 (28.9%) felt that all animal bite victims should get antibiotics prophylactically. 37 (13.7%) felt that it should be given only if the wound is severe. 22 (18.2%) preferred injectable antibiotics. With regard to prevention of rabies, 37 (13.8%) knew about rabies immunoglobulin (RIG), 178 (66.7%) knew about rabies vaccine. All the respondents who had adequate knowledge about rabies immunoglobulin also had knowledge about the vaccine / vaccination. 45 (16.8%) felt that only 1 injection is sufficient to prevent rabies. Only 101 (37.8%) knew that 5 injections were required and 32 (12.0%) believed that 14 injections were required. 109 (40.8%) knew that the injections are given to the arm and 158 (59.2%) believed that it is given elsewhere (gluteal region, around the umbilicus etc.). 114 (42.7%) knew that tetanus toxoid had to be taken after animal bite. 107 (40.1%) knew that 1 injection suffices to prevent tetanus. 93 (34.8%) knew that the injections are given to the arm. It was noted with concern that the correct knowledge regarding the complete treatment which consists of immediate proper wound wash with soap and water thoroughly, rabies vaccine with immunoglobulin if necessary, injection tetanus toxoid and antibiotics for animal bite victims was seen in only 31 (11.6%) students. Of the 267 para-medical students, 218 (81.6%) opined that not chasing animals and 169 (63.3%) felt that not throwing stones at animals are the best way to avoid animal bites. (Table 2)
DISCUSSION
Studies have been conducted on the knowledge and awareness regarding prevention of rabies among various health care personnel in many places of India. The correct perceptions regarding washing the wound with soap and water was 51 to 98% in other studies, as compared to 31.4% in the present study.5,6,7,8The knowledge regarding application of antiseptic to the bite wound was 05% to 31%, compared to 05.7% in the present study.5,6 71 to 88% did not know about rabies immunoglobulin which is similar to present study.5, 7 The knowledge & awareness about animal bites and its consequences is deficient to a large extent among para-medical students. They do not perceive the dangers of the diseases caused by animal bites and the fatality of these diseases. Awareness regarding treatment and prevention of animal bites is substantially inadequate.
CONCLUSION AND RECOMMENDATIONS
The knowledge of animal bites and its consequences is lacking among the study population. Majority of the para-medical students were ignorant of the proper post exposure treatment of animal bites. The knowledge regarding and animal bites, its prevention and prevention of rabies can be improved by annual training programmes for the newly inducted students or incorporation into their syllabus, the protocol to prevent and treat animal bites.
ACKNOWLEDGEMENTS
We sincerely acknowledge Study subjects and scholars whose articles are cited and included in our references, grateful to authors and journals whose articles are reviewed and discussed in our article. We also thank, The Director, Staff of the Department of Community Medicine, Mandya Institute of Medical Sciences, Mandya
Englishhttp://ijcrr.com/abstract.php?article_id=942http://ijcrr.com/article_html.php?did=942REFERENCES
1. World Health Organization. Rabies Fact Sheet No. 373 available at http://www.who.int/mediacentre/factshe
2. Sudarshan MK, Mahendra BJ, Madhusudana SN, Ashwath Narayana DH, Abdul Rahman, Rao NSN, et al., An Epidemiological Study of Animal Bites in India: Results of a WHO Sponsored National Muticentric Rabies Survey, Journal of Communicable Diseases2006:38(1):32-9.
3. Rural Health Statistics in India 2011. Available athttp://nrhmmis.nic.in/UI/RHS%202011/RHS%202011%2 0 accessed on 28/06/2013at 4.55pm
4. Press information bureau – Doctor patient ratio in the country Available at http://pib.nic.in/newsite/erelease.aspx?relid=7 7859 accessed on 11/01/2014 at 8.00 pm
5. Haldhar SR, Satapathy DM, Jena D, Tripathy RM. Perceptions of Para-medical students on Rabies and its prevention. APCRI Journal 2012;13(2):25-6.
6. Das S, Satapathy DM, Malini DS, Jena D, Tripathy RM. Perceptions of AYUSH Doctors on Rabies Prevention. APCRI 2012;14(1):37- 9.
7. Undi M, Masthi NRR. Knowledge and Practices of primary care providers and school teachers regarding human rabies and its prevention in a rural area, near Bangalore. APCRI journal 2013;14(2):15-7.
8. Vinay M , Asha B, Mahendra BJ. Perceptions regarding Dog bite and its treatment among accredited social health activist of Mandya Taluk Karnataka State. APCRI journal 2013;15(1):24-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareTHE REST CELLS IN PERIODONTAL REGENERATION - A REVIEW
English1318Maheaswari RajendranEnglish Logarani A.English Sathya S.EnglishThe major goal of periodontal therapy is periodontal regeneration including regeneration of alveolar bone, cementum and periodontal ligament fibres. Recapitulation of embryology shows the importance of Hertwig's epithelial root sheath (HERS), involved in cementogenesis and root formation. The remnants of these cells are found in normal periodontal ligament as the epithelial cell rests of Malassez (ERM). The cells of ERM are known to retain the functions of HERS by expression of various proteins and growth factors. These cells have stem cell characters and known to express stem cell related genes and thus lead to the hypothesis that they can contribute to true periodontal regeneration. This article reviews about the embryology and morphology of ERM. It intends to describe the functional roles of ERM not only in maintaining the periodontal ligament homeostasis but also in contributing to periodontal regeneration.
EnglishHertwig's epithelial root sheath, Epithelial cell rests Malassez, cementogenesis, stem cells, growth factors.INTRODUCTION
Regeneration of periodontium rather than repair of lost tissues is the major goal of any periodontal therapy. Regeneration is the reproduction or reconstitution of a lost or injured part with form and function of lost structures restored.1 Periodontal regeneration involves cementogenesis, osteogenesis, and formation of the periodontal ligament fibres. But current treatment strategies like non-surgical therapy, or surgical procedures with guided tissue regeneration or the use of growth factors, a complete periodontal regeneration remain clinically unpredictable. To achieve a complete regeneration, recapitulation of the processes of embryogenesis and morphogenesis becomes essential. The most important structure implicated in the development of periodontium is the cells of Hertwig's epithelial root sheath. HERS initiates cementoblast differentiation and thus is known to be involved in the development of root and also in the formation of the attachment apparatus. After completion of the root formation, these cells remain quiescent as rest cells. These rest cells have been the subject of interest from the earliest days of periodontal research. Originally described as ‘restes de l’organe de l’email’ (Rests from the enamel organ) by Serres in 1817, are named as epithelial rest cells of Malassez in 1885 as a credit for his work on the cells and their distribution2 . These cells form part of normal periodontium and are considered as cells with no known function. Recent researches show that these cells retain the functions of HERS and play an important role in periodontal regeneration. This article briefs about the development, structure of the epithelial rest cells of Malassez, and intends to describe their part in the maintenance of periodontal health and their putative roles in periodontal regeneration.
Development of the Epithelial Cell Rests of
Malassez Root development begins when the formation of anatomical crown is completed. The cervical margin of the enamel organ forms the cervical loop which consists of inner and outer enamel epithelium. The mitotic activity in the cervical loop initiates root formation. The cells divide to produce apical elongation of its double layer of epithelial cells. This structure is referred to as the Hertwig's epithelial root sheath, and it is the vehicle that is directly responsible for inducing the formation of root. As the first layer of dentin is formed, the HERS starts disintegrating and form fenestrations. Through these fenestrations, mesenchymal cells from the surrounding dental follicle enter and contact the newly formed dentin. These mesenchymal cells then differentiate to form cementoblasts forming cementum. Once the root formation is completed, the remains of the Hertwig's root sheath is represented by the Epithelial cell rests of Malassez.2,3,4
Structure
The epithelial cell rests of Malassez (ERM) were originally described as small circular aggregates of cells in routine sections and are usually close to the cementum. In oblique sections of the periodontal ligament, these epithelial cell rests can be seen as a network, similar to a fishnet, surrounding the root. 5 The question of continuity or otherwise is important. If the network is continuous, covering the whole root, it shows that it could play some local physiological role in the functioning of the periodontal ligament. On the other hand, if the continuous network were absent over the ligament it rules out any possible role contributing to the local physiological functioning of the periodontal ligament. They are comparatively close in the gingival region; more prominent in the mesial side of molars than distal side. Eventhough the cell rests may persist throughout life, they decrease in prominence with age. The mode of distribution also varies with age. In first two decades, the ERM are more common in apical third of the periodontal ligament and in old age, the distribution is such that - 53% is found in cervical third, 26% in middle third and only 21% in apical third.6 Yamasaki and Pinero described three morphological subtypes of these cells as - Resting epithelial rests of Malassez, Proliferating epithelial rests of Malassez, Migrating epithelial rests of Malassez.7 This classification shows that cells of ERM are not resting but can get activated and subsequently proliferate on some stimuli like inflammation or any other environmental changes.
Protein expression by ERM
Different types of proteins are expressed by ERM and these can be broadly classified as cytokeratins and neuropeptides. Studies with immunohistochemistry demonstrate the expression of cytokeratins in ERM. Cytokeratins 1, 2, 5, 6, 7, 8, 10, 11, 16, 18 and 19 are specifically identified in humans which confirm the epithelial phenotype of these cells.8 They express a number of neuropeptides that includes calcitonin gene-related peptide, substance P, vasoactive intestinal peptide, tyrosine receptor kinase A and parathyroid hormone related protein. 9 ERM also express matrix macromolecules like, glycosaminoglycans, hyaluronic acid, dermatan sulphate, chondroitin sulphate and type IV collagen; fibronectin, laminin and laminin-5; and proteins that are more commonly associated with mesenchymal tissues like osteopontin (OPN), bone sialoprotein (BSP) and osteoprotegerin. 10 Growth factors like granulocyte–macrophage colony-stimulating factor (GM-CSF), epidermal growth factor, bone morphogenetic proteins, enamel matrix proteins (EMP) amelogenin and enamelin11 and various cytokines like interleukin- 1α, interleukin-6, interleukin-8 and β defensin (BD-1), prostaglandins E and F 12,13 are found to be expressed by ERM.
Putative roles of ERM in periodontium
Initially it was supposed that ERM were either quiescent or involved only in generating diseases like periapical cysts, marginal periodontitis or periodontal pockets. This view has been changed with the evidence of expression of various proteins by these cells. Now it is believed that these cells have some putative roles in: 1. Regulation and maintenance of the periodontal ligament space 2. Prevention of root resorption and alveolodental ankylosis 3. Maintenance of homeostasis in periodontium 4. Induction of acellular cementum formation 5. Cementum repair and regeneration 6. Stem cells and periodontal regeneration.
