Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcareSTUDY OF COMPARTMENT PRESSURE IN SUSPECTED CASES OF ACUTE COMPARTMENT SYNDROME IN LEG
English0104Naresh KumarEnglish Sandesh ChaudhariEnglishBackground: The present study has been done on the patient with suspected cases of increased compartment pressure in leg with history of trauma, using Whiteside needle manometer technique to make early diagnosis and early intervention to save the limb1 . Materials and Methods: The study has been conducted over 40 patients in the age range between 10-45 yrs from April 1999 to March 2000. The compartment pressure of the injured leg has been measured using Whiteside needle manometer technique from the time of admission till the pressure came to normal or till the patient need decompression of the compartments. Result: This series shows that compartment syndrome is not an uncommon complication of leg fracture. The site of fracture found to affect more in upper third 23(57.5%) than in middle third 14(35%). In lower third 2(5%) cases and only 1(2.5%) case of segmental fracture both bone leg were affected. High energy trauma 2 was the common 37(92.5%) cause of raised intracompartmental pressure than low energy trauma 3(7.5%). Conclusion: This series shows that compartment syndrome is not an uncommon (7.5%) complication of leg fracture. The raised compartment pressure is mainly seen with the fracture affecting the upper third of leg. The patient needs to be monitored for at least 72 hr. following trauma. The critical pressure of fasciotomy is the raising value of compartment pressure of 30 mm Hg3 . with clinical signs and symptoms. It is important to release of all the four compartments of leg within 6 hrs. of the diagnosis of acute compartment syndrome for better prognosis.
EnglishCompartment pressure, Double incision fasciotomyINTRODUCTION
Acute compartment syndrome is an orthopaedic emergency, if not diagnosed and treated in time will cause permanent functional loss of the limb 4 . It was Volkman who drew attention to the development of ischaemic injury following trauma as early as in 1872, but in 18815 he described interruption of blood supply as a cause of paralysis and contracture of muscle of the affected compartment. A compartment syndrome as defined by Mubarak et al (1964) is any clinical condition in which increased interstitial pressure in closed ossteofacial compartment result in microvascccular compromise and possible muscle and nerve damage 6 .Increasing number of vehicle on road and fast life lead to an increased in incidence and severity of fracture. Tibia being subcutaneous bone is prone to get fractured. It is the site and amount of energy that is transmitted to the limb; decide whether or not compartment syndrome will develop De Lee and Stiehl in 19817 . Compartments most commonly affected are a. Anterior and deep posterior compartments of leg b. Volar compartments of forearm However, compartment syndrome can develop anywhere, where skeletal muscle is surrounded by substantial fascia ,such as in : Buttocks, thigh, foot, shoulder, arm, hand, lumbar paraspinous muscles. The exact mechanism causing the high compartment pressure is unknown but shift of fluid between blood and tissue have been strongly implicated8 .
Ellis in 1958 reported a 2% incidence of ischaemic contracture in the lower extremity following tibial fracture 9 .The incidence of lower limb compartment syndrome in the adult has been reported by De Lee and Stiehl (1981)7 as 6% in the open fracture of the tibia and 1.2% in the closed tibial fractures. Mc Queen and Court Brown (1996) 10 describe only 1.2% incidence. If compartment syndrome is not recognised or the diagnosis is delayed it lead to serious complications.
This study has been undertaken to identify the patients at risk and to avoid the complications of compartment syndrome like; a. Ischaemic necrosis of muscles b. Neurological deficit c. Volkmann’s contracture ,and d. Amputation MATERIALS AND METHODS The study has been conducted over 40 patients in the age range between 10-45 yrs from April 1999 to March 2000 , in the department of orthopaedics Hamidia Hospital Bhopal. These were the patients who were suspected to develop Compartment syndrome. Right leg 26(65% ) of the patient was affected more than the Left leg 14(35% ) with male is to female ratio 19: 1. The number of cases with open (Gustilo G-1 ) were 24 (60%) and 14 (40%)cases were closed fractures.
The site of fracture found to affect more in upper third 23(57.5%) than in the middle third 14(35%).In lower third 2(5%) cases and only 1(2.5%) case of segmental fracture both bone leg were affected. In our study only 6 (15%) cases were having associated orthopaedic injuries. The compartment pressure of the injured leg has been measured from the time of admission till the pressure came to normal or till the patient need release of all the compartments. Preoperative radiograph were taken in all patients and associated orthopaedic injuries were noted. Inclusion criteria for this study were ; Acute trauma causing leg fracture within 72 hrs. of injury , tense swelling in leg and knee; blisters on the skin and stretch pain on passive dorsiflexion of toes, paresthesia over the area supplied by peroneal nerve and status of peripheral circulation of leg.
Cases not included in our study are Gustilo Anderson Grade 2 and above. Strict limb elevation, serial compartment pressure monitoring using Whiteside technique and frequent clinical examination was done to identify the signs of compartment syndrome. Patient with impending compartment syndrome were operated within 6 hours of raised compartment pressure and clinical appearance of signs and symptoms using double in cision technique. Material used are one triway stopcock, one 20ml syringe, two 18 guage needle, two i.v. plastic extension tubes, one bottle of bacteriostatic normal saline and one mercury mannometer.
Steps used in the technique: Clean and prepare the extremity to be evaluated. Break the vacuum in a sterile saline bottle with a sterile needle. Assemble 20 ml. syringe with the plunger at the 15ml. mark, a 3- way stopcock, a plastic i.v. extension tube and a 18 guage needle. Insert the tip of 18 gauge needle into the saline and aspirate the saline without bubble into approx. half of the length of extension tube. Turn the 3- way stopcock to close this tube so that the saline is not lost during transfer of the needle. Insert the 18 gauge needle into the muscle of the compartment in question. Connect the second extension tube to the manometer at one end and to the 3-way stopcock at the other. Turn the stopcock so that the syringe is open to both the extension tubes forming a “T” connection. This produce a closed system in which the air flow into both the extension tubes as the pressure within the system is increased. Increase the pressure in the above closed system by slowly pressing the plunger of the syringe at the same time watch the movement of the saline column in the extension tube.
The mercury in the manometer will rise as the pressure within the system rises. When the pressure in the system just crosses the tissue pressure surrounding the needle, small amount of the saline will be injected into the tissue and the saline column will move in the extension tube. When the column moves, stop the pressure on the syringe plunger and read the level of the column in manometer. The manometer reading at the time saline column moves, is the tissue pressure in “mm” of mercury of the involve compartment. Serial measurement of compartment pressure in the Anterior compartment of the leg and blood pressure (in mm Hg.) was taken every 4 hourly and the clinical findings noted till the critical pressure of 30 mmHg. or more was reached or compartment pressure started decreasing.
The cases with compartment pressure between 19- 29 mmHg. were grouped as transient compartment syndrome. These patients were observed very closely. The treatment given in suspected cases of acute compartment syndrome are : 1. All the suspected cases of closed or open fractures were immobilized in toe to groin slab, proper limb elevation was done and toe movement advised.
2. All the cases of compound fracture were given injectable antibiotic. 3. All the cases were given Tab. Serratiopeptidase 10 mg. TID orally. 4. The cases were kept under closed observation. The cases having compartment pressure greater than 30 mmHg or differential pressure less than 30 mmHg. were taken as the candidate for the decompression. The operative technique used in this study was double incision fasciotomy 11.
Diagram showing double incision fasciotomy ; Cross section (1) All four compartments released- (a)Anterior(b),Lat eral(c),Superficial posterior and (d) Deep posterior group of muscles. (2) Line of Incision (e)Anterolateral and (f) Posteromedial.
Double incision fasciotomy: The patient was taken in operation theater, kept in supine position and using aseptic precaution the affected limb was prepared and drapped. The first incision was the anterior incision that was centred over the anterior intermuscular septum, and the second incision was posteromedial incision that was centered 1 cm. or so behind the posteromedial border of the tibia. The anterior incision was made and the intermuscular septum is identified. It is important to identify the intermuscular septum because the terminal branch of the deep peroneal nerve perforate the septum in the distal one-third of the lower leg and this could be cut if not identified. The anterior and lateral compartments are then released by doing fasciotomy 1cm. in front and behind the anterior intermuscular septum.
The deep compartments are exposed through the posteromedial incision by retracting the saphenous vein and nerve and releasing the fascia over the superficial posterior compartment. In order to decompress the deep posterior compartment, it is necessary to detached the soleal bridge which is then retracted to expose the fascia covering the flexor digitorum longus and tibialis posterior muscles. The condition of the muscles in all the four compartments were noted for color, contractibility and circulation. The non-viable muscles were debrided and muscles with doubtful viability left as such, sterile dressing done and toe to groin slab was applied.
Postoperative protocol A second examination performed 24-48 hrs. after fasciotomy at which time all the non viable muscles were debrided and after 10-15 days as the wound improved, split thickness graft was applied. When graft was accepted toe to groin cast was applied under general anaesthesia and patient is discharged with advised for follow up. All patient were advised to attend orthopaedic out patient department on a fixed date at regular interval on each occasion status of union and functional evaluation and complication if any where assessed in the following manner: 1. Patients were asked about any subjective complain like pus discharge, fever, pain, swelling, range of movement, loss of function, etc. 2. Movement of knee, ankle, foot and toes checked. 3. Standard anteroposterior and lateral X-ray were to asses the radiological union. 4. Any complication like residual deficit was noted.