Maintenance of the periodontal ligament space and prevention of ankylosis
Several studies show the relationship between periodontal ligament homeostasis and cell rests of Malassez and their role in maintenance of the periodontal ligament space. The meta-analysis in the evolution of Hertwig's epithelial root sheath showed that only in mammalian dentition no ankylosis is seen. This is because the root sheath is continuous along the root surface and so their remnants.14 Loe and Waerhaug did tooth transplantation experiments and noted that ankylosis did not occur after tooth transplantation in areas where periodontal ligament was vital with rest cells. It resulted in ankylosis, in areas where the ligament was dried or physically removed before reimplantation. They concluded that normal periodontal ligament was established only in areas where the vitality of the rest cells was maintained.15 Usually dental traumas cause ankylosis due to the destruction of ERM cells. During orthodontic treatment ankylosis does not occur. This is because ERM cells are not destroyed. They participate in the induced tooth movement and increase the production of Epidermal Growth Factor (EGF), prostaglandins and stimulate bone resorption while maintaining periodontal ligament space.16,17
Maintenance of the periodontal ligament homeostasis
Maintenance of the periodontal ligament homeostasis is mainly accomplished by the expression of proteins like epidermal growth factor, hyaluronidase, prostaglandins. Epidermal growth factor stimulates osteoclastogenesis and thus induces bone resorption. It also stimulates mitosis in many cell types like epithelial cells, fibroblasts, endothelium, chondrocytes, smooth muscles and hepatocytes and plays an essential role in tissue repair. There is constant release of EGF by ERM cells that will induce resorption of the alveolar bone surface, thus ensuring the preservation of the periodontal ligament space within a range of 0.20 and 0.40 mm 17 (i.e., 0.25 mm on average).
Cementogenesis and cemental repair
The fact that ERM can express a number of cementum-related proteins, (osteopontin and bone sialoprotein) associate them in cementogenesis and cemental repair. These proteins are found to be expressed by cementoblasts along the root surface. Both BSP and OPN are expressed by cells related to the formation of mineralized tissues, like bone and cementum while OPN is also expressed by cells within the newly forming periodontal ligament. It shows that BSP is localized in cementum and bone while OPN is distributed in the periodontal ligament, cementum and bone.18,19 OPN has been found to be involved in the regulation of ectopic crystal formation, i.e., in controlling the extent of hydroxyapatite crystal nucleation and/or growth. OPN has been stated to inhibit apoptotic events, like those associated with inflammation.20 This ability suggests that they may have some significance in the regulation of cells during cementogenesis and during wound healing.21 BSP acts as an adhesion molecule, maintains applicable cells and acts as an initiator of mineralisation at the root surface. The temporal and spatial expression during cementum formation and bone formation is consistent with its role in promoting mineral formation.22
Role of ERM in periodontal regeneration
Periodontal regeneration involves interaction of several cell types, including gingival fibroblasts (GF), periodontal ligament fibroblasts (PDLF), cementoblasts and osteoblasts, macrophages and endothelial cells. The current treatment modalities mostly are involved in the repair of damaged periodontium rather than regeneration i.e., they do not regenerate cementum or form attachment of new connective tissue fibers. The fact that ERM are involved in cementogenesis and cementum repair suggests that these cells can play a role in bringing true periodontal regeneration. It is also shown that ERM express enamel matrix proteins amelogenin and enamelin. Such proteins are known to induce the formation of the periodontal attachment during tooth formation. Enamel matrix derivatives enhance the expression of tissue-specific maturation markers like alkaline phosphatase, collagen, osteocalcin, etc. Now, emdogain (Enamel Matrix Derivative), the commercially available form of enamel matrix proteins, is largely used in periodontal therapy as an alternative for achieving periodontal regeneration. It acts as a tissue-healing modulator taking off the events that come about during root development and helps to kindle periodontal regeneration Thus ERM can be used as a source of enamel matrix proteins and thus in periodontal regeneration.23,24
Stem cell characters of ERM
Cells of ERM are also found to have primitive stem cell characters i.e., those of embryonic stem cells and epithelial stem cells. Expression of epithelial stem cell-related genes such as ABCG2, ANp63, p75, EpCAM, Bmi-1 and embryonic stem cell markers like Oct-4, Nanog, and SSEA-4 have been detected by the studies done by Nam H et al., 2011. They also demonstrated that the expression of these stem cell markers was also found to be maintained during further sub-cultures and showed various expression levels of these genes at each passage, maintaining their expression right through the passages.25 Xiong J et al in 2012 stated that cells of ERM have unique stem cell characters. They by their in vitro studies showed that these cells can undergo epithelial-mesenchymal transition i.e., these cells can differentiate into osteocytes/cementocytes, adipocytes, or chondrocytes, which are the cells of mesodermal origin. They also demonstrated that these cells can differentiate into neural cells under suitable conditions.26 The findings that ERM express stem cell related genes and their pluripotent nature suggest that epithelial cell rests of Malassez can be used as a source of stem cells in accomplishing tissue engineering.
CONCLUSION
A true periodontal regeneration requires the formation of bone, cementum and periodontal ligament fibres. Among the current regenerative techniques, none proved to be 100% effective as they lack in mimicking embryological formation of cementum or attachment apparatus. With the knowledge that ERM is involved in maintaining periodontal ligament homeostasis, aiding in cementum repair and regeneration and expressing proteins like OPN, BSP and enamel matrix derivatives and with stem cell markers, it is considered that these cells can serve as a source for complete periodontal regeneration. Further studies are needed to elaborate their role in cementogenesis, and the nature of their stem cell characteristics so that with these epithelial cell rests of Malassez a true and complete periodontal regeneration will be possible in the future.
ACKNOWLEDGEMENT
We acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript
Englishhttp://ijcrr.com/abstract.php?article_id=943http://ijcrr.com/article_html.php?did=943REFERENCES
1. American Academy of Periodontology. Glossary of Periodontal terms. 3rd Edition 1992. Chicago (IL): American Academy of Periodontology.
2. Spouge JD. A new look at the rests of Malassez. A review of their embryological origin, anatomy, and possible role in periodontal health and disease. J Periodontol 1980;51:437–44.
3. Spouge JD. Rests of Malassez and chronic marginal periodontal disease. J Can Dent Assoc1980;46:712–6.
4. Thurley DC. Development, growth and eruption of permanent incisor teeth in Romney sheep. Res Vet Sci 1985;39:127–38.
5. Malassez L. Sur l’existence damas epitheliaux autour de la racine des dents chez l’homme adulte et a l’etat normal (debris epitheliaux paradentaires). Arch Physiol 1885;5:129–48.
6. Reeve C, Wentz F. Epithelial rests in the periodontal ligament. Oral Surg Oral Med Oral Pathol 1962;15:785–93
7. Yamasaki A, Pinero GJ. An ultrastructural study of human epithelial rests of Malassez maintained in a differentiated state in vitro. Arch Oral Biol 1989;34:443–51.
8. Berkovitz BK, Whatling R, Barrett AW, Omar SS. The structure of bovine periodontal ligament with special reference to the epithelial cell rests. J Periodontol 1997;68:905–13.
9. Tadokoro O, Maeda T, Heyeraas KJ, Vandevska-Radunovic V, Kozawa Y, Hals Kvinnsland I.Merkel-like cells in Malassez epithelium in the periodontal ligament of cats: an immunohistochemical, confocal-laser scanning and immuno electron-microscopic investigation. J Periodont Res 2002;37:456– 63.
10. Hasegawa N, Kawaguchi H, Ogawa T, Uchida T, Kurihara H. Immunohistochemical characteristics of epithelial cell rests of Malassez during cementum repair. J Periodont Res 2003;38:51–6
11. Fong CD, Hammarstrom L. Expression of amelin and amelogenin in epithelial root sheath remnants of fully formed rat molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:218–23.
12. Nordlund L, Hormia M, Saxen L, Thesleff I. Immunohistochemical localization of epidermal growth factor receptors in human gingival epithelia. J Periodont Res 1991;26:333–8.
13. Thesleff I. Epithelial cell rests of Malassez bind epidermal growth factor intensely. J Periodont Res 1987;22:419–21
14. Xianghong Luan, Yoshihiro Ito, and Thomas G.H. Diekwisch Evolution and Development of Hertwig’s Epithelial Root SheathDev Dyn. 2006 May;235:1167– 80.
15. Löe, H., and Waerhaug, J.: Experimental replantation of teeth in dogs and monkeys. Arch Oral Biol 1961;3:176.
16. Alberto Consolaro, Maria Fernanda M-O. Consolaro ERM functions, EGF and orthodontic movement Dental Press J. Orthod. 2010;15:24-32.
17. Uematsu S, Mgi M, Deguchi T. Interleukin-1 beta, IL-6, tumor necrosis factor-alpha, epidermal growth factor, and beta 2- microglobulin levels are elevated in gingival crevicular fluid during human orthodontic tooth movement. J Dent Res.1996;75:562-7.
18. Lekic P, Sodek J, McCulloch CA. Osteopontin and bone sialoprotein expression in regenerating rat periodontal ligament and alveolar bone. Anat Rec 1996;244:50–8
19. Ivanovski S, Li H, Haase HR, Bartold PM. Expression of bone associated macromolecules by gingival and periodontal ligament fibroblasts. J Periodont Res 2001;36:131–41.
20. Giachelli CM, Liaw L, Murry CE, Schwartz SM, Almeida M. Osteopontin expression in cardiovascular diseases. Ann N Y Acad Sci 1995;760:109–26.
21. Feng B, Rollo EE, Denhardt DT. Osteopontin (OPN) may facilitate metastasis by protecting cells from macrophage NO-mediated cytotoxicity: evidence from cell lines downregulated for OPN expression by a targeted ribozyme. Clin Exp Metastasis 1995;13:453– 62.
22. Saygin NE, Giannobile WV, Somerman MJ. Molecular and cell biology of cementum. Periodontol 2000 2000;24:73–98.
23. Hammarstrom L. Enamel matrix, cementum development and regeneration. J Clin Periodontol. 1997;24:658–668.
24. Margarita Zeichner-David. Regeneration of Periodontal tissues: Cementogenesis revisited. Periodontol 2000 2006; 41: 196-217.
25. Nam H, Kim J, Park J, Park JC, Kim JW, Seo BM, Lee JC, Lee G.Expression profile of the stem cell markers in human Hertwig's epithelial root sheath/Epithelial rests of Malassez cells. Mol Cells 2011;31(4):355-60.