RESULTS In our study out of 40 patient, 10 (25.5%) cases reached stage of transient compartment syndrome out of which 2(20%) developed compartment syndrome. Each of the 2 cases were closed fracture both bone leg (one oblique fracture upper third and one middle third respectively) One case was open compound comminuted fracture both bone leg who came late as 48 hrs., following injury with full blown signs and symptom of compartment syndrome and was decompressed within one hour of arrival in hospital but ended up with foot drop and infection.
Two cases were monitored closely and undergone double incision fasciotomy within 6 hours of reaching peak intercompartment pressure greater than 30mmHg. These two patient showed only mild limb residual deficit in late follow up. Right leg 26(65% ) of the patient was affected more than the Left leg 14(35% ). The number of cases with open (Gustilo G-1 ) were 24 (60%) and 14 (40%)cases were closed fractures. The site of fracture found to affect more in upper third 23(57.5%) than in the middle third 14(35%).
In lower third 2(5%) cases and only 1(2.5%) case of segmental fracture both bone leg were affected. In our study only 6 (15%) cases were having associated orthopaedic injuries. The male to female ratio is 19: 1. All those cases who underwent fasciotomy were assessed according to limb residual deficit. The “Limb Residual Deficit “ was measured using classification proposed by Scott Mubarak and Charles Owen (1975) 12 as : 01- Mild – Residual deficit consisted only of slight intrinsic contract with intact motor and sensory function.
02- Moderate- Limbs with digital hyperasthesia, intrinsic paralysis and contracture of only the muscles of deep compartment. 03- Severe – Limbs with marked sensory and motor loss with severe contracture (classical Volkmann’s Contracture)
DISCUSSION In present series one patient reached the peak pressure of 24 mmHg.(transient compartment syndrome) at 49 hrs. and started decreasing after 65 hrs. following injury. After 50 hours 12.5% patient required compartment pressure monitoring and only 5.1% patients after 60 hours. None of our patients required monitoring after 72 hrs. following injury. This series shows that compartment syndrome is not a uncommon(7.5%) complication of leg fracture. The raised compartment pressure is mainly associated with the fracture affecting the upper third of leg. The patient need to be monitored for at least 72 hrs. following trauma. The critical pressure of fasciotomy is raising value of compartment pressure of 30 mmHg. with clinical signs and symptoms. It is mandatory to release all the four compartments of leg within 6 hrs. of diagnosis of acute compartment syndrome for favorable outcome.
TRANSIENT COMPARTMENT PRESSURE AND CRITICAL PRESSURE Depending on severity of injury the patient are prone to develop compartment syndrome. In our present series 10 patients reached peak absolute pressure between 19 -29 mmHg. These patients were taken as having transient or impending compartment syndrome, out of which two (20%) developed compartment syndrome. The absolute pressure of 30 mmHg. in association with clinical findings was taken as critical pressure of fasciotomy. There was no correlation found between diastolic blood pressure and development of compartment syndrome, may be because none of the patient were hypotensive.
TIME INTERVAL BETWEEN INJURY AND FASCIOTOMY In two cases, fasciotomy was performed within 3hrs. of reaching critical compartment pressure of 30 mmHg. In all the three cases double incision fasciotomy was done two of which developed mild squeal and came up with good result because of operating within 6 hrs. One case ended up with poor results because of delay in coming to the hospital hence delay in diagnosis and treatment. It has been noted that delay of even 6-12 hrs. between onset of symptoms and treatment ends up with poor result as advised by Whiteside, Harada (1971), Aschton and Heath 11.
CONCLUSION The raised compartment pressure is mainly associated with the fracture affecting the upper third of leg. The patient need to be monitored for at least 72 hrs. following trauma. The critical pressure of fasciotomy is the raising value of compartment pressure of 30 mmHg. with clinical signs and symptoms. Release of all the four compartments of leg within 6 hrs. of diagnosis of compartment syndrome is required for favorable outcome.
ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to authors /editor/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=187http://ijcrr.com/article_html.php?did=1871. Whitesides TE Jr, Haney TC, Morimoto K; Harda H: Tissue pressure measurement as a determinants for the need of fasciotomy, Clin Orthop 113:43,1975.
2. Watson JT. High energy fractures of the tibial plateau Orthop Clin North. Am 1994; 25:723-52.
3. Whitesides TE Jr, Haney TC, Morimoto K; Harda H: Tissue pressure measurement as a determinants for the need of fasciotomy,Clin Orthop 113:43,1975.
4. Child, C.G.III Noninfective Gangrene following fracture of lower leg Ann. Surg. 116:721-728, 1942.
5. Volkmann, R.V. Die ischaemischern muskellahmungen and Kontracturen.z. chir. 5 1, 1881.
6. Mubarak. S.J., and Hargens, A.R : Compartment Syndrome and Volkmann’s Contracture . Philadelphia, W.B. Saunder,1981.
7. De Lee & StiehlClin Orthop Relat Res. 1981 Oct;(160):175-84.
8. Hargens, A.R.; Akeson ,W.H. Mubarak, S.J.; Owen; C.A.; Evans, K.L.,Garetto, L.P. ; Gonsalves, M.R.; and Schmidth, D.A. fluid Balance within the Canine Anterolateral compartment pressure and its relationship to compartment syndrome. J. Bone and Joint Surg. 60A: 505 1978.
9. Ellis, H.: Disabilities after tibial shaft fracture with special reference to Volkmann’s ischaemic contracture J.Bone & Joint Surg. 40-B: 190-197, 1958.
10. Mc Queen, M.M., J. Christie, C.M. Court Brown.: Acute compartment syndrome in tibial diaphyseal fractures, J. Bone and Joint Surg., 78 B., No. 1 ,1996.
11. Scott J. Mubarak,M.D.,and Charles A. Owen.M.D., J. Bone and Joint Surg.,Vol. 59-A No. 2, pp. 184-187, March 1977.
12. Mubarak, Scott and Owen C.A.: Compartment Syndrome and its relation to the Crush Syndrome: A Spectrum of Disease. A Review of 11 cases of Prolonged Limb Compression. Clin. Orthop., 113: 81- 89, 1975.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcareA STUDY ON KNOWLEDGE REGARDING PREVENTION OF IRON DEFICIENCY ANEMIA AMONG ADOLESCENT GIRLS IN SELECTED PRE-UNIVERSITY COLLEGES OF MANGALURU
English0507Niba JohnsonEnglish Noufeena D. Y.English ParvathiEnglish Priya JosephEnglish Priya Reshma AranhaEnglish Asha P. ShettyEnglishIntroduction: Adolescent period is a critical link between childhood and adulthood, characterized by significant physical, psychological, and social transitions. Adolescent girls are particularly vulnerable to nutritional problems and anemia is one among them. Adequate knowledge can promote good practice and help in the prevention of iron deficiency anaemia. Objectives: The study was carried out to determine the knowledge regarding prevention of iron deficiency anemia among adolescent girls and to find the association between knowledge scores and selected demographic variables. Materials and method: A descriptive survey approach was used in the study, non probability purposive sampling technique was used to select 100 adolescent girls and data was gathered using the structured knowledge questionnaire on iron deficiency anemia. Data was analyzed by using descriptive and inferential statistics. Results: The study result showed that majority (84%) of study sample had moderately adequate knowledge, 11% had inadequate knowledge and 5% had adequate knowledge on prevention of iron deficiency anaemia. There was no significant association found between knowledge scores and the selected demographic variables of the adolescent girls (p>0.05) Conclusion: This study concluded that majority (84%) of the study sample had moderately adequate knowledge on prevention of iron deficiency anemia so it is advisable to provide educational programs for the adolescent girls regarding iron deficiency anemia.
EnglishKnowledge, Prevention, Iron deficiency anaemia, Adolescent girlsINTRODUCTION Adolescence has been defined by WHO as the period of life span, the age between 10- 19 years. It is a formative period of life when maximum amount of physical, psychological and behavioural changes take place1 . Adolescence is a critical stage in the life cycle, when health of the female is affected due to growth spurt, beginning of menstruation, poor intake of iron due to poor dietary habits and gender bias2 which may lead to iron deficiency anaemia among the adolescent girls. The average monthly menstrual blood loss is about 45 ml and causes the loss of about 22mg of iron3 . Anemia during adolescence limits its growth and delays the onset of menarche, which in turn may later lead to cephalopelvic disproportion.4 About 75% teenage girls, do not meet their dietary requirements for iron, compared to only 17% of teenage boys.5 Total nutrient requirements are increased during adolescence period to support a dramatic growth and development. Eating right food at right time will prevent nutritional deficiencies especially iron deficiency disorders.6 The prevalence of anaemia is disproportionately high in the developing countries, due to poverty, inadequate diet, worm infestations, pregnancy/ lactation and poor access to the health services.7 Iron deficiency anaemia is one of the most prevalent common nutritional deficiencies in the world especially among adolescent girls4 . According to WHO 2014 survey estimation the highest prevalence of anaemia is in pre-school children (47.4%), and the lowest prevalence is in men (12.7%) nearly 50% of women in reproductive age are anemic.8 National family health survey in 2006 stated that 56% adolescent girl are anaemic in India.9 In the world health report of world health organization, it was seen that the worldwide mortality rate of iron deficiency anaemia was 60,404,000 and mortality rate in India was 13,704,953 in 200510. A study was conducted on prevalence of iron deficiency anaemia among adolescent girls in 16 districts of India in 2006. The survey showed that 90.1% adolescent girls were exposed to moderate iron deficiency anaemia and 71% of girls were exposed to severe iron deficiency anaemia .11 The prevalence of iron deficiency anaemia among adolescent girls is consistently high nowadays because most of the adolescent girls have an intention to maintain a slim structure. An influence of junk foods and fast foods will reduce the intake of dietary iron rich foods.12 To prevent iron deficiency anaemia, teenage girls and young women need to be aware of the condition. Education and motivation can bring in awareness and it is hoped that other females will also be more inclined to eat iron-rich foods and foods that are iron sources, practice home-based methods of food fortification and monitor monthly bleeding.13 The study was conducted on women of reproductive age in a rural area showed that 55.8% of the participants had inadequate knowledge and 44.2% had adequate knowledge on prevention of iron deficiency anemia.14 Adolescent girls are very important section of our society as they are our potential mothers and future homemakers.15 Therefore they should be targeted in providing education regarding iron deficiency anaemia and help them to have a healthy life. The investigators during their clinical practice have come across many adolescent girls with iron deficiency anaemia and they were interested to study whether the adolescent girls posses adequate knowledge on iron deficiency anaemia. Therefore a study was conducted to assess the knowledge regarding prevention of iron deficiency anemia among adolescent girls.
MATERIAL AND METHODS A descriptive survey design was used for this study. The sample consisted of 100 adolescent girls who were studying in a selected college of Mangaluru. Ethical clearance was obtained from the institution ethics committee. Formal permission was taken by the authorities. Sample was selected by non probability purposive sampling technique. The variable under study was knowledge of adolescent girls regarding prevention of iron deficiency anaemia. The demographic variables were age, religion, parent education, parent occupation, type of family, area of residence, monthly income, source of information regarding iron deficiency anemia. With the informed consent to participate in the study the data was collected using structured knowledge questionnaire on iron deficiency anemia. Then the data was analyzed by using descriptive and inferential statistics.
RESULT The study revealed that majority (53%) of girls were in the age group of 15-16 years. All were Muslims by religion. Regarding parental education, majority (46%) were with high school education. Majority (57%) of the student’s parents had business as occupation. Majority (86%) belonged to nuclear family. Majority (73%) were residing in urban area. Majority (41%) had family income of Rs.10000-20000/month. Among the sample who received the information regarding prevention of iron deficiency anaemia, 47% received from media and 45% from family and friends. It was seen that majority (84%) of the study sample had moderately adequate knowledge, 11% possessed inadequate knowledge and 5% had adequate knowledge regarding prevention of iron deficiency anaemia. The mean knowledge score of adolescent girls was 13.05±3.056 .When area wise knowledge was assessed it was seen that the mean % for the knowledge score regarding general question about iron deficiency anemia was 59.85%, causes or risk factor of iron deficiency anemia was 43%, signs and symptoms of iron deficiency anemia was 35.8%, physiology and diagnostic measures of iron deficiency anemia was 59%, management of iron deficiency anaemia was 43.66%, prevention of iron deficiency anemia was 64.5% respectively. The study did not show any significant association between the knowledge score and the selected demographic variables (p>0.05)
DISCUSSION The current study results are also supported by a study conducted to assess the effectiveness of structured teaching program on knowledge regarding iron deficiency anaemia and its prevention among 60 adolescent girls of Bhavnagar where the study showed that in the pre test 53.3% had inadequate knowledge and 46.7% had moderate knowledge on prevention of iron deficiency anaemia.16 The current study findings are also consistent with a study which was conducted to assess the effectiveness of planned teaching program on prevention of anaemia among 60 adolescent girls in Belgaum, which showed that all the adolescent girls in pre-test had average knowledge17
CONCLUSION This study concluded that majority (84%) of the study sample had moderately adequate knowledge on prevention of iron deficiency anemia so it is advisable to provide educational programs for the adolescent girls regarding iron deficiency anemia.
ACKNOWLEDGEMENT The authors wish to thank the authorities for permitting to conduct the study and the study participants for their whole hearted support. 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=188http://ijcrr.com/article_html.php?did=1881. Siddharam S, Venkitish G M. Prevalance of anemia among adolescent girls. International journal of biological and medical research, 2011; 12(1):1-28.
2. Kauri S. Deshmukh PR, Grag B.S. Epidemiological correlates of nutritional anemia in adolescent girls of rural Wardha . Indian J Community Med. 2006; 31(1):55-58.
3. Jemal Haidar. Prevalence of anemia, deficiencies of iron and folic acid and their Determinants in Ethiopian women. J of Health, Population and Nutrition, 2010; 28(4):359-368.
4. Latham Mc .Human nutrition in the developing world..J of Food and Nutrition,. 1997;3(1):147-155.
5. Bruno de Benoist , Erin McLean , Ines Eglin , Mary .Worldwide prevalence of anemia . July-February 6th(Internet). 2014(Cited 2015 Oct 3) Available from: URL:http://www.whqli bdoc.who.int/publication
6. Joyce M Black, Jane hokanson Hawks, medical surgical nursing. 7th edition. New Delhi: Elsevier .2005.
7. Wang. Essentials of Peadiatric nursing 8th edition. Published in India: Published by mosby publisher; 2009.
8. Kamla Gupta,Sulabha Parasuraman,Arokiasamy P,Singh SK, Lhungdim H. National family health survey.(Internet). 2005-2006(Cited 2015 Oct 3)Available fropm:URL:http://www. nfhsindia.org
9. Jetea G.S Singh. Prevalance ofAnemia among adolescent girls. J of Food and Nutrition Bulletin.2006; 14(1): 311-315.
10. Nirmala T,Sathya P .Prevalence of anemia among adolescent girls .Nightingale Nursing Times 2011 ; 7(2) :12-16.
11. Hurlock BE .Developmental psychology a life span approach. 5th edition. New Delhi:Tata McGraw Hill company 2006.
12. Suraj gupta . Text book of peadiatrics. 11th edition. New Delhi: JP brothers. 2009.
13. Pattnaik S, Kumar A. prevalence of anemia among adolescent girls in rural area of Odisha. Ind J Mat child Health . 2002;15(1):1-11.
14. Imuntica Francis Tashara. Knowledge and self- reported practices on prevention of iron deficiency anemia. /International J of Advances in Scientific Research. 2015;1(07):289-29.
15. Saillo. Programming for adolescent health and development: report of a WHO/UNFPA/UNICEF study group on programming for adolescent health.(Internet). 1996(Cited 2015 Oct 3) Available from:URL:http://www:apps.who.int .
16. Moreshwar S.A, Naik V. A, Chrostina B.C. A study to assess the effectiveness of planned teaching program on prevention of anemia among school going adolescent girls. International J of Nursing education. 2014;6(1):234-237.
17. Ruhi Varghese, Minakshi Rai. A study to assess the effectiveness of structured teaching program on knowledge regarding iron deficiency anemia and its prevention among adolescent girls. The J of Commu Health Mngt.2015; 2(3):95-96.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcareGASTROINTESTINAL STROMAL TUMORS: A CLINICOPATHOLOGICAL AND IMMUNOHISTOCHEMICAL STUDY
English0815Nivedita SinghEnglish Vijay M. MulayEnglish Rajan S. BinduEnglishAims: 1. To study the clinicopathological features of Gastrointestinal stromal tumors (GISTs). 2. To study and confirm the diagnosis GISTs by Immunohistochemistry and to establish the correct final diagnosis to help treatment of patient. Methodology: Thirty one cases of GISTs were diagnosed between January 2010 to October 2015. Their clinical presentations, gross and microscopic features were studied. The surgical specimens were categorized into risk groups based on the National Institute of Health (NIH) consensus criteria. Immunohistochemcal study was done on formalin fixed, paraffin embedded tissue blocks with a panel of five antibodies; CD-117, CD-34, SMA, Desmin and S-100. Result: • Peak age of occurrence was between 5th and 7th decade. More cases were diagnosed in males than in females. • Pain in abdomen was the most common presenting complaint. • Small intestine was the most common site followed by stomach, colon and rectum. There were 16.1% cases of EGISTs (extragastrointestinal stromal tumors). • The size of tumor as measured by the maximum diameter ranged from 2.5-30 cm. Average size was maximum for EGISTs. • Based on the National Institute of Health (NIH) consensus criteria 60.9% (n=14) of cases belonged to the high risk group. 21.7% (n=5) were in the low risk group while 17.4% (n=4) belonged to intermediate risk group. • Spindle cell type was the most common histological type (90.3%). • Immunohistochemistry was done in all the cases and 90.3% (n=28) of cases were CD-117 positive. 35.5% (n=11) were positive for CD-34. Conclusion: Gastrointestinal stromal tumors (GISTs) are rare tumors of the GI tract and account for only 0.1-3% of the gastrointestinal neoplasms. Mitotic rate and tumor size have gained the greatest acceptance as being predictive of outcome. The role of Immunohistochemistry is well known in the diagnosis of GISTs and there has been continuing attempts at finding a more specific and sensitive marker than CD117. New markers like PDGFRA, PKC θ and DOG1 are being analyzed. The combination of a detailed histopathological examination and Immunohistochemistry is important for diagnosis, management and prognostication of patients of GISTs.