26. Xiong J. Mrozik K, Gronthos S, Bartold PM.Epithelial Cell Rests of Malassez Contain Unique Stem Cell Populations Capable of Undergoing Epithelial–Mesenchymal Transition. Stem Cells And Development 2012; 21(11):2012-25.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareMACRO MINERALS PROFILES IN CAMEL'S MEAT
English1924Omer H. ArabiEnglish Selma Fadl ElmawllaEnglish Elsir AbdelhaiEnglish Abdel Moneim E. SuliemanEnglishThe macro minerals presented in this study have an essential role in the physiological activities in camels. The aim of this study was to determine the macro minerals profiles in camel’s meat in different seasons and ages. Methodology: the study focused on the determination of macro minerals profiles in camel's meat. Meat 180 samples were taken monthly in summer, winter and autumn, from three groups of ages; 1-3, 4-6 and 7-9 years, Ash samples were analyzed for macro minerals (Ca, Mg, P, Na and K,). These minerals were determined according to the AOCS method. Results: It was found that the macro minerals (Ca, P, Mg, Na and K) profile in camel's meat showed a significant difference (p>0.05) in different season. The concentration of Ca and Mg was higher in summer in young age animals (1-3 years) and lower in old age animals (7-9 years). While the concentration of K was higher in winter in old age animals (7-9 years) and lower in young age animals (1-3 years). There was no significant difference in concentration of P after three months of preservation (pEnglishCamel meat , Camelus dromedaries, Macro MineralsINTRODUCTION
Camels are one of the most important source of the national economy and food security for many countries in the world. They occupy a very useful role in human food, especially meat. Meat is an essential food for human growth and development, as it provides protein, energy, vitamins and some minerals and these contribute to health (Sarmad et al., 2011). Camels are an excellent source of high quality animal protein, especially in areas where the climate adversely affects the performance of other meat animals. This is because of their unique physiological characteristics, including a great tolerance to high temperatures, solar radiation, water scarcity, rough topography and poor vegetation (Kadim et al., 2007). The amounts of mineral elements in ash and protein contents in camel's meat are reported to be similar to beef (Kadim et al., 2006). Except for Na, camels have a similar elemental composition (Zn, Ca, K, Mg, Cu and Mn) to beef (Fennema, 1996). The quality of meat from young camels of three years old or less is comparable to beef (Elgasim and Elhag, 1982 and Kadim et al., 2007). Kadim and Mahgoub (2009) reported that minerals content of muscles generally tend to increase with age of the camel. The proposed study area (Tambul, Albutana area, Central Sudan) is famous of its high population of camels. No analytical work has so far been undertaken on macro minerals content in meat of camel in Tambool area. In this study, data are presented for Ca, K, Mg, Na and P in camel's in this area, because no mineral supplementation for camels is used. The hypothesis assumes that the level of macro elements is influenced by seasons age of animal and preservation period. The objective of this study is to determine the macro minerals profiles in camel’s meat in different seasons and ages.
MATERIALS AND METHODS Samples
The meat samples were collected from 180 mature camels, varying age (1-9 years old) in Tamboul local market. Samples were taken monthly in summer, winter and autumn. These samples were transported hygienically to the Department of Physiology and Biochemistry, Faculty of Veterinary Medicine, University of Albutana. According to the storage period, samples were divided into four groups: fresh samples, one month-stored samples, two months-stored samples and three months-stored samples. The samples were labeled, wrapped and kept in a refrigerator at (- 4ºC) overnight and then kept on a deep freezer at (-18ºC). At the end of each storage period the samples were transported hygienically to Department of Meat Production, Faculty of Animal Production, University of Khartoum, where they were labeled, wrapped and kept in a refrigerator overnight until used.
Macro minerals determination
Camel meat samples were subjected to chemical analysis to determine moisture, total protein, total fat and ash as described by (AOCS, 1990). Ash samples were analyzed further for macro minerals (Ca, Mg, P, Na and K,).
Determination of potassium and sodium
Potassium (K) and sodium (Na) concentrations were accomplished by means of flame photometer model (Corning 400 flam photometer). These minerals were determined according to the AOCS (1984) method.(1984) metho
. Determination of calcium and magnesium
Calcium (Ca+2) and magnesium (Mg+2) were determined together according to the AOCS (1984) method.
Determination of phosphorus
Phosphorus (P) was determined by Spectrophotometer at 440 um according to fertilizers and feeding stuffs regulations, after diluting the ash extract (1:20) then the solution was reacted with ammonium vando molybdate reagent. An orange and yellow complex vanadium phosphomolybate was formed.
Data analysis
Data were analyzed as with a 3x3 factorial arrangement of treatments using analysis of variance. To test the research hypothesis ANOVA table and an interaction between three factors (preservation period, season and age of animal) analyzed by general linear model by using SPSS version 21 computer programs. Duncan's for multiple comparison test was used. Main effects were considered significant at P>0.05.
RESULTS AND DISCUSSION
Camel's meat production represents about 0.7% of the world meat production (216, 315 tons) (Anderson and Hoke, 1990). The objectives of this study is to determine the macro minerals profiles in camel’s meat in different seasons and ages. Ca, P and Mg have structural function and Na and K involved in membrane function (Mertz and Underwood, 1987). The concentration of these minerals were converted to a dry mass as g/100g of sample, highlighted in Tables 1. 2 and 3. The camel's meat from Tambool area revealed that the concentration of the macro minerals; Ca, K, Mg, Na and P were found within the normal range. Therefore, the natural food of camels generally consists of the foliage of trees, shrubs and grass. When left to graze freely, camels food may include a large number of different species (Higgins, 1986). Trace element levels in camel's meat are affected with camel food and the pasture soils (Barrett and Larkinc, 1974). The concentration of Ca, Mg, Na, K and P was higher in summer and lower in autumn and winter, and significantly different (P>0.01) (table 1), because these camels depend on well water during summer (Sarmad et al., 2011). There was a significant difference (p>0.05) due to the age of animal on the concentration of Ca, Mg, Na, K and P (table 3), the concentration of these minerals was lower in young animals. This is consistent with the findings of (Kadim et al., 2008) who reported that mineral content of muscle generally tends to increase with the age of the camel. There was a significant difference (p>0.05) due to the preservation period on the concentration of Ca, Mg, Na, K and P (table 3), the concentration of these minerals was not consistent with different preservation periods. When, study the interaction of age*season*preservation periods, there was a significant difference at (p>0.05) on the concentration of Ca, Mg, Na, K and P, a higher concentration of Ca, Mg, P and Na was found in summer then autumn and winter. While, the concentration of K was higher in autumn and winter and lower in summer (table 4). When, study the interaction of season*age*preservation periods, there was a significant difference at (p>0.05) on the concentration of Ca, Mg, Na, K and P a higher concentration of Ca was found in old age animals (7-9 years), and lower concentration was found in young age animals (1-3 years). Higher concentration of K and Mg was found in young age animals (1-3 years), and lower concentration was found in old age animals (7-9 years)(table 5). There was a significant difference in concentration of Na and P according to interaction of season*age in different preservation periods (p>0.05). There was no significant difference in concentration of P after three months of preservation (pEnglishhttp://ijcrr.com/abstract.php?article_id=944http://ijcrr.com/article_html.php?did=944REFERENCES
1. Anderson, B.A. and I.M. Hoke (1990). Composition of Foods: Beef Products, Raw, Processed, Prepared. 1st Edn., United States Development of Agriculture, Washington, DC, USA.
2. AOCS, (1990). Official Methods and Recommended practices. 5th ed. Commercial Fats and Oil. Washington, DC. USA.
3. AOCS, (1984). Official Methods and Recommended practices. 5th ed. Commercial Fats and Oil. Washington, DC. USA.
4. Barrett, M.A. and P.J. Larkinc, (1974). Milk and Beef Production in the Tropics. 1st Edn., Oxford University Press, London, ISBN: 9780198594406, pp: 245.
5. Elgasim, E.A. and Elhag, G.A. (1982). Carcass characteristics of the Arabian Camel. Camel News Letter (9): 20-24.
6. Fennema, O.R. (1996). Food Chemistry. 3rd Edn. Marcel Dekker Inc., New York, USA., ISBN: 9780824796914, pp: 1069.
7. Higgins, A. (1986). The Camel in Health and Disease. 1st Edn. Bailliere Tindall Press, London, ISBN: 9780702011672, pp: 168.
8. Kadim, T. Isam, Osman Mahgoub, Waleed Al-Marzooqi and S. K. Khalaf (2009). Journal of Camelid Sciences. 2, 30 http://www.isocard.org 37.
9. Kadim, T. Isam, Osman Mahgoub and Waleed Al-Marzooqi (2008). Journal of Camelid Sciences. Meat Quality and Composition of Longissimus thoracis from Arabian Camel (Camelus dromedaries) and Omani Beef: A Comparative Study. 37-47 http://www.isocard.org 37.
10. Kadim, I.T.; Mahgoub, O. and R.W. Purchas (2007) A review of the growth, and of the carcass and meat quality characteristics of the one-humped camel (Camelus dromedaries) Department of Animal and Veterinary Sciences, College of Agricultural and Marine Sciences, Sultan Qaboos University,
11. Kadim, T. Isam, Mahgoub, O., Al-Marzooqi, W., Al-Zadgali, S., Annamali, K., Mansour, M. H. (2006). Effects of age on composition and quality of muscle Longissimus thoracis of the Omani Arabian camel (Camelus dromedaries). Meat Sci., 73, 619-625.
12. Mertz, W. and E.J. Underwood (1987). Trace Elements in Human and Animal Nutrition. 5th Edn., Academic Press, San Diego, ISBN: 9780124912519, pp: 480.
13. Sarmad G. Mohammed, Hassan T. Abdulsahib, Ibrahim M. Jasim and Mushtak T. Jabbar (2011). Assessment of Camel Meat Pollution with Trace Metals in Desert Area of Basra Province. American Journal of Agricultural and Biological Sciences 6 (4): 475-479
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareCOMPARATIVE STUDY OF FUNCTIONAL OUTCOME OF TIBIAL CONDYLE FRACTURE OPERATIVE (LOCKING COMPRESSION PLATE) VS CONSERVATIVE METHOD
English2531Nitin SanadhyaEnglishAim: was to study the short term follow up and functional outcome of treatment of fracture tibial condyles by conservative and operative methods. And Comparison of result of conservative and operative treatment of the above.And to study the complications of conservative and operative methods. Methodology: The present study had been conducted in Department of Orthopedics Dhanwantri Hospital and research center, Jaipur during the period March 2009 to March 2011. This was a prospective study consist of 50 randomized selected cases of fracture of tibial condyles, treated by conservative and by operative method. Patients older than 15 years were included in this study. Results: In the present study 50 cases of fracture tibia condyle were included patient were divided in 2 groups on random basis managed conservatively and operatively. Majority of cases fall between age group 31-40 and 41-50 age group with average age of 43.86 years and 88% of affected persons were male and commonest mode of injury was RTA accounting for 48% of cases. Most common type of fractures in type C accounting for 40% of cases. Knee instability was found in 32% cases and can be managed conservatively. In the cases with high functional demands type A fracture and type B fractures operative method should be used and in bicondylar comminuted fractures of tibial condyles C3 both the modalities had poor results. Patient treated with operative methods had over all acceptable results in 91.6% as compare to conservative group having 61.5% acceptable results. Conclusion: from this study of 50 cases of tibial condyle fracture we can conclude that the tibial condyle fracture was most commonly caused by RTA and , due to high energy trauma bicondylar fracture were most common type. Type A has excellent results with both the modalities of treatment and type B, C1 and C2 fractures have good results with operative methods; while type C3 had poor results with either of modality.
EnglishFunctional Outcome, Tibial Condyle Fracture, Conservative MethodINTRODUCTION
With the increased density of automobile traffic on our city roads and ever increasing number of road traffic accidents, fractures around the knee have assumed an importance and frequency. In the precarious plight of the city pedestrian, the knee seems to be the most vulnerable point. A hinge joint at the exact level of automobile bumper is most commonly struck on its lateral side resulting in ligament sprains or fracture of one or both condyles. Fracture of tibial condyle were brought into prominence in 1925 by the papers of cotton and Berg in Boston and Conlley and Seiffert in Chicago, one calling them, fender fracture’ and other bumper fracture. The fractures of tibia condyles have three main features. 1) Fractures are intra- articular 2) Occurs in cancellous bone. 3) Involve weight bearing bone. There was great controversy in the past regarding the treatment of fracture of tibial condyles but now with improvement in material and treatment methods of fixation more and more authors agreed that spilt fracture with more than one centimeter displacement, depressed fractures with more than 1 cm displacement Bicondylar fracture with more than 7 mm displacement and depressed fractures of medical condyle shows better results when treated by open reduction and firm internal fixation. (Burri C. et al, 1973: Waddell J.P.et at: 19821: Mason Hole, 1982). While there is still great controversy in the treatment of split depressed fractures with less than 1 cm. displacement, and comminuted fractures. Some authors advocate open reduction and internal fixation (Palmer 1940, Schatzker J. 1979) while other authors advocate conservative treatment (Hohl M. et al 1982; Hugh Dovery 1971: Blockker C.P. et al 1983.) Following operative treatment there is restoration of articular congruity, axial alignment, joint stability and functional movement of joint. Early mobilization is also possible; post traumatic osteoarthritis is less common with operative than with conservative treatment. This treatment modality compromises soft tissue, devascularizes bone fragments and may be complicated with infection, implant failure and wound dehiscence. Difficulties with conservative treatment included inadequate reduction, instability and prolong hospitalization while open reduction and internal fixation is a difficult operation, even in experienced hands. Locking compression plate for proximal tibia are anatomically contured plates with a limited contact profile. The plate is indicated for treatment of split and depressed fractures of the medial and lateral plateau as well Bicondylar fractures of proximal tibia. The goal of treatment of tibial condylar fractures is to obtain a stable pain free, mobile joint and to prevent early degenerative arthritis. The factors producing permanent disability by current methods of treatment are pain, limited motion of the joint, instability, angular deformity, lack of full extension, quadriceps weakness and early degenerative arthritis. An effort was made in this study to analyze the various types of fractures and comparison of end results by conservative and operative treatment. Keeping this in view it is worthwhile to study and evaluate the results of conservative and operative treatment of various types of fracture of tibial condyle and to find out suitable method of treatment for different type of fractures.
AIMS AND OBEJECTIVES
1. To study the short term follow up and functional outcome of treatment of fracture tibial condyles by conservative and operative methods. 2. Comparison of result of conservative and operative treatment of the above. 3. To study the complications of conservative and operative methods.
MATERIAL AND METHODS
The present study has been conducted in Department of Orthopedics Dhanwantri Hospital and research center, Jaipur during the period March 2009 to March 2011. This is a prospective study consist of 50 randomized selected cases of fracture of tibial condyles, treated by conservative and by operative method. Patients older than 15 years were included in this study. Initial management and resuscitation done
CONSERVATIVE METHOD
a) Close reduction and skeletal traction followed by cast brace with hinge knee joints
DISCUSSSION
The ideal outcome after a tibia plateau fractures is stable, pain-free, non osteoarthritic knee joint with a range of motion that is adequate for functional requirements. There is virtual universal agreement that reduction and stabilization of displaced fragments , early mobilization and delayed weight bearing are necessary to achieve the optimal results, however controversy exists as how to achieve these aims . There is debate about the efficacy of the different modalities. Closed reduction with lower tibial skeletal traction for three weeks followed by hinge knee cast and later weight bearing permitted as the fracture consolidates, is cost effective treatment with less chances of infection and can be applied to medically unfit patients. In the modern age operative treatment with locking compression plate fixation after adequate reduction permits better stabilization and early weight bearing .But this type of management needs experienced hands ,requires extensive exposures of the knee joint, and have a risk of further devascularization of the bone and chances of infection . In this study critical evaluation is done of the tibial fractures treated with either of the modality. We have classified the fractures according to AO classification and the most common type of fracture in our series was type C (40%) followed by type B (32%) subtype B1 and C1 20% cases was the commonest subtype fracture pattern ,their was no case of subtype A1 in our study. In the study majority of the cases sustained injury due to RTA(48%). 16% were injured due to the motorcycle / scooter skid while in 20% cases the injury was due to pedestrian accidents. The commonest injury results from RTA were A3, B1, C1, C3 due to severe trauma which shatters the upper end of the tibia. The common fracture in the motorcycle skid was C2, C1, B3, while pedestrian commonly had B1 or depressed B2 type fractures. In the present series, 32% cases had ligamentous injuries of the knee, Medial collateral ligament injury was found in 12% cases and the lateral collateral ligament was found in 4% cases. The anterior cruciate ligament injury was in 16% cases. Blocker CP (1983) reported MCL injury in 20% cases. Schatzker et al (1979) reported ligamentous injuries in 32% cases. The associated meniscal injuries cannot be diagnosed at the time of injury because of severe pain and haemarthrosis. After the period of 4 weeks enough fibrosis in the capsule and meniscus developed, so it cannot also be diagnosed at follow up. Diagnosis requires MRI and arthroscopy. These diagnostic tools are not used in the present study. The associated ligament injuries were treated conservatively, provide sufficient ligamentous healing. out of 16 patients of ligament injuries 50% had acceptable results and do well in there daily living activities. In the study no case of peroneal nerve palsy reported. Associated fracture of fibula was found in 64% cases, in displaced lateral condyle and bicondylar fractures. They were treated conservatively and didn’t affect the final out come. Barford (1980) rightly said that fibula head act as a buttress of the lateral plateau, if this gives way entire lateral segment slides down enmass, causing major displacement. Burn (1940) also made similar findings. In the present series knee flexion was restricted in 22 (44%) cases out of which 10 (20%) had minimal restriction (100-120 degree) while 12 (24%) patients had gross restrictions of the knee movements. Most of the patients regain their functional range of motion within 12 weeks of injury. Patient with more comminuted fractures regain their flexion range more slowly because of more pain and swelling. Over all 75% of the patients in our study had acceptable range of movements, results were slightly better in operative group than conservative group. George Rasmussen 1973, Dewelios PJ 1997 Dendrinos GK 1996, Weigel D.P. Marsh JL 2002 ,Lubowitz 2004 reported slight better range of movements from 117 to 120 degrees in cases treated operatively. Extension lag of 5 degree to 10 degree was seen in 8 (16%) cases and was mainly seen in bicondylar fractures with poor fractures reduction , similar observation is noted by Fryjordet (1972) 21%, Jacobson (1953) 17% and Huge Dovery (1971) 22% cases. they all have thigh muscle wasting so advised continues quadriceps strengthening exercises. In the present study, deformities of the knee were found in 14 (28%) cases. varus deformity in 10 (20%) cases and valgus in 4(8%) . Rombold C in 1960 reported deformities of knee in 40% cases and Jacobson (1953) reported deformities in 15% and Huge Dovery (1971) in 10% cases. No deformity was found in undisplaced fractures, varus deformity is a sequel of either displaced medial condyle fracture or bicondylar fracture. In our series varus and valgus deformity were seen in cases treated with skeletal traction with hinge knee cast mainly seen in C3 type of fractures that were severely comminuted and displaced fracture, Displacement may occur during traction, mobilization or weight bearing. Over all 16 patients (32%) complain pain in the present series our findings are similar to Fryjordet (1967) who reported it in 33% cases but in contrast to our study Jacobson reported pain in 63% cases in his series. Pain was more common in patients of bicondylar fractures treated conservatively. Ligamentous injuries are treated conservatively and majority of patients performed well. similarly Moore (1976) and Weisseman and Hrold (1964) favored the non operative treatment; in contrast to view of O,Donogue ( 1976) and Robert J (1960) who insisted upon the open repair of the collateral ligament rupture for optimal joint function. In the present study instability of the knee was found in 16 cases (32%) out of which 50% are asymptomatic and perform well. Similarly knee instability is reported by Rombold C (1950) 20%, Fryjordet (1967) 30% and Huge Dovery (1971) 39%. In this present series Hohl and Luke (1976) criteria was used for the assessment of final results .we had 100% acceptable results in type A fractures, 66.6% in the type B and only 33.3% in type C fractures in the patients treated conservatively. The over all acceptable results with conservative treatment was 61.5% which was similar to the series of Thomas Decoster 1988,who reported 61% good results but results of George brown (1976) 70% and Rick D Hole (1989) 76% were better than our present study. Our results were much better in patient treated by open reduction and internal fixation. There were 100% acceptable results in type A and B fractures while in type C fractures were 75% acceptable results. The over all good results were in 91.6% patients. Similar results had been reported by Dennan and Lubowitz (2004) 94% and Krappinger (2008) 96% our results were slightly better than Rasmessun (1973) 86% , Mikulu(1988) 87%, Weigel DP marsh 87%,Ballmer (2000) 86.7%. Over all results in our series irrespective of method of treatment were 100% acceptable in type A fractures, 87.5% in type B fractures and 50% in type C fractures. We have acceptable results in 76% cases while in 24% cases it is unacceptable. In type C3fractures results were uniformly bad in the cases treated by either method. It can be concluded from the present study that type A fractures can be treated by any of the method with 100% acceptable results. In type B fractures our results were better with open reduction and internal fixation as compared to conservative treatment, 100% and 66.6% respectively. In type C fractures there were only 33.3% acceptable results with conservative treatment as compared to 75% acceptable results with operative treatment. The over all results of type C3 fractures treated by either of method are uniformly bad. However over all results in present series were superior in patients treated by internal fixation than treated conservatively
CONCLUSION
In this study of 50 cases of fractures of tibial condyle. Treatment modalities included were lower tibial skeletal traction and later hinge knee cast, open reduction with proximal tibial locking compression plate fixation. ? Minimum follow up period was 6 months and maximum was 20 months. Average is 13.86 months. ? Majority of cases were in 31-40 and 41- 50 age group with average age was 43.86 years and sex ratio M:F is 7.33:1. ? Left and right knee were involved in equal percentage, lateral condyle was involved in 28% cases, medial condyle was involved in 20% cases and both condyle were involved in 52% percentage of cases. ? Commonest mode of injury was RTA ? No case of common peroneal nerve injury occurred. ? Associated fracture of fibula was found in 64% cases. ? Commonest fracture was type C fractures and subtypes B1 and C1 20% cases each. ? Knee instability was found in 32% cases. An can be managed conservatively. ? Thigh muscle wasting was found in 32% patients but no functional weakness found. ? Gross restriction of knee flexion was present in 24% cases. ? Extension lag was seen in 16% cases. ? Varus deformity was seen in 20% cases and valgus deformity in 8% cases. ? Patient treated with lower tibial skeletal traction and hinge knee cast shows over all 61.5% satisfactory results with subtype A had 100%, subtype B had 66.6% and sub type C had 33.3% acceptable results. ? Patient treated with open reduction and internal fixation shows over all 91.6% satisfactory results with subtype A and B had 100% and sub type C had 75% acceptable results. ? Displaced fractures better be treated with open reduction and internal fixation and comminuted bicondylar fractures C3 has equally poor results with both conservative and operative treatment.