EnglishGastrointestinal stromal tumors (GISTs), Immunohistochemistry, Extragastrointestinal stromal tumors (EGISTs).INTRODUCTION Although far less common than epithelial neoplasms, mesenchymal tumors of the GI tract are not rare. Gastrointestinal stromal tumors (GISTs) constitute approximately 2% of all neoplasms of the GI tract.1 Over 90% of GISTs occur in adults over 40 years old.GISTs can arise anywhere in the GI tract from esophagus to the colon and rectum. 10% of cases arise outside the tubal gut, in locations such as the mesentery, omentum and retroperitoneum, and have been referred to by the acronym EGIST (extragastrointestinal stromal tumors).1 The presenting manifestations depend on the site of involvement in the GI tract, the size of the tumor, and the precise portion of the gut wall in which the tumor is located.2 Clinical symptoms vary and many tumors are discovered incidentally.3 GISTs show a wide spectrum of histologic features and have distinctive appearances depending on their primary location.4 An evidence-based approach for defining the risk of aggressive behaviour in GISTs, based on tumor size and mitotic count, has been presented. Other factors as anatomic location, cellular atypia and necrosis have been shown to be independent prognostic factors.5 With the discovery of high prevalence of c-Kit mutations and development of STI-571 (Imatinib [Gleevec]), the treatment of GIST has been revolutionized.6
MATERIALS AND METHODS Cases of GISTs morphologically diagnosed on histopathology from January 2010 to October 2015 were included in the study. During this period 23 surgical specimens and 8 biopsies were diagnosed as GISTs. Histopathological diagnosis was achieved based on gross and microscopic examination of Hematoxylin and Eosin stained slides. The clinical details and pathological findings were obtained from the records available. Clinical data included patient’s age, gender, clinical presentation, physical examination and other investigations (hematological, radiological, and endoscopic, FNAC). The pathological findings including tumor location, gross appearance, tumor size (maximum diameter in cm), metastases and microscopic findings were noted. The surgical specimens were categorized into risk groups based on the National Institute of Health (NIH) consensus criteria (so called Fletcher’s criteria- Table a) Based on this system, benign GISTs do not exist and instead the most harmless tumors have been assigned a “very low malignant potential”.7 Immunohistochemistry (IHC) was performed according to the protocol prescribed Thermo Scientific Immunohistochemistry Solutions, with a panel of five antibodies, CD- 117, CD-34, SMA, Desmin and S-100.
RESULTS Thirty one surgical specimens and biopsies were diagnosed as GISTs on histopathological examination, including twenty three surgical specimens and eight biopsies. Surgical specimens of the biopsies were not recieved. One case located in small intestine (ileum) was diagnosed on fine needle aspiration cytology (FNAC) and was followed by its specimen which was confirmed to be GIST on histopathology (Figure 1). Most of the cases of GISTs were between 5th and 7th decade (64.5%). The youngest age was 19 years and the oldest was 80 years. The mean age was 57.8 years. Median age was 60 years. There were 24 (77.4%) cases in males and 7 (22.6%) cases in females. (Male:Female = 3.5:1)
Some tumors presented with more than one complaint. The main complaint was taken into consideration. One patient presented with difficulty in deglutition and was diagnosed as squamous cell carcinoma of the oesophagus (Figure 2) with incidentally diagnosed GIST in stomach. Out of the 31 cases, 7 (22.7%) were located in the stomach, 10 (32.2%) in small intestine, 4 (12.9%) in colon and 5 (16.1%) in rectum. There were 5 (16.1%) cases of EGISTs, 2 in mesentery and 3 in retroperitoneum.
Two cases had liver metastasis. In one case liver biopsy along with the primary tumor in large intestine was received (Figure 3). Two cases, one in large intestine and other in small intestine (duodenum) showed regional lymph node metastases. The size of tumor ranged from 2.5-30 cm. For biopsies the radiological size was considered. The average size was 8.7cm with no tumor of size less than 2cm. Average size was 9.0cm.
The average size was 18.0cm in EGISTs (mesentery and retroperitoneum), which was greater than at other sites (Figure 4)
The surgical specimens (n=23) received were put into risk groups as per the National Institute of Health (NIH) consensus criteria 2002 of risk assessment of GISTs. As 8 were biopsies whose specimens were not received, they were not included.
NIH-National Institute of Health HPF = high power field (x 400 microscopic magnification) S= small intestinal; G= gastric; C= colon/rectum; A= abdominal (mesentery,retroperitoneum) * The first line of prognostic assessment was the tumor size. E.g. if a tumor was larger than 10 cm and had mitotic count over 10/50 HPFs, it was stratified to high-risk >10 cm, any mitotic rate group. All the cases of GISTs presenting in the mesentery or retroperitoneum (EGISTs) belonged to high risk group. In small intestine also a higher percentage of cases belonged to high risk group (77.8%). In stomach most cases belonged to low or intermediate risk group (83.3%) and only 16.7% cases were in high risk group Out of 31 cases of GISTs, 28 were of spindle cell type (90.3%). Only 1 case arising from colon showed pure epitheloid histology. 2 cases had mixed histology, one in stomach and other in large intestine. Immunohistochemistry was applied on all cases.
Desmin and S-100 was negative in all cases. So there was no case of GNAT with neural differentiation. Only one case, located in the stomach, was positive for SMA. It was also positive for CD-117 but negative for CD-34.
Three cases were CD-117 negative, two in colorectum (1 in large intestine, 1 in rectum) and one in stomach. Out of these, tumor located in rectum was positive for CD-34. All other markers were negative. IHC findings of EGISTs were similar to that at other sites. CD-117 was positive in all five cases of EGISTs and CD-34 was positive in only one case.
DISCUSSION Gastrointestinal stromal tumours (GISTs), despite being rare, pose a relevant medical problem from the viewpoint of diagnosis and management.9 These tumors are a heterogeneous group of neoplasms, and prediction of clinical behavior requires a multiparametric evaluation. However, the same criteria for malignancy do not apply to stromal tumors from different sites within the gastrointestinal tract, and the relative importance of each of these features is somewhat controversial.10 The true incidence may also be rising.11 As GIST are highly resistant to conventional chemotherapy and radiotherapy12-15, and carry a high risk of metastatic relapse after initial surgery, survival rates were poor until 2002, when the FDA approved the tyrosine kinase inhibitor (TKI) imatinib mesylate (formerly STI571) for their treatment.9 The results of the study were compared with similar studies in India and abroad. In the present study, the age range was between 19-80 years. Most of the cases (64.5%) were in the 5th and 6th decade. The mean age was 57.8 years. Median age was 60 years. The age was comparable to all other studies. (table 7)
In most studies done in foreign countries and with more number of cases, the incidence in males and females were comparable with slightly more incidence in males. (table 8) However, in studies done in India, more cases were diagnosed in males than in females. A longer duration study with more cases will be needed to draw definitive conclusion.
In the present study the most common site of occurance was colorectum as a group, which represented 29.0% (n=9) of the cases [Colon-12.9%(n=4); Rectum-16.1%(n=5)]. But as a single entitity the most common site was small intestine (32.2%; n=10). In most other studies stomach was found to be the most common site. However, in the study of 50 cases at Hyderabad by Rajappa S et al. (2007)19 and 92 cases from Tamil Nadu, by Lakshmi VA et al. (2010)21, small intestine was the most common site. In the present study cases of EGISTs were slightly more than in other studies. However, in the study done at All India Institute of Medical Sciences, New Delhi, by Iqbal N et al. (2015)22 which included 13 cases of EGISTs of mesentery and retroperitoneum, similar findings were noted and it was concluded that EGISTs may actually be more frequent, as they were found at a rate of 12% of all stromal tumors.
Vij M et al. (2010)20 observed that frequency of CD-34 positivity varied significantly in GISTs of different locations. Maximum positivity was present in gastric GIST (73%). Similar finding was noted in the present study with gastric GIST showing maximum positivity (57.1%).
CONCLUSION Gastrointestinal stromal tumors (GISTs) are rare and account for only 0.1-3% of the gastrointestinal neoplasms.20 Even though a number of studies on GISTs are available from foreign countries, the studies from our country are still limited. The exact incidence, age and sex data of GISTs in our country is not yet available. Criteria for distinguishing benign from malignant GISTs, or at least to identify those lesions that are more likely to metastasize, have been sought, analyzed and disputed for many years. Many parameters have been proposed but mitotic rate and tumor size have gained the greatest acceptance as being predictive of outcome.23 The combination of a detailed histopathological examination and use of Immunohistochemistry is important for diagnosis, management and prognostication of patients of GISTs.
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. Authors declare and acknowledge that there is no conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=189http://ijcrr.com/article_html.php?did=1891. Laurini JA, Carter JE. Gastrointestinal Stromal Tumors- A Review of the Literature. Arch Pathol Lab Med 2010 Jan;134;134- 7.
2. Goldblum JR. Mesenchymal tumors of the GI tract. In: Schmitt W, editor. Odze & Goldblum: Surgical pathology of the GI tract, liver, biliary tract, and pancreas. 2nd ed. Philadelphia: Elsevier; 2009. p. 682-95.
3. David A. Owen. The Stomach. In: Mills SE, editor. Sternberg’s Diagnostic Surgical Pathology. 5th ed. Lippincott Williams & Wilkins; 2010. p.1304-422.
4. Day WD, Jass JR, Price AB et al. Non-epithelial tumours of the stomach. In: Brown A, editor. Morson and Dawson’s Gastrointestinal Pathology. 4th ed. Hong Kong: Blackwell Science Ltd; 2003. p. 196-200.
5. Steigen SE, Bjerkehagen B, Haugland HK et al. Diagnostic and prognostic markers for gastrointestinal stromal tumors in Norway. Modern Pathology 2008;21:46–53.
6. DeMatteo RP, Lewis JJ, Leung D et al. Two Hundred Gastrointestinal Stromal Tumors. Annals of Surgery 2000;231:51-8.
7. Agaimy A. Gastrointestinal stromal tumors (GIST) from risk stratification systems to the new TNM proposal: more questions than answers? A review emphasizing the need for a standardized GIST reporting. Int J Clin Exp Pathol. 2010; 3(5): 461–471.)