Englishhttp://ijcrr.com/abstract.php?article_id=945http://ijcrr.com/article_html.php?did=945REFERENCES
1. Blockker: A clinical and radiological study tibial condyle fracture:J of ortho trauma:1983, JBJS , 450-60.
2. Dendrinos GK.: Treatment of high energy tibial plateau fractures by the contured locking plates, journal of bone and joint surgery78 (5): 710-7,1996.
3. Duwelivos PJ: Treatment of tibial plateau fracture by limited internal fixation. Clinical orthopedics and related research (339): 47-57, 1997.
4. Fryjordet A. Jr.: Operative treament of tibial condyler fractures. Acta. Orthop Scand: 1967; 113-17.
5. Hohl M. and Luck J.V. Fractures of tibail condyle. A clinical and experimental study. J. Bones and joint Surg. 1967; 49 A: 1455.
6. O’Dongue: Ligament in tibial condyle fracture diagnisis and operative management:JBJS:124-130:1976
7. Porter B. : Crush fractures of the lateral tibial plateau J.Bone and Joint Surg. 1970;528:676.
8. Rombold C,: Depressed fractures of tibial plateau J.Bone and joint Surg. 1960;42A:783.
9. Rasmussen et al: Operative treatment and their outcome of tibial condyle fractures:J of ortho trauma 1973.
10. Rick D and Hole:Conservative treatment of tibial condyle fracture with functional cast brace. JBJS: 23: 132-139:1989.
11. Schatzker et al: Tibial condyle fractures classification and management :1979.JBJS
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareAN EVALUATION OF THE STRESS DISTRIBUTION IN CORTICAL AND CANCELLOUS BONE AROUND A MICROIMPLANT UNDER VARIOUS LOADING CONDITIONS -AN FESA STUDY
English3242P. PremanandEnglishAim: This study is to evaluate the pattern of stress distribution and bone failure around the Absoanchor micro-implant under various loading conditions and various force levels. Materials and Methods: FESA was originally introduced as a numerical form of analysis in aeronautical engineering and has the potential to obtain a computer generated mathematic model of a real object of complicated shape with its different physical material properties in order to identify the stresses and displacement. Finite element structural models of the Absoanchor implant, cortical bone and cancellous (trabecular) bone of both maxilla and mandible were generated using solid modeling software NASTRAN. In this present study three types of loads were applied on head of implant to simulate different loading conditions. The forces applied were in the range of 25-300gms in both horizontal and diagonal plane, while forces of 10-100gms were applied in vertical plane. Results: There is no bone deformation seen in this study in all the three loading conditions. Conclusion: Since there is no bone deformation for the normal range of force in all the three planes the absoanchor titanium micro-implant placed in maxilla and mandible provide stable anchorage for orthodontic force.
EnglishCortical Bone, Cancellous Bone, Absoanchor Microimplant, FESA.INTRODUCTION
Successful orthodontic treatment has always required intra oral anchorage with a high resistance to displacement. Extra oral traction can be an effective reinforcement but demands exceptional patient co-operation. The size, bulk, cost and invasiveness of prosthetic osseointegrated implants have limited their orthodontic application. Conventional bone screws can be used with bone plates to provide intra oral anchorage, but the screw heads fail to protect the gingiva from the impingement of ligatures or attached elastics and make it difficult to attach coil springs and other orthodontic appliance. Failure of large titanium implants led to the development of micro-implant which is small, affordable, easy to place, routinely resistant to orthodontic forces, can be immediately loaded and easy to remove. One such implant is Absoranchor micro-implant. Current research on implants indicates that bone adaptation to implants is an important factor for successful implant treatment. Incorrect loading or overloading as a result of ineffective implant geometries may lead to implant loss [1, 2] . The Finite element structural analysis (FESA) represents an extension of the matrix method for the analysis of framed and continuum structure. This method is extremely powerful as it helps to accurately analyze structures with complex geometrical properties and loading conditions. The most important step in the Finite element method of structural analysis is to generate, using finite number of discrete elements, a mathematical model which should be as near as possible equivalent to the actual continuum. Such a formulation of a model is referred to as structural idealization or discretization. The continuum is a physical body, a structure or a solid, which needs to be analyzed. The discretization process of continuum is called elements and is connected to the adjacent element only at limited number of points called node [3] . Thus, FESA offers an ideal method of accurate modeling of tooth, periodontium, bone and implant with its complicated three-dimensional geometry representing the in vivo condition similar to clinical situation, thereby permitting the application of various force systems at a point or vice versa and to study the distribution of forces in a qualitative and quantitative form. Thus Finite element Structural analysis (FESA) of the implant can be empirically used for the investigation of maximum anchorage success. The aim of this study is to produce an insight into the influence of an implant system (Absoanchor micro-implant), the direction and magnitude of force application and its stress distribution on the surrounding bone using the Finite element structural (FESA) method.
AIMS AND OBJECTIVES
The aim of the present study was: ? To evaluate the pattern of stress distribution in the cortical and cancellous bone of maxilla and mandible around the microimplant under the following directions of force a) Vertical b) Horizontal c) Diagonal ? To evaluate the pattern of stress distribution in the cortical and cancellous bone of maxilla and mandible around the micro-implant under various force levels. ? To evaluate the amount of bone deformation present around the implant under various loading conditions
MATERIALS AND METHODS
Finite element modeling Finite element structural method offers various advantages including accurate representation of complex geometries, easy model modification and representation of the internal state of stress and other mechanical quantities (Lavernia et al 1981, Huiskes and Chao, 1983)[4,5] . Three Dimensional (3D) CAD Finite element structural models of the implant, cortical and cancellous bones of both maxilla and mandible were generated using solid modeling software NASTRAN. A Finite element structural mesh was used to represent the model of the implant, cortical and cancellous bone. In general, increasingly fine mesh size ensures convergence of a FE solution. Use of large number of elements was especially important in this problem, where stress singularities were expected at the sharp corners [6] . The thickness of the cortical bone in the interdental area between the second premolar and first molar in maxilla and mandible was evaluated with the help of CT scan in a series of patients and was found to be of 2mm thickness in maxilla and 3mm in mandible. The cortical bone was modeled as a cylinder of 2mm thickness for maxilla and 3mm thickness for mandible around the implant with a diameter of 6mm. Cortical bone was generated with 59500 nodes and 59649 elements (Figure-1). The trabecular bone was modeled with a length of 6.5mm and diameter of 6mm for both maxilla and mandible around the implant below the cortical bone model. Trabecular bone was generated with 51309 nodes and 51140 elements (Figure-2). The Absoanchor titanium micro implant [2, 7] with a length of 6mm and diameter of 1.2 mm was modeled, with linear elastic, isotropic and homogenous properties. In the present study Absoanchor implant model was derived from a single mesh pattern that was generated with 20283 nodes and 20360 elements (Figure-3). Implant to bone contact was assumed to be 100% indicating complete osseous integration [8]. Finite element structural models of the implant bone complex (Figure-4) were used to determine stresses and strains in the bone adjacent to the implant surface, under loading. The results were recorded during static loading on the implant.
Material
Properties In the absence of information about the bones precise material properties, assumptions were made according to the majority of studies that used FEM [9]. All materials used in the models were considered to be isotropic, homogenous and linearly elastic [10] . In the cortical bone, Young’s modulus was assumed to be E = 1.37 + 04 N/mm2 and Poisson's ratio = 2.6 - 01 N/mm2 [11] . In the trabecular bone, values were set to E = 1.37 + 03 N/mm2 and Poisson's ratio = 3.0 - 01 N/mm2 [11], and for titanium (implant material) the values were taken to be E = 1.10 + 05 N/mm2 and Poisson's ratio = 3.0 - 01 N/mm2 [11] . Implant loading The force exerted on the head of the implant varies in direction and magnitude. In the present study, 3 types of loads were applied on the head of implant to simulate different loading conditions. a) Horizontal – the load on implant head in horizontal direction was investigated under orthodontic forces ranging from 25gms to 300gms (Figure-5). b) Vertical – the load on implant head in vertical direction was investigated under orthodontic forces ranging from 10gms to 100gms (Figure-6). c) Diagonal - the load on implant head in diagonal direction was investigated under orthodontic forces ranging from 25gms to 300gms (Figure-7).