8. Parkin B, Chugh R. Molecular Pathology of Gastrointestinal Stromal Tumors and Implications for Treatment and Prognosis. Curr Probl Cancer 2011 Sep/Oct;35(5):245-54.
9. Dirnhofer S, Leyvraz S. Current standards and progress in understanding and treatment of GIST, Swiss Med Wkly 2009;139 (7–8):90-102.
10. Goldblum JR. Gastrointestinal Stromal Tumors: A Review of Characteristic Morphologic, Immunohistochemical and Molecular Genetic Features. Am J Clin Pathol 2002;117(Suppl 1):S49- S61.
11. Steigen SE, Eide TJ. Trends in incidence and survival of mesenchymal neoplasms of the digestive tract within a defined population of northern Norway. APMIS. 2006;114(3):192–200.
12. Blay JY, Le Cesne A, Verweij J, et al. A phase II study of ET- 743/trabectedin (“Yondelis”) for patients with advanced gastrointestinal stromal tumours. Eur J Cancer. 2004;40(9):1327-31.
13. Ryan DP, Puchalski T, Supko JG, et al. A phase II and pharmacokinetic study of ecteinascidin 743 in patients with gastrointestinal stromal tumors. Oncologist. 2002;7(6): 531-8.
14. Ng EH, Pollock RE, Munsell MF, Atkinson EN, Romsdahl MM. Prognostic factors influencing survival in gastrointestinal leiomyosarcomas. Implications for surgical management and staging. Ann Surg. 1992;215(1):68-77.
15. Ng EH, Pollock RE, Romsdahl MM. Prognostic implications of patterns of failure for gastrointestinal leiomyosarcomas. Cancer. 1992;69(6):1334-41.
16. Ueyama T, Guo KJ, Hashimoto H, Dairnaru Y, and Enjoji M. A Clinicopathologic and lmmunohistochemical Study of Gastrointestinal Stromal Tumors. CANCER 1992 Feb; 69(4):947-55.
17. DeMatteo RP, Lewis JJ, Leung D et al. Two Hundred Gastrointestinal Stromal Tumors. Annals of Surgery 2000;231:51-8.
18. Orosz Z, Tornóczky T, Sápi Z. Gastrointestinal Stromal Tumors: A Clinicopathologic and Immunohistochemical Study of 136 Cases. Pathology Oncology. Research 2005:11(1):11–21.
19. Rajappa S, Muppavarapu KM, Uppin S, Digumarti R. Gastrointestinal stromal tumors: a single institution experience of 50 cases. Indian Journal of Gastroenterology. 2007 Sep-Oct;26:225-9.
20. Vij M, Agrawal V, Kumar A, Pandey R. Gastrointestinal stromal tumors: a clinicopathological and immunohistochemical study of 121 cases. Indian J Gastroenterol 2010 Nov;29(6):231-6.
21. Lakshmi VA, TR. Chacko, Kurian S. Gastrointestinal stromal tumors: A 7-year experience from a tertiary care hospital. Indian Journal of Pathology and Microbiology. 2010 OctDec:53:628-33.
22. Iqbal N, Sharma A, Iqbal N. Clinicopathological and treatment analysis of 13 extragastrointestinal stromal tumors of mesentery and retroperitoneum. Annals of Gastroenterology 2015;28:105- 8.
23. Fletcher CDM, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Int J Surg Pathol 2002;10:81-9.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcareCHANGE OF PROTEIN CONTENT IN CEREBRO-SPINAL FLUID(CSF) WITH THE DIFFERENT TYPES OF MENINGITIS
English1620Srabonti SahaEnglish J. D. SharmaEnglish Mahmood A. ChowdruryEnglish Mohammad AlauddinEnglishAim: In our study we observed that changes in the findings of CSF differs and increase in the protein content of the CSF in particular varies with the types of meningitis. The study was aimed at finding the relationship of the range of elevation of protein with different types of meningitis.
Methodology: Total 40 subjects were included in this study. The subjects were selected from the patients admitted in the Pediatric in-patient department of the Chattagram Ma-Shishu O General Hospital Medical College, Chittagong and Bangladesh. This study was done during the period of November 2008 to June 2009. Among the cases, preceding other infections were very high e.g. Pneumonia was present in 15, Measles in 2,Tuberculosis in 5 cases and preceding Seizure disorder was present in 4 cases. Most of the patients had the features of meningism, i.e. Neck rigidity was positive in 30%, Kernig sign in 22%, and Brudziniski sign in 24% patients respectively. Pyogenic meningitis was diagnosed in 68%, viral meningitis in 12% of the patients and Tubercular meningitis was clinically diagnosed in 2 patients.
Results: The protein level was significantly increased (>80mg/dl) in 65%, moderately increased (61-80mg/dl) in 20% and mildly increased (46-60mg/dl) in 15% of the patients. Patients with Pyogenic meningitis and Tubercular meningitis had significantly increased protein level (>240mg/dl) in their CSF whereas in viral meningitis the CSF protein level is highly variable and in between 62-178.3 mg/dl. Furthermore, lymphocyte and neutrophils were also detected in the CSF of 5 (12.5%) and 34 (85%) of the patients respectively. In pyogenic meningitis, the Neutrophil count was very high compared to that in viral meningitis - the finding which helps in disease management.
Conclusion: The study demonstrates that protein level in CSF might be a potential tool for detecting and differentiating different types of meningitis more precisely.
EnglishProtein, Cerebrospinal fluid (CSF), MeningitisINTRODUCTION
Meningitis is a common disease of the central nervous system (CNS) resulting from inflammation of the meanings (1) The inflammation is mainly caused by infection with viruses, bacteria or other microorganisms. (2) Meningitis can be life-threatening because of the inflammation’s proximity to the brain and spinal cord; therefore the condition is classified as a medical emergency. (3) Bacterial cell wall components, such as the lipopolysaccharide (LPS) molecules of gramnegative bacteria and teichoic acid and peptidoglycans of S. pneumoniae, induce meningeal inflammation by stimulating the production of inflammatory cytokines and chemokines by microglia, astrocytes, monocytes, micro vascular endothelial cells, and CSF leukocytes. This cytokine response is quickly followed by an increase in CSF protein concentration and leukocytosis. (4) The classic CSF abnormalities in bacterial meningitis are: (1) Polymorphonuclear(PMN) leukocytosis (>100 cells/L in 90%), (2) Decreased glucose concentration (45 mg/dl) in 90%) and (4) Increased opening pressure (>180 mmH2 O in 90%).Suspicion of viral meningitis is based on the clinical presentation and presence of certain CSF findings. Presence of less than 500 mononuclear cells/ mm3 of CSF (pleocytosis) is characteristic.(5) CSF pressure may be elevated, whereas the glucose level is characteristically normal or only modestly decreased and CSF protein level usually is elevated (50-100 mg/dl). PCR screening of CSF has become an important diagnostic tool and can help in the isolation of several viruses (6). The diagnosis of tuberculous meningoencephalitis (TBM) can be difficult and may be based only on clinical and preliminary cerebrospinal fluid (CSF) findings without definitive microbiological confirmation.(7)Characteristic CSF findings of TBM include the following: (1)Lymphocytic-predominant pleocytosis,(2) Elevated protein levels, typically between 100 and 500 mg/ dl,(3)Low glucose, usually less than 45 mg/dl.(8)Despite culture is time consuming and with variable sensitivity(40 – 80%), it should be performed to determine drug susceptibility because isoniazid(INH) resistance is associated with twofold increase in mortality.(9)Neuroimaging like Magnetic Resonance Imaging (MRI) showing basal meningeal enhancement, hydrocephalus, hypo densities due to cerebral infarcts, cerebral edema and nodular enhancing aids to the diagnosis of TBM. (7).
MATERIALS AND METHODS
Patient selection
The study was conducted in the Department of Pediatrics and Pathology and Microbiology and Biochemistry laboratory of ChattagramMaa-Shishu-O-General Hospital, Agrabad, Chittagong, during the period of November 2008 to June 2009. Total 40 subjects presenting with the complaints of fever and features suggestive of meningitis were included in this study without any specific predilection for race, religion and socioeconomic status. In all cases, the suspected meningitis subjects were between 0 and 12 years old. The study subjects were subdivided into four groups including 27subjects with pyogenic meningitis, 5 subjects with viral meningitis, 2 Subjects with tubercular meningitis and 6 subjects were normal. The observations were recorded with relevant information of demographic and socio-economic data including anthropometric data, birth history, immunization history, past medical history and clinical information.
CSF collection
CSF was collected from suspected patients by lumber puncture, a process that done usually in the space between 3rd and 4th lumber vertebra. The procedure was done with a sterile needle and collected the fluids into three sterile vials. First one for biochemical, second one for cytological and third one for microbiological examinations. In each vial 10 ml samples were collected and sent to laboratory after proper labeling.
Estimation of protein in CSF
The quantity of protein in cerebrospinal fluid was estimated by automated clinical chemistry analyzers (Humalyzer 2000, Germany, Ultrasensitive protein). In short, 20 µl of the reagent (Pyrogallol-red-molybdate) complexes were mixed with 20 µl of CSF supernatant and incubated at room temperature for 10 minutes. The binding of pyrogallol-red-molybdate to the proteins in the CSF causes a shift of the absorbance peak to 600nm. The increase of absorbance at 580 nm is directly proportional to the protein concentration. (10)(11)(12)(13) and (14).
Microbiological study
5µl of CSF was placed on agar plate and incubated at 37°C for overnight. Depending on the development of colonies and colony morphologies, the presence and absence of organism was detected.
Cytological study of CSF
Cell counts were done by spreading a drop of CSF on a microscope slide. The slide was stained with a Giemsa stain and examined under a microscope at 100X. The neutrophils were detected with their granules and polymorphic nucleus. On the other hand granules and polymorphic nucleus are not present in lymphocytes. Lymphocytes were detected with their single nucleus.
RESULTS
The risk factors and side effects were determined by different parameters such as socio-economic condition of both rural and urban areas. Family history, birth history, immunization history, developmental history including the time of the appearance of social smile, neck control, sitting, standing, walking and speech were also undertaken. Anthropometric variables like height, weight, age, sex, pattern of feeding, occipitofrontal circumference were also studied. Among the 40 patients, 40% were male and 60% were female (Table-I). In terms of socio-economic status, the distribution of the patients were upper class (15%), middle class (30%) and lower class (55%), indicating that the disease can affect people regardless of their socioeconomic status with lower class people being more susceptible(Table-I). Moreover, most of the patients exhibited the sign and symptoms of meningitis i.e. vomiting (80%), headache (15%), convulsion (65%) and as well as those of microbial infection (Table-I). It was also observed that meningitis occurred even in vaccinated children (Table-I). Although meningitis can be caused by many causes, in this study only three types were found predominant i.e. Bacterial, Viral and Tubercular. Among them bacterial cases were 68%, viral 12% and tubercular cases were 5% respectively (Table-I).
The microbiological studies further revealed the presence of Diplococci and Gram -ve bacilli in 6 (15%) and 2 (5%) patients respectively, while no microbial pathogens were detected in the rest 32 patients (Table-II). But the changes in their CSF were suggestive of bacterial meningitis. In thirtytwo patients no organism was isolated (culture -ve bacterial meningitis). On the other hand, the present study revealed a previous history of Pneumonia in 15, measles in 2, convulsion in 4 and Tuberculosis in 5 cases (Table-II), visual problem especially blurring of vision in 34 cases and a history of weight loss in17 cases (Table-II). This study also documents two cases of TBM admitted to the hospital over the 8-month period and compare the clinical picture with that of meningitis of pyogenic origin. Most of the patients of both bacterial and viral meningitis shared the common features of meningism; Neck rigidity in 30%, Kernig’s sign in 22%, Brudziniski sign in 24% cases. Bulged Fontanels was present in 85% patients (Table-II). In our study, we observed high lymphocyte count in 5 patients, high neutrophil count in 34 patients (Table-II). In this study it was found that protein content in CSF was significantly increased in 65% while moderately and mildly increased in 20% and 15% of the patients respectively (Table-II). More specifically, in Streptococcus-mediated meningitis, the protein level was 243mg/dl while that in culture negative bacterial meningitis and in viral meningitis were 223mg/dl and 112.12mg/dl respectively (Table-II). In two cases of tubercular meningitis the protein contents were 319.5 and 312.6 mg/dl.
DISCUSSION
In order to differentiate between different types of meningitis analysis of the cerebrospinal fluid (CSF) changes was done in patients admitted in ChattagramMaa-Shishu-OGeneral Hospital, Chittagong from November 2008-June 2009, with the signs and symptoms of meningitis (headache, nausea, vomiting, fever, restlessness, irritability, neck pain, poor feeding, neck rigidity, Kernig’s sign, Brudzinski’s sign, etc.).(15) (16) the study was designed on the basis of detailed background history including previous records of infectious diseases/illness, vaccination, socioeconomic status etc. and detailed clinical, cytological and biochemical examinations of their cerebrospinal fluid. The microbiological studies further revealed the presence of Diplococci and Gram -ve bacilli in6 (15%) and 2 (5%) patients respectively, while no microbial pathogens were detected in the rest 32 patients. But the changes in their CSF were suggestive of bacterial meningitis. These observations though greatly deviated from a previous observation but also showed some similarities(17) where the authors showed that among the 86 bacterial meningitis patients, Meningococci was isolated in 36 (41.86%), S. Pneumoniae in 22 (25.58%), Staph. Aureus in 2 (2.32%), Klebsiella Pneumoniae in two (2.32%), Strept. Agalactiae in one (1.16%) and E.Coli in 1(1.16%) patient. In twenty-two (25.58%) patients no organism was isolated (culture -ve bacterial meningitis). On the other hand, the present study revealed a previous history of Pneumonia in 15, measles in 2, convulsion in 4 and Tuberculosis in 5 cases, visual problem especially blurring of vision in 34 cases and a history of weight loss in 17 cases, suggesting the risk factors of meningitis. Therefore, observations in this study regarding the absence of any microbial pathogens in their CSF could be due to the fact that from the beginning of the disease the patients were treated with antibiotics. This study also documents two cases of TBM admitted to the hospital over the 8-month period and compare the clinical picture with that of meningitis of pyogenic origin. At present, the diagnosis of TBM is difficult in the absence of microbial isolation, as the clinical presentation is often deceptive and the response to treatment is not as satisfactory as in pyogenic meningitis. (18)(19) and (20)The key to diagnosis of infections is the isolation of the causative microorganism from the tissues involved. In case of TBM, TB bacilli can be isolated directly by Ziehl-Neelsen stain or culture from CSF. To extract more information regarding the disease initiation followed by pathophysiological lesions after the onset of the disease could benefit the disease management process At present differentiating the diagnosis of viral and bacterial meningitis is very difficult. Most of the patients of both bacterial and viral meningitis shared the common features of meningism; Neck rigidity in 30%, Kernig’s sign in 22%, Brudziniski sign in 24% cases. Bulged Fontanels was present in 85% patients, which is clearly in line with a previous study. (21) It is well reported that all forms of pyogenic meningitis are frequently associated with neutrophilic leucocytosis and a raised ESR (erythrocyte sedimentation rate) and viral meningitis is associated with high lymphocyte count though in a few cases lymphocyte count were found normal. In our study, we observed high lymphocyte count in 5 patients, high neutrophil count in 35 patients which are in line with the results of Negrini et.al (22). They showed that the CSF leukocyte count was higher with predominant polymorphs (95%) in bacterial than viral (7%) cases. Most of the patients with aseptic meningitis had a PMN predominance where neutrophils accounted for >50% of CSF leukocytes.(22). In this study it was found that protein content in CSF was significantly increased in 65% while moderately and mildly increased in 20% and 15% of the patients respectively. More specifically, in Streptococcus-mediated meningitis, the pro-tein level was 243mg/dl while that in culture negative bacterial meningitis and in viral meningitis were 223mg/dl and 112.12mg/dl respectively. A similar observation has also been reported by Zeni et.al. (23) (24) and (25). These observations thus clearly indicate that protein content in the CSF could be good a parameter for differentiating the bacterial and viral meningitis.
CONCLUSION
Meningitis is highly prevalent in third world country especially in Bangladesh. Accurate and rapid diagnosis of acute bacterial meningitis (ABM) is essential for favorable outcome, especially in infants and children. Although immediate confirmation of ABM is diagnosed by the examination of CSF but sometimes it is insufficient to distinguish between ABM and acute viral meningitis (AVM). Current guidelines recommend starting antibiotics whenever a bacterial etiology cannot firmly be ruled out. However, the cost of antibiotic therapy and its attendant hospitalization, as well as its potential side effects, have raised concern about unnecessary administration of antibiotics in patients with AVM. It was observed that the identification of the causative agents of meningitis, medical history of the patients, microbiological/ cytological and detailed biochemical investigations of the CSF of patients suffering from meningitis could aid more accurate discrimination of different meningitis in children. Especially, the protein status of the CSF can guide in identification of the types of the disease to facilitate the disease management more precisely avoiding unnecessary administration of antibiotics.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are 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=190http://ijcrr.com/article_html.php?did=1901. Sáez-Llorens X, Mc Cracken GH. Bacterial meningitis in children. Lancet 2003; 361 (9375): 2139–48.
2. Ginsberg L. Difficult and recurrent meningitis.J NeurolNeurosu rgPsychiatry.2004;75(suppl1):i16–21.
3. Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL,Scheld MW, et al. Practice guidelines for the management of bacterial meningitis. Clinical Infectious Diseases 1994; 39 (9):1267–84.
4. Kasper DL. Braunwald E. Fauci AS. Hauser SL. Longo DL, Jameson JL. Harrison’s Principles of Internal medicine. 16th ed. New York:McGraw-Hill Professional;2004.
5. Jeffery KJ, Read SJ, Peto TE, Mayon-White RT, Bangham CR. Diagnosis of viral infections of the central nervous system. Lancet 1997;349:313-17.
6. Kumar R, Singh SN,Kohli N. A diagnostic rule for tuberculous meningitis. Arch Dis Child 1999; 81(3): 221 – 24.
7. Thwaites, GE. Chau TTH. Stepniewska K, Chuong LV, Sinh DX, White NJ. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet 2002 ; 360(9342):1287- 92.
8. Micheal DI. A Clinician guide to Tuberculosis.1sted. New York: Lippincott William and Wilkins publisher; 2000.
9. Vinnard, C, Winston CA, Wileyto EP, Macgregor RR, BisonGP. Isoniazid resistance and death in patients with tuberculous meningitis: retrospective cohort study. BMJ 2010; 341: 4451.