RESULTS
The output results of the Finite Element Structural Analysis are presented in colorful contours. Spectrum of different colour bands on right side of the figure indicates the stress pattern and level of stress distribution in the bone, under various levels of force and direction. (Figure-8) Results were expressed as Principal stresses – Maximum and Minimum. The maximum principal stresses were mostly tensile while the minimum principal stresses were compressive in nature, used on side of force direction [11] . The forces applied were in the range of 25 – 300gms in both horizontal and diagonal while forces of 10 – 100gms were applied in the vertical plane. The stress distribution pattern in maxilla and mandible were assessed for all the three types of force application and the results were graphically represented. (Figure-9-14)
DISCUSSION
Anchorage control is of great importance in orthodontic treatment. The long term stability of an implant used as an anchorage for orthodontic or orthopedic forces depends on its resistance to displacement forces in all planes [12]. This could be best assessed by observing the stress patterns created around the implant. The present study was aimed at evaluating these stress patterns under various directions of load, which mimics the clinical situation using the Finite element structural analysis (FESA) method. Inappropriate loading causes excessive stress in the bone around the implant and may result in bone resorption. Therefore it is valuable to investigate the stresses / strains in both cortical and cancellous bone. The FESA method is one of the most frequently used methods in stress analysis in both industry and science. It is used for analyzing hip joints, knee prostheses and dental implants [13]. The result of the FESA computation depends on many individual factors, including material properties, boundary condition, and interface definition and also on the overall approach to the model. It is apparent that the presented model was only an approximation of clinical situation. In the present study the force levels of maximum 300gms were used. Since a force of up to 400gms orthodontic force (which is greater than the normal range required for conventional orthodontic tooth movement) has been successfully anchored against an implant anchor in several malocclusions [14, 15] . The results show that all four-stress components in both maxilla and mandible, expressed a linear increase in the stress distribution with an increase in the magnitude of force (Figure-9-14). Stress distribution in cortical bone The stress distribution in the cortical bone was significantly greater than in the cancellous bone (Figure-9, 11and13) as shown in previous studies [8] . Although the present study shows almost identical distribution of the stress in maxillary and mandibular cortical bone under horizontal loading (Figure-13), whereas under diagonal and vertical loading, the stress distribution in the maxillary cortical bone was slightly lesser than that of its mandibular counter parts (Figure-9and11). This could be attributed to the difference in the thickness of cortical bone. Since the cortical bone has much higher elastic modulus than cancellous bone, it is considered the major stress bearing area of the implant [9]; the stresses are more evenly distributed in the mandibular cortical bone than in maxilla. This is further stressed by the work of Miyawaki et al [16] who states that the success rate of implants could be slightly higher than that in the maxilla. This result of this study is in accordance with other studies. [8, 17] The study by Martin et al [18] reported that the ultimate stress of the cortical bone to be higher in compression (170 MPa) than in tension (100 MPa). In the present study the ultimate stress of the cortical bone (1.89 x 10-1 N/mm2 = 0.189MPa) was very much within this limits when a maximum load of 300gms was applied in the horizontal direction (Figure-15), indicating an absence of bone deformation around the implant anchor.
The “strength of materials” [10] principles states that the implant supporting tissue has homogeneous elastic properties, the axial load transmitted from implant to bone concentrates highly in the upper region of bone and decreases rapidly towards the implant base. This phenomenon was observed in that present study showing a rapid decline in the stress distribution from the cortical bone to the cancellous bone. Stress distribution in cancellous bone The results of the present study show that the stress distribution of the maxillary cancellous bone is more than that of the mandibular cancellous bone (Figure-10, 12and14), which is in contrast to the stress distribution found in cortical bone. This could be explained by the fact that owing to reduced thickness of cortical bone of maxilla the significant portion of the load is to be borne by the cancellous bone than that of the mandibular counterpart. This in accordance with the study by Fanuscu et al[8] who demonstrated higher overall stresses in the cortical bone and least overall stresses in the cancellous bone. Comparison of stress distribution under various loading conditions The maximum stress distribution was observed in the horizontal loading condition, which is in accordance with the study by Pierrisnard et al. [19] whereas under the same magnitude of loading, the stress distribution under diagonal loading was significantly lower than that of horizontal loading condition (Figure-13and14). This could be effectively utilized by placing the implant higher up towards the vestibule where by a retractive force from such an implant could be well utilized for both intrusion and retraction of an entire anterior segment, mimicking the power arm design placed on molar anchor tooth. This could also be utilized for efficient use of class II retractive force. Under vertical loading condition a further reduction of stress distribution was noted than the other two loading conditions (Figure-9and10). As only minimal force (10-20 gm) [20] is required for intruding single tooth (for correction of supra erupted molar) or group of teeth (correction of deep bite) the mini implant can effectively serve as a source of anchorage for intruding the above conditions.
CONCLUSION
The pre adjusted edgewise appliance has always been popular because it is easy to work and also provides good control of the tooth during the process of retraction. But anchorage control has always been a trouble to this appliance system, and hence there was always a need to control it. The advent of microimplant enhances orthodontic anchorage without the need for special patient compliance. The result of this three dimensional Finite element structural method shows that - There is no bone deformation seen in this study, in all the three loading condition. - The stress distribution pattern seen in mandibular cortical bone when compared with maxillary cortical bone shows that implant is more stable in the mandible than in maxilla. - Since there is no bone deformation for the normal range of force in all the three planes, the Absoanchor titanium micro implant placed in maxilla and mandible provide stable anchorage to orthodontically intrude hyper erupted unopposed molars, intrusion and retraction of entire anterior segment and can be efficiently used for class II retractive force. In the future modeling the bone as the regenerative tissue, responding to stresses by resorption or regeneration may be a key improvement to the current state of art of FESA models to address the issues found in the study. As developments occur in implant technology, they may have a significant role as anchorage reinforcement aids and make head gear obsolete. However there is a need for high quality research in this area.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=946http://ijcrr.com/article_html.php?did=946
1. Alberto R. Mazzocchi and Silvia Bernini. Osseointegrated implants for maximum orthodontic anchroage. JCO 1998 July. 412- 415.
2. Hee-Moon Kyung, Hyo-Sang Park, SeongMin Bae, IL-Bong Kim and Jae-Hyun Sung. Development of orthodontic Micro implants for intra oral anchorage. JCO 2003, vol. 37, No.6: 321-328.
3. Wail N. Al-Rifaie and Ashok K. Govil. Finite element method – for structural Engineers (A Basic Approach).
4. Lavernia C J, Cook S D, Weinstein A M, Klawitter J J 1981 An analysis of stresses in a dental implant system. Journal of Biomechanics 14: 555-560.
5. Huiskes R, Chao E Y 1983 A survey of finite element analysis in orthopedic biomechanics: the first decade. Journal of Biomechanics 16: 385- 409.
6. Dincer Bozkaya, Siman Muftu and Ali Muftu. Evaluation of load transfer characteristics of five different implants in compact bone at different load levels by finite element analysis. J. Prosthet. Dent 2004; 92:523-530.
7. Hee - Moon Kyung, Hyo-Sang Park, and JaeHyun Sung. A simple method of molar uprighting with micro- implant anchorage. JCO – 2002 vol. 36, No. 10, 592-596.
8. Mete. I Fanuscu, Hung V. Vu and Bernard Poncelet. Implant Biomechanics in grafted sinus: A Finite element analysis. J. Oral. Implantology 2004, vol-30, No: 2; 59-68.
9. Cruz et al. Three- Dimensional finite element stress analysis of a cuneiform geometry implant. Int. J. Oral maxillofacial implants 2003; 18: 675-684.
10. Shinichiro Tada, Roxana Stegaroiu, Eriko Kitamura, Osamu Myakawa and Haruka Kusakari. Influence of implant design and bone quality on stress/strain distribution in bone around implants: A Finite element Analysis. Int. J. Oral. Maxillofacial. Implants 2003; 18: 357-368.
11. Monica Vasquez et al. Initial stress differences between sliding and sectional mechanics with the Endosseous implant as anchorage: A 3- Dimensional Finite element analysis. Angle orthod 2001; 71: 247-256.
12. Nilgun- Akin –Nergiz, Ibrahim Nergiz, Axel Schulz, Nejat Arpak and Wilhelm Niedermeier. Reaction of peri-impalnt tissues to continuous loading of osseointegrated implants. AJO 1998; 114: 292-298.
13. Lucie Himmlova, Tatjana Dostalova, Alois Kacovsky and Svatava Konvickova. Influence of implant length and diameter on stress distribution: A finite element analysis. J.Prosthet. Dent. 2004; 91:20-25.
14. Higuchi KW and Slak JM. The use of titanium fixture for Intra oral anchorage to facilitate orthodontic tooth movement. Int. J. Oral Maxillofacial Implants 1991; 69: 401-407.
15. Ismail S.F.H. and A.S. Johal et al. The role of implants in orthodontics. Journal of Orthodontics, 2002, vol. 29, 239-245.
16. Miyawaki et al. Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. AJO 2003, 124: 373-378.
17. Masumoto T, Hayashi I, Kawamurn A, Tanuku K and Kasai K. Relationship among facial type, buccolingual molar inclination and cortical bone thickness of the mandible. E JO 2001; 23: 15-23.
18. Martin RB et al Skeletal tissue mechanics. Springer 1998; 127-178.
19. Laurent Pierrisnard, Guy Hure, Michel Barquins and Daniel Chappard. Two Dental implants Designed for immediate loading: A Finite Element Analysis. Int J. Oral Maxillofacial. Implants. 2002; 17: 353-362.
20. William R. Proffit et al. Contemporary orthodontics. Third Edition.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareCOMPARISON OF BRONCHOALVEOLAR LAVAGE CYTOLOGY AND BIOPSY IN LUNG MALIGNANCY
English4347Richa SharmaEnglish Hemina DesaiEnglish Pankaj MalukaniEnglish R.N.GonsaiEnglish H.M.GoswamiEnglishBackground : Respiratory tract cytology is well established throughout the world as a vital diagnostic procedure in the evaluation of any patient with suspected lung malignancy and with the introduction of Flexible Fiberoptic Bronchoscopy, Bronchoalveolar Lavage is a popularly accepted tool for diagnosing lung cancer. Aims and Objestives : 1) To determine the efficacy of BAL cytological technique in diagnosing carcinoma of lung and correlating them with histopathological diagnosis by Bronchial Biopsy 2) To study the variation in the results with regards to different morphological types of lung malignancies. Material And Methods : A retrospective study was conducted at our tertiary care hospital. We selected 100 cases where bonchoalveolar lavage cytology samples as well as Bronchial Biopsy were taken. Samples were processed and reported as per the standard methods. Histopathological diagnosis by Bronchial Biopsy was considered as the “Gold Standard.” The samples were obtained by Flexible Fiber-optic Bronchoscopy done by the clinician. Result : Sensitivity of BAL was 42% and Specificity was 89.6%. Positive Predictive Value (86%) and Negative Predictive Value (48%), False Negative Index (60%) and False Positive Index (11%) were also calculated. Accuracy was 59%. Morphologically,44% were classified as poorly differentiated carcinoma, 28% were adenocarcinoma, 16% were squamous cell carcinoma and 12% were small cell carcinoma on BAL cytology. While on Bronchial Biopsy 29% were poorly differentiated carcinomas, 21% were adenocarcinoma,15% were squamous cell carcinoma and 15% were small cell carcinoma. Conclusion: Bronchoalveolar Lavage cytology is a good screening method for diagnosing lung malignancy as it is fairly sensitive and specific when compared with Bronchial Biopsy which is the “Gold Standard” method.