10. Bablok W, Passing H, Bender R, Schneider B. A general regression procedure for method transformation.J ClinChemClinBichem 1988; 26:783-90. 11. Iwata I, Nishikaze O. ClinBiochem 1979; 25(7): 1317-19.
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14. Passing H, Bablok W. A new biometrical procedure for testing the equality of measurements from two different analytical methods.J Chin Chem. ClinBiochem 1983;21:709-20.
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17. Hussein AS, Shafran SD. Acute bacterial meningitis in adults: A 12-year review. Medicine (Baltimore) 2000;79:360-68.
18. Satya SS. In: Textbook of pulmonary and extra pulmonary tuberculosis.2nd ed. New Delhi: 1995 pp. 206–208, 221–230.
19. Daniel TM. New approaches to the rapid diagnosis of tuberculous meningitis.J Infect Dis 1987; 155(4):599–602.
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21. Abro AH, Abdou AS, Ali H, Ustadi AM, Hasab AAH. Cerebrospinal fluid analysis acute bacterial verses viral meningitis. Pak J Med Sci 2008. 24(5):645-50.
22. Negrini B, Kelleher KJ, Wald ER.Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics 2000; 105:316-19.
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24. Jaeger F, Leroy J, Duchêne F, Baty V, Baillet S, Estavoyer JM, et al. Validation of a diagnosis model for differentiating bacterial from viral meningitis in infants and children under 3.5 years of age. Eur J Clin Microbiol Infect Dis 2000; 19:418–21.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcarePREVALENCE OF OVERWEIGHT AND OBESITY AMONG ADOLESCENTSIN INDIA: A SYSTEMATIC REVIEW
English2125Nirpal Kaur ShuklaEnglish Mukesh ShuklaEnglish Dhruv AgarwalEnglish Ram ShuklaEnglish Harinder Pal Kaur SidhuEnglishBackground: Obesity among adolescent is emerging as a major global public health problems leading more preponderance towards associated morbidity and mortality in later stages of life. So, a systematic review of published studies was done to have an overview over prevalence of overweight and obesity among adolescents in India.
Methods: A systematic review of literature of research papers on prevalence of overweight and obesity among adolescent in India was done published from 2006 to 2016. Literature search was conducted using electronic databases. Data were extracted independently with respect to epidemiological estimates, study population characteristics, study design, and assessment methods and criteria. Out of 234 published articles screened, 12 studies were included in the review that met the inclusion criteria.
Results: Overweight and obesity in adolescent ranged from 2.2 to 25.8% and 0.73 to 14.6 % respectively. The prevalence was comparatively higher in urban areas than in rural areas and males were more preponderate to get overweight/ obese.
Conclusions: The study revealed towards rise in prevalence of overweight and obesity especially in male adolescents belonging to urban area thereby indicating the need to provide of immediate and comprehensive targeted intervention for adolescents.
EnglishAdolescents, Obesity, OverweightINTRODUCTION
Obesity has been evident in human records for over twenty thousand years and has affected numerous aspects of human life and society.[1]WHO defines overweight and obesity as “abnormal or excessive fat accumulation that presents a risk to health”.[2] Obesity can be viewed as the first wave of a defined cluster of NCDs (Non-communicable diseases) called -New World Syndrome, creating an enormous socio-economic and public health burden associated with an increased risk for type 2 diabetes mellitus, hypertension, dyslipidemia, cardiovascular diseases, obstructive sleep apnea, musculoskeletal disorders, some cancers, as well as mortality.[3] According to World Health Organization (WHO) obesity has reached to epidemic proportions globally, with more than one billion adults overweight with 300 million of them clinically obese. The problem of overweight and obesity is confined not only to adults but also being reported among the lower age groups and evidences over the past decades indicate towards increasing childhood and adolescent obesity. Various studies conducted in India reported prevalence of overweight among adolescents ranging between 2.2% to 25.0%.[4]According to the latest estimates from the International Obesity Task Force about 155 million school-age children between 5 and 17 years of age, worldwide are overweight and 30-45 million within that are classified as obese. [5] Globally an estimated 10.0% of children in school-age group are overweight and 2-3% of them are obese.[5]Overweight and obesity among children and adolescents has increased significantly in the developed economies during the last two decades and same type trends are being observed even in the developing countries, though less rapidly. India is also passing through phase of transition in terms of socio-economic development which has the potential effects to alter the nutritional status. Over the past few years, childhood obesity is increasingly being reported with the transforming behavioral lifestyle of families with increase in their purchasing power. Proportion of hours spend in sedentary in have also increased due to television, video games and computers which have replaced social activities including the outdoor games. In India, a large proportion of overweight children coexist along with those who are undernourished. The problem of overweight and obesity is not restricted only to the urban areas but also spanning its wings among children and adolescents in rural areas. Adolescent overweight and obesity is of major concern because overweight during adolescence is associated with increased morbidity and mortality in adulthood and overall increase in morbidity and mortality in later life.[6] Adolescent life phase is best opportunity for appropriate interventions aimed to prevent overweight and obesity because they possess the cognitive as well behavioral abilities necessary to understand and act on health and behavioral change instructions, while treatment of overweight and establishing behavioral changes in adults are difficult and often not effective or feasible, especially in the long term.[6] Acquiring healthy dietary and physical activity habits during childhood and adolescence thus seem a more promising formula than altering in unhealthy habits in adults. India is mainly associated with under nutrition but the problem of overweight and obesity is now an emerging health problem and is likely to be a major public health problem in the near future. There are very few studies on overweight and obesity among adolescent school girls and majority of them have been carried out in metropolitan cities.The aim of the present study is to systematically review prevalence of Overweight and Obesity in Adolescents in India.
Methods:
Search strategy for identification of studies:
We systematically searched online databases for articles published since 2008. The literature search was conducted in Cochrane, Medline, Scopus and various other electronic data bases using MeSH terms: “overweight”; “obesity”; “adolescent”; “prevalence” and “India” following Boolean search strategy. In total 234 articles were selected, which were screened by two authors independently and thereafter data was extracted from 12 reliable studies. Data available for obesity and overweight were deeply reviewed for each study.
Study selection
The study selections were based on original articles for overweight and obesity in adolescent in India. Both title and abstract review of all the selected articles, with the following inclusion and exclusion criteria were assessed for reliable studies.
Inclusion criteria:
1. Cross-sectional studies conducted in between 2006- 2016.
2. Studies in context to Indian population with age group 11-19 years.
3. Weight and height objectively measured.
Exclusion criteria:
1. Case-reports, review articles and conference abstracts.
Study selection and data extraction:
List of references were indecently appraised by two reviewers and their assessment was done for their eligibility to be included in review. Data were obtained based on operational criteria and assessment methods, study design, study population characteristics and study time frame.
Analysis
As the present review aimed to have an overview over prevalence of overweight and obesity among adolescent in India in different demographic populations and at unlike frame of time, a wide variation in the results was expected. Since the timing of obtaining samples, demographic area and assessment methods and criteria were more likely to be dissimilar over time, pooled estimates for any demographic variables or epidemiological indices were not estimated and only a descriptive analysis has been provided.
RESULTS
Various electronic databases were searched for studies and after screening of title, abstract and full articles 12 research studies were found to meet the inclusion criteria. The prevalence of overweight and obesity in adolescent ranged from 2.2 to 25.8% and 0.73 to 14.6 % respectively. Laxmaiah et al., studied the factors affecting prevalence of overweight urban adolescents in Hyderabad, India found that the prevalence of overweight among adolescents was 7.2% and prevalence of obesity was 1.3%.[7]Deshmukh et al.,reported the prevalence of overweight/obesity to be 2.2% in the rural area of Wardha District.[8]Kotian et al., reported the prevalence of overweight and obesity as 9.9% and 4.8% respectively amongst the adolescent school children of Mangalore city, Karnataka.[9]Agarwal et al., conducted a school based cross sectional study on thousand adolescents, having equal number of boys and girls and reported overall incidence of obesity 3.4%; however a significantly greater number of boys (15%) as compared to girls (10.2%) were overweight.[10] Bharati et al., studied the correlation of overweight and obesity among school going children found 4.3 per cent of the children were overweight/obese.[3] It was also found that the risk of overweight/ obesity was significantly higher among children from urban area than rural area. Unnithan and Syamakumari assessed the prevalence of overweight, obesity and underweight among school children in the rural and urban areas of Thiruvananthapuram and showed that the prevalence of overweight and obesity were higher among urban children.[11] Tharkar and Viswanathan studied the impact of socioeconomic status on prevalence of overweight and obesity among children and adolescents in urban India and reported overall prevalence of overweight 15.5 % among the adolescents and both overweight (22%) and obesity (13.7%) were highest among girls from affluent families.[12] Goyal et al., carried out the study school going adolescents and found prevalence of overweight as 14.3% among boys and 9.2% among girls and obesity was 2.9% in boys and 1.5% in girls. [13]Vohra et al., studied children from 5th to 12th standard at Lucknow city and found4.17% were overweight, and 0.73% were obese. Risk of overweight/obesity was significantly higher in children who played outdoor games for lesser duration and those who consumed fast foods.[14] Nawab et al., studied the prevalence and behavioral determinants of overweight and obesity in school going adolescents from affluent and non-affluent school of Aligarh and reported prevalence of overweight and obesity was 9.8% and 4.8%, respectively. [16] Sohani et al., studied the prevalence of obesity related indices and reported prevalence of obesity was 4.5% while there were 20% overweight subjects.[17]
DISCUSSION
The study was aimed to review systematically the available literature on overweight and obesity prevalence amongst adolescents in India. Twelve original articles were considered that met the inclusion criteria. When the prevalence was analysed according to gender, majority of the studies reported boys as compared to girls were more overweight and obese;[8, 9, 13, 15, 16] while study conducted by Tharkar and Vishvanathan reported both overweight and obesity to be higher among the girls. [12]However in one of the study conducted by Marcelino et al. any such type of difference was not observed in the prevalence of overweight / obesity with respect to gender. This might be due to difference in sample size or baseline characteristics of the study population or may be attributed to the method of assessment of the obesity. When the studies were reviewed with respect to place of residence adolescents residing in urban areas were found to be more overweight and obese than those belonging to be rural areas.[3, 11, 15] The probable cause might be the difference with respect to lifestyle, eating habits and comparatively less physical activity among those belonging to urban areas. The adolescents residing in urban areas are more exposed to junk foods, used to indoor games spending majority of their times in television watching. Similar findings were also reported in other studies. [19, 20] Apart from that SES and standard of living were found to have influential effect on overweight and obesity status. Goyal et al., reported prevalence of overweight and obesity to be more in both the genders in upper SES group. [13]Similarly Nawab et al., showed higher prevalence of overweight and obesity among adolescents and obesity belonging to affluent group. Adolescents belonging to affluent group are more pre-pondered towards sedentary lifestyle and luxurious living pattern.