EnglishBAL (Bronchoalveolar Lavage), Bronchial Biopsy, Lung cancer.INTRODUCTION
Respiratory tract cytology is well established throughout the world as a vital diagnostic procedure in the evaluation of any patient with suspected lung malignancy1,2 . Flexible Fiberoptic Bronchoscopy with its extended visual range, excellent patient?s acceptance, low complication rate, and high diagnostic yield, provides a safe and effective means for making the diagnosis2 and sampling of suspected areas for cytology. Broncho-alveolar lavage (BAL) was originally developed as a therapeutic tool for pulmonary conditions like pulmonary alveolar proteinosis, cystic fibrosis and intractable asthma. Bleeding is always a concern when an airway lesion is biopsied. Pneumothorax occurs in 1-10% of cases of transbronchial biopsies (TBB). Bronchoalveolar lavage cytology is a minimally invasive method and has no absolute contraindications beyond those commonly associated with bronchoscopy. Application of BAL to the diagnosis of pulmonary malignancy was first reported in the early and mid-1980s and has since gained acceptance and steady popularity as a tool for diagnosing lung cancer.1,3,10-16 In this study our objective was to determine the efficacy of BAL cytological technique in diagnosing carcinoma of lung by correlating them with histopathological diagnosis by Bronchial Biopsy. We also aim to study the variation in the results with regards to different morphological types of lung malignancies.
MATERIAL AND METHODS
A retrospective study was conducted at our tertiary care hospital. We selected 100 cases where both Bonchoalveolar Lavage cytology as well as Bronchial Biopsy samples were taken. BAL cytology samples were obtained by Flexible Fiberoptic Bronchoscopy by the clinician. Smears were prepared after centrifugation and were stained as per routine protocol.4 Biopsy samples were processed by routine paraffin method followed by Hematoxylin and Eosin stain.5 For reporting, WHO Classification System was followed.6 Histopathological diagnosis by Bronchial Biopsy was considered as the “Gold Standard.”
RESULTS
All the patients who were diagnosed with lung malignancy were in the age group of 55 to 75 years and most of them were males. Out of 100 cases, 66 were diagnosed by Bronchial Biopsy as lung cancer. Rest of the cases showed non specific inflammatory or tuberculous lesions or no significant pathology. BAL cytology showed 25 True Positive cases and 34 True Negative cases, as confirmed by Biopsy. 4 cases were diagnosed as False Positive and 37 cases as False Negative by BAL. (Table 1). Thus, Sensitivity of BAL was 42%. And Specificity was 89.6%.Similarly Positive Predictive Value (86%) and Negative Predictive Value (48%), False Negative Index (60%) and False Positive Index (11%) of BAL were calculated. Accuracy of BAL was 59%. (Table 2). Out of 25 True Positive cases diagnosed by BAL, 11 (44%) were classified as Poorly Differentiated Carcinoma (Figure 1), 7(28%) were Adenocarcinoma(Figure 2), 4 (16%) were Squamous Cell Carcinoma(Figure 3) and 3 (12%) were Small Cell Carcinoma. While only 19 (29%) cases out of 66 positive Bronchial Biopsies, were labelled as Poorly Differentiated Carcinomas, 14 (21%) were Adenocarcinoma, 10 (15%) were Squamous Cell Carcinoma and 3 (15%) were Small Cell Carcinoma. (Table 3)
DISCUSSION
Lung cancer is currently the most frequently diagnosed and the most common cause of cancer mortality worldwide.6 Since cytological sampling by BAL technique relies mainly on cells „exfoliated? from the malignant lesion in the bronchial epithelium, the adequacy of its samples depends on several vital factors, especially a) the degree of differentiation of malignant growth; b) preservation of the morphology of cytological material obtained; and c) technical skill of the clinician who is retrieving the lavage fluid from the bronchus1 In our study of 100 cases suspected of lung malignancy 66 were actually diagnosed positive for malignancy. The mean age of positive cases for malignancy was 60 years in our study and majority were males which correlated with most other studies.2,3,7,8 (TABLE : 4) The sensitivity (42%), specificity (89.6), False Negative Index (60%) and False Positive Index (11%) and accuracy (59%) were comparable to a similar study done by Gaur DS et al in which sensitivity, specificity, False Negative Index, False Positive Index and Accuracy were 39.4%, 89.6%, 60.6%, 10.4%, 71.4% respectively.1 In general, less differentiated, anaplastic lesions have more loosely cohesive cells in comparison to well differentiated lesions. Thus such lesions exfoliate larger number of cells into the Bronchial cavity than the well differentiated lesions.1 In our study too poorly differentiated lesions (44%) exceeded all other types among True positive cases. Similar results were obtained by Gaur DS et al also.1 Squamous Cell Carcinoma (35%) was second most common type after Poorly Differentiated Carcinoma in Biopsy samples as against BAL in which Adenocarcinoma (28%) was the second most common morphological type detected. This is supported by the fact that Squamous Cell Carcinoma followed by Adenocarcinoma are the two most common morphological type of lung malignancy worldwide.7 Similar results were also noted by Poletti et al.9 Small Cell Carcinoma was the next morphological type in both BAL(12%) and Biopsy(15%) samples and results were comparable with Gaur DS et al1 (7.1% BAL, 19.7%Biopsy) and Firoozbakhsh SH et al3 (2/17=12% BAL, 6/47=13% Biopsy). Only one case of Carcinoid tumor was diagnosed in Biopsy which was given falsely negative by BAL cytology much similar to the study by Gaur DS et al.1
CONCLUSION
Considering its safety, Bronchoalveolar Lavage cytology is a good screening method for diagnosing lung malignancy as it is fairly sensitive and specific when compared with Bronchial Biopsy which is the “Gold Standard” method.
a
Englishhttp://ijcrr.com/abstract.php?article_id=947http://ijcrr.com/article_html.php?did=947REFERENCES
1. Gaur DS, Thapliyal NC, Kishore S, Pathak VP. Efficacy of Broncho-Alveolar Lavage and Bronchial Brush Cytology in Diagnosing Lung Cancers,Journal of Cytology 2007; 24 (2) : 73- 77
2. Tuladhar, Panth, Joshi. Comparative analyses of cytohistologic techniques in diagnoses of lung lesions, Journal of Pathology of Nepal (2011).Vol.1, 126-130
3. Shahram Firoozbakhsh, Enayat Safavi. Bronchoalveolar Lavage in the Assessment of Peripheral Lung Cancer, Tanaffos 2003; 2(7) : 7-10
4. Johnston WW, Elson CE. Respiratory tract. In: Bibbo M, editor. Comprehensive cytopathology. 2nd ed. Philadelphia: W.B.Saunders Company; 1997. p. 325-401.
5. Bancroft JD, Gamble M, editors. Theory and practice of histological techniques. 5th ed. New York: Churchill Living Stone; 2002.
6. Travis, W. D., Colby, T. V., Corrin, B., Shimosato, Y., and Brambilla, E. Histological typing of tumours of lung and pleura. In: L. H. Sobin (ed.), World Health Organization International Classification of Tumours, Ed. 3. New York: Springer-Verlag, 1999.
7. Husain AN, Kumar V. The Lung. In: Robbins and Cotran. Pathologic basis of disease. 7th ed. Philadelphia: W.B. Saunders Company; 2006. pp711-22.
8. Rosai and Ackerman?s, surgical pathology, 3rd edition, :Chapter 7:291-340.
9. Venerino Poletti, M.D.,Giovanni Poletti, M.D., Bruno Murer, M.D., Luca Saragoni, M.D.,and Marco Chilosi, M.D. Bronchoalveolar Lavage in Malignancy, Seminars In Respiratory And Critical Care Medicine/Volume 28, Number 5 2007 1
0. John D. Mina. Neoplasms of the lung in Braunwald et al.Harrison?s Principle of Internal Medicine 15th ed. United States of America. MC Graw Hill Inc 2001; 567-71.
11. Springmeyer SC, Hackman R, Carlson JJ, et al. Bronchoalveolar cell carcinoma diagnosed by Bronchoalveolar Lavage.Chest 1983;83:378–379Q48
12. Stover DE, Zaman MB, Hajdu SI, Lange M, Gold J,Armstrong D. Bronchoalveolar Lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med 1984;101:1–7
13. Young JA, Hopkin JM, Cuthberston WP. Pulmonary infiltrates in immunocompromised patients: diagnosis by cytological examination of Bronchoalveolar Lavage fluid.J Clin Pathol 1984;37:390–397
14. Sestini P, Rottoli L, Gotti G, et al. Bronchoalveolar Lavage diagnosis of bronchiolo-alveolar carcinoma. Eur J Respir Dis1985;66:55–58
15. Rossi GA, Balbi B, Risso M, Repetto M, Ravazzoni C.Acute myelomonocytic leukemia: demonstration of pulmonaryinvolvement by Bronchoalveolar Lavage. Chest 1985;87:259–260
16. Weynants P, Cordier JF, Chapuis Collier C, et al. Primary immunocytoma of the lung: the diagnostic value of Bronchoalveolar Lavage. Thorax 1985;40:542–54
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524165EnglishN-0001November30HealthcareHISTOPATHOLOGICAL REVIEW OF SPLEEN SPECIMENS (200 CASES)
English4858Shah S.English Gosai R.English Gonsai R. N.EnglishThis is a descriptive / retrospective crosssectional study. This study was carried out at the histopathology laboratory, Department of Pathology, B. J. Medical College, Ahmedabad from January 2008 to December 2009 on all splenecand tomy specimens and one splenculi biopsy. Total 200 cases were studied which were received already fixed in 10% neutral buffer formalin. Among the specimens the most common age group fell in 21-30 years (30%). Male to female sex ratio was1:1.1. In 30% cases cause of splenomegaly was not identified. Most common known cause for splenomegaly was portal hypertension (23.5%) followed by trauma (12.5%). Most common diagnosis made after microscopy and correlating clinical and radiological findings was fibrocongestive splenomegaly (67%), which was most commonly due to hepatic cause. Most common cause identified later in unidentified cases of splenomegaly was also fibrocongestive splenomegaly (69%).