LIMITATION
The reviews have some limitations; limited numbers of reliable studies were available on overweight and obesity among adolescent in India over past few years. Apart from that, those available were quite heterogeneous with respect to study population, sampling method, sample size, agegroups; method and criteria for assessment of obesity and overweight and in terms of their baseline characteristics. Despite these limitations the current review provides inferential results about prevalence of overweight and obesity among adolescents in India.
CONCLUSIONS
The inference of the review indicates towards increasing prevalence of overweight and obesity with males adolescent residing in urban areas having more susceptibility. The results from the study emphasise the need for immediate primordial and primary prevention based intervention so as to prevent the consequences and complication in future.
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.
Ethical Clearance:
NA Informed Consent:
NA Source of Funding:
None Conflict of interest: NIL
Englishhttp://ijcrr.com/abstract.php?article_id=191http://ijcrr.com/article_html.php?did=1911. Bray GA. History of obesity. Page 3-18. http://media.wiley.com/ product_data/excerpt/15/04700191/0470019115.pdf [Accessed on 10 December 2015]
2. WHO. Health topics. Obesity. http://www.who.int/topics/obesity/en/. [Accessed on 10 December 2015]
3. Bharati DR, Deshmukh PR, and Garg BS. Correlates of overweight and obesity among school going children of Wardha city, Central India. Indian J Med Res 127, June 2008, pp 539-543.
4. Tiwari HC, Dwivedi S, Bali S and Parveen K. Overweight and Obesity and its Correlates among School Going Adolescents of District Allahabad- A Cross Sectional Study; ISSN- 0301-1216. Indian J. Prev. Soc. Med. Vol. 45 No. 1-2, 2014.
5. Ahmad QI, Ahmad CB, and Ahmad SM. Childhood Obesity. Indian J Endocrinol Metab. 2010 Jan-Mar; 14(1): 19–25.PMCID: PMC3063535.
6. Singh AS, Paw MJMCA. Short-term Effects of School-Based Weight Gain Prevention among Adolescents. Arch pediatradolesc med. June 2007; 161:565-566.
7. Laxmaiah A, Nagalla B, Vijayaraghavan K, and Nair M.Factors Affecting Prevalence of Overweight Among 12 to 17 year-old Urban Adolescents in Hyderabad, India. Obesity (2007) 15, 1384–1390.
8. Deshmukh PR, Gupta SS, Bharambe MS, Dongre AR, Maliye C, Kaur S, et al. Nutritional status of adolescents in rural wardha. Indian J Paediatr.2006, 73:15-7.
9. Kotian MS, S GK, Kotian SS. Prevalence anddeterminants of overweight and obesity among adolescents school childrenof South Karnataka, India. Indian Journal of Community Medicine 2010; 35:176-78.
10. Agarwal T, Bhatia RC, Singh D, and Sobti PC. Prevalence of obesity and overweight in affluent adolescents from Ludhiana, Punjab. Indian Pediatrics 2008; 45; 500 - 502.
11. Unnithan A, Syamakumari S. Prevalence of Overweight, Obesity and Underweight among School Going Children in Rural and Urban areas of Thiruvananthapuram Educational District, Kerala State (India). The Internet Journal of Nutrition and Wellness. 2007; 6 (2): 1-6
12. Tharkar S, Viswanathan V. Impact of Socioeconomic Status on Prevalence of Overweight and Obesity among Children and Adolescents in Urban India. The Open Obesity Journal. 2009; 1(1):9-14.
13. Goyal RK , Shah VN , Saboo BD , Phatak SR , Shah NN , Gohel MC , et al. Prevalence of overweight and obesity in Indian adolescent school going children: its relationship with socioeconomic status and associated lifestyle factors. The Journal of the Association of Physicians of India. 2010; 58:151-158.
14. Vohra R, Bhardwaj P, Srivastava JP, Srivastava S, Vohra A. Overweight and obesity among school-going children of Lucknow. Journal of Family and community medicine. 2011, MayAug; 18(2) 59-62.
15. Parekh Alok, Parekh Malay, Vadasmiya Divyeshkumar. Prevalence of overweight and obesity in adolescents of urban and rural area of Surat, Gujarat .National Journal Of Medical Research 2012;2(3):325-29.
16. Nawab T, Khan Z, Khan IM, Ansari MA. Influence of behavioral determinants on the prevalence of overweight and obesity among school going adolescents of Aligarh. Indian J Public health.2014; 58(2):121-4.
17. Sohani A, Chincholikar S, Patnaik B, Raje S. Obesity related indices for screening of Obesity in adolescents. Indian J comm health.2015; 27,3 304-310
18. Marcelino G, Oliveira JM, Ravasco P, Vidal PM. Weight concerns and weight reduction practices of Portuguese adolescents. Nutritional Therapy and Metabolism, 2009; 27(4), 189-192
19. Al-Haifi AR, Al-Fayez MA, Al-Athari BI, Al-Ajmi FA, Allafi AR, Al-Hazzaa HM et.al. Relative contribution of physical activity, sedentary behaviors, and dietary habits to the prevalence of obesity among Kuwaiti adolescents. Food and Nutrition Bulletin. 2013; 34(1): 6 – 13.
20. Gupta BK. Assessment of Lifestyle and Habits associated with Obesity among the School Children of Bhirahawa, Nepal - A Cross Sectional Survey. J Adv Med Dent Scie Res. 2015; 3(6):107-110.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcareINTRODUCING VERTICAL INTEGRATED TEACHINGFOR 3RD M.B.B.S. PHASE II STUDENTS
English2629Nitin R. MudirajEnglish Priya S. PatilEnglish Manisha R. DhobaleEnglishAims: Current medical education imparts knowledge in a disjoined manner so that it is difficult for undergraduates to co-relate information in clinical context. The aim of this study was to introduce vertical integration for undergraduate medical students and to analyse its impact on the students and faculty.
Materials and Methods: An innovative Vertical integrated teaching module was carried out at our Medical College with the cooperation of Surgery and Anatomy departments. Framing of proposed time table and curriculum design was done. 40 students and 19 faculties participated in this project. Pre-test and post-test assessment was carried out after each session. A separate questionnaire was given to students and faculties for their feedback.
Result: Statistical analysis showed that there was a significant improvement in the students’ mean scores, knowledge and understanding level. The students were highly satisfied with this method of teaching and interestingly 95 % of students showed positive behavioural changes. The response of the faculty was of mixed type but most of them responded positively to the exercise of integrated teaching.
Conclusion: We conclude that vertical integrated teaching in a medical curriculum is found to facilitate attainment of knowledge and improve the affective and psychomotor domains along-with creating a positive behavioural change in the students. The results of VIT are encouraging so that it can be expanded to many more topics to enable a smooth transition from traditional to integrated teaching over the coming years
EnglishVertical integrated teaching, Medical curriculum, Curriculum designINTRODUCTION
Current medical education imparts knowledge in a disjoined manner. Theundergraduate students are unable to co-relate and analyse information and aptly use it in clinical context. Vertical integration is defined as the integration betweenthe clinical and basic science sections of the curriculum.[1,2] Integration can occur throughout the curriculum with the basic medicaland clinical sciences beginning in the early years ofthe curriculum and continuing until the later years.[1]Integrated teaching is considered as the best reform in the medical curriculum.[2]It is found to be beneficial in facilitation of attainment of knowledge. It enables the students to correlate the topic taught in a clinical subject to biological principals and mechanisms, as taught in basic medical sciences. It is thought to enhance the skill of clinico- pathological correlation and also help to improve the cognitive and psychomotor domains of the students.[3]In 1997 the regulation on undergraduate medical education recommendedefforts to encourage integrated teaching betweenthe traditional subject areas. [2] Using a problem based learning approach would avoid compartmentalization of various disciplines and achieve both horizontal and verticalintegration in the different phases.[3,4] Considering this the present study was undertaken with the aim of introducing the method of vertical integrated teaching [VIT] for undergraduate medical students and to analyse its impact on students’ knowledge level and components of affective domain (satisfaction level and behavioural changes) as well as to assess the impact of VIT on the faculty.
Methodology
An innovative vertical integrated teaching module was carried out at our Medical College with the co-operation and active participation of departments of Surgery and Anatomy. Framing of proposed time table: The head of departments