Englishsplenectomy specimens, splenculi biopsyINTRODUCTION
Spleen is mysterious organ, it can be troublesome specimen for surgical pathologist due to discordance between patient’s clinical condition and perceived findings. Patients with a dramatic clinical presentation that point to splenic pathology not infrequently have no discernable or have barely perceptible histological abnormalities of the spleen. Similarly, patients whose spleens contain histological findings that seem to deviate significantly from the “norm” may have no clinically detectable haematological complains.This review presents practical aspects of splenic histopathology specimens and relates this to the pathologist’s approach in evaluating the abnormal spleen and assists in resolving such discordance.Splenectomy dates back to1549 when first reported by Zacarello in Italy. In 1826 Quittenbaum did first elective splenectomy for portal hypertension and in 1866, Bryant did first splenectomy for leukemia. In 1892 emergency splenectomy was done for trauma in Germany. In 1911 and 1916 elective splenectomy was done for autoimmune haemolytic anemia and ITP respectively.6The spleen, in healthy adult human is approximately 11 cms4.3in length,usually weights 150 grams and lies beneath 9th to 12th thoracic rib and between fundus of stomach and diaphragm. It filters foreign matter including old / damaged blood cells : participates in immune response to blood borne antigens; major repository of mononuclear phagocytic cells in red pulp ,lymphoid cells in white pulp and platelets and produces new blood cells in infants / children or adults with severe anemia.Composed of red pulp(76-79%) and white pulp(5-20%) separated by marginal zone (diag 2) Massive splenomegaly ( Spleen > 1000 g) is due to CML, Gaucher’s disease, hairy cell leukemia, marginal zone B cell lymphoma,myelofibrosis,plasmacytoma,prolymph ocytic leukemia.Rupture is due to blunt trauma or abdominal surgery, causing haemoperitoneum and emergency splenectomy.spleen only rarely ruptures spontaneously (associated with infectious mononucleosis, malaria, Typhoid fever, leukemia / Lymphoma, other tumours,subacute bacterial endocarditis, peliosis lienis, acute splenitis, pregnancy) Gross rupture may be a very small capsular tear, often in superior pole or hilum Micro: neutrophil below capsular tear with intraparenchymal haemorrhage ; also lymphoid hyperplasia with prominent marginal zone. Splenectomy is usually performed for traumatic rupture.Usually no clinical consequence in adults. In children, it is associated with increased incidence and severity of infections, particularly encapsulated bacteria such as Streptococcus pneumonia, Neisseria meningitides, Haemophilus influenza; overwhelming infections may begin days to years after splenectomy, without an identifiable focus and have 50-80% mortality despite antibiotics. In children, splenectomy is avoided in favour of splenic repair, partial splenectomy is performed for haematological disorder. Howell-Jolly bodies are evidence of no splenic function.
OBJECTIVE: \
To study incidence of splenectomy in relation to different age ,sex, cause of splenomegaly and final diagnosis of splenectomised patients.\
MATERIALS AND METHODS\
This is a retrospective study carried out in histopathology laboratory of department of pathology, B.J.Medical College, Ahmedabad from January 2008 to December 2009 comprising of 200 cases.The parameters like age, sex, cause of splenomegaly and splenectomy, macroscopic appearance of spleen, final diagnosis ofsplenectomized patients were studied. All specimens were complete splenectomy samples except one which was a splenculi biopsy specimen.the spleens were already fixed in 10% neutral buffer formalin. Detailed clinical histories.clinical examinations and investigations done on patients were noted like personal history,past history, family history, clinical examinations, CBC, serum chemistry,coagulation profile, X-Ray, USG. Indication of splenectomy was noted. Spleens were sectioned serially by blade loafing and re-fixedin 10% formalin saline for 24-48 hrs before sectioning and processing.Gross and microscopic findings were note were weight, size, gross and microscopic findings and finally the pathological diagnosis in respect of different pathologies. In addition to hematoxylin and eosin, stains such as Giemsa, Perl’s, Prussianblue, congo red and Periodic Acid Schiff were used when necessary. RESULTS Total 200 specimens of spleen were studied in histopathology department of BJ medical college, civil hospital, Ahmedabad in period of 2008 to 2009. Table 1 shows age and sex distribution of splenectomy and chart 1 shows bar diagram of age. The age range was 2 to 65 years. Highest incidence was in 21 – 30 yrs group which was 30%, next was 31-40 yrs in which was 24.5%. Incidence declined after 40 yrs and least number of cases were in 61-65 yr group. M:F ratio was almost equal except in 2-10 yr group in which it was 2.6:1 and 31-40 age ratio was 1:1.88
Macroscopic examination Table 3 shows dimentions of spleen specimens. Dimension of spleen were varying from normal size and weight to massively enlarged spleen >1000 gm and huge in size in reactive follicular hyperplasia hyperplasia , hemangioma of spleen and splenomegaly due to other reasons. Out of 25 traumatic cases, laceration was found in 9 cases. Hemorrhagic area was found in 5 cases.spleniculi was found in 5 cases (2.5%), 2 in thalassemia patients, one each in tropical splenomegly syndrome, ITP case and portal hypertension. Infarct like areas were noted in 30 spleens, one in sickle cell anemia patients and all other due to large size of spleen.
Histopathological Diagnosis
Table 4 shows distribution of various diagnoses made by microscopy and correlating clinical and radiological findings. Fibrocongestive splenomegaly was the most common diagnosis made by microscopy. It was most commonly found in splenomegaly due to hepatic cause .congestion of red pulp and fibrosis was noted. In traumatic spleen no specific findings was noted except hemorrhage and necrosis. 9 cases were diagnosed as tropical splenomegaly – multiple eosinophils, sinusoidal dilation but no fibrosis or hemosiderin deposition led to this diagnosis. Extramedullary haematopoiesis was present in 10 cases in which 2 were of extensive degree found out to be myelofibrosis. In others it was due to chronic haemolytic conditions .Special mention is for a case of multinodular hemangioma found in 23 yr female in which grossely detected tumour of 10 cm size was present.Microscopically markedly proliferating and anastomosing vascular channels lined by endothelial cells showing vague hemangiopericytoma like pattern.At places vascular channels showed evidence of lobular pattern surrounded by hyalinised stroma. Two cases of solitary splenic lymphoma were found in 47 and 60 year males presented with provisional diagnosis of splenic abscess. Grossely multiple whitish nodule was present. Microscopically proliferation of white pulp was noted. There was formation of multiple nodules consisting of monomorphic small lymphocyte like cells having hyperchromatic vesicular nucleus and prominent nucleoli. Diagnosis of NHL of spleen – small lymphocytic variant was made which was confirmed on IHC. Two cases of TB were found having caseous inflammation and two of granulomatous inflammation with abscess formation. One case of reactive follicular hyperplasia was found.
Histopathology in undetermined causes of splenomegaly
splenomegaly Table 5 shows findings in splenomegaly due to undetermined causes. Out of 59 cases in which no cause was determined clinically or radiologically, in 69 % cases diagnosis of fibrocongestive splenomegaly was given.Hepatic causes were found out in 15 % cases by liver biopsy. In 7 % cases diagnosis of Tropical splenomegaly was given. Liver biopsy was done with splenectomy in 27 cases out of 200 (13.5%) Table 6 shows various liver biopsy findings.Cirrhotic changes were present in 2% of cases. Chronic venous congestion was found in 19% cases. 9 biopsies (33.3 %) gave final diagnosis as hepatic cause of splenomegaly, which is a significant finding.
DISCUSSION
There are very few studies based on Histopathological findings in spleen..This study is a novel study as it involves 200 cases and focussed on histopathological correlation of clinical findings.It revealed cause of splenomegaly in 31 % cases in which no diagnosis was made clinically which is quite significant. A hospital based study of splenomegaly with special reference to the group of indeterminate origin was done in March 2008 by Sundaresan JB, Dutta TK, and et. Al.1 at Department of Medicine, JIPMER, Pondicherry. But it was a clinical study.The common causes of splenomegaly in this study were malaria (22%), chronic myloid leukemia (11%), NCPF(9%), enteric fever (9%), cirrhosis of liver (8%) and HMS (7%). This is significantly different from the observations in previous studies 2,3 on splenomegaly from india. Malaria was observed in 3 patients (4%) only. In 32 patients (42.7%) the cause of splenomegaly could not be determined. In the study of Chandra et al (4) the common cause found were again cirrhosis of liver and chronic myloid leukemia. Idiopathic splenomegaly was found in 15 patients (18.1%) Histopathological study and audit of the spleen in Nigerians was done by Kayode et.al5 during the period of 18 yrs between 1988 and 2005. Only 123 specimens of spleen were received. 119 had adequate data to be included in this study. There were 76 males and 43 females. The age range was 1 yr to 86 yrs. The highest number of splenectomy was in the age group 11-20 (16 male, 6 females). The incidence declined after age of 60. Table 7 shows age wise distribution of various causes of splenomegaly (clinical causes) Thalassemia was most common cause of splenectomy in 2-10 year age group. Portal hypertension and Trauma being the leading cause of splenectomy in 21-30 yr age groupTropical splenomegaly was found out to be most common in 31-40 yr age group. ITP being most common in 31-40 yr age group and male female ratio was 1:5. Lymphoma is common in old age as expected.In present study most common cause of splenomegaly as well as indication of splenectomy comes out to be hepatic.Portal Hypertension is very common in Gujarat, Rajasthan, Maharashtra and M.P. which forms our main patient group. Malaria is common but splenomegaly is rarely needed as diagnosis is earlier and antimalarial are given. Haematological malignancies like CML, is not included our study as most malignancies are referred to Gujarat Cancer Research Institute(GCRI) which is not part of this study . In SB et.al (1) study only causes of splenomegaly are enumerated. It is not based on splenectomy specimens .Trauma is not included in this study.However if we exclude trauma and splenectomy due to other reasons then out of 168 splenectomy cases, as Table 11 showscomparison between present and SB et al study for causes of splenomegaly(clinical only): hepatic cause are the predominant one.Almost 25% cases remain undetermined and no specific cause is identified. Infectious diseases like TB, Hydatid disease, Typhoid are common but typhoid rarely needs splenectomy but it is not present in SB et al study. Hemangioma is most common primary tumour of spleen and it is included in our study
SUMMARY
For the pathologist in training and attending alike, the spleen can be deceptively simple. It is rare as a surgical specimen and when it is encountered ,it seldom contains an abnormality. however occasionally the spleen’s troublingly complex nature is unmasked whenfindings do not correspond to a well definded category of disease of disease or the splenic parenchyma obscures diagnostic features. In our study due to large number of cases the results are fairly significant. Hepatic disease remains the top of all. Trauma is also common indication for splenectomy. Primary splenic tumours like hemangioma are rare but can be encountered. Lymphoma can also be underdiagnosed as reactive so pathologists should be alert. Hydatid disease, TB, Abscess formation are also not very uncommon. Inevitably ,it is these cases in which there is often great clinical pressure and the temptation may be great to force the findings into an existing category of node based or soft tissue based nosology. The key to timely and accurate diagnosis in such situations lays in preparations: obtaining complete clinical information about the patient, taking a systematic approach to prosection, preparing thin sections from well fixed tissue and becoming familiar with the stains and studies that define the intactness of splenic immunoarchitecture.
Englishhttp://ijcrr.com/abstract.php?article_id=948http://ijcrr.com/article_html.php?did=948REFERENCES
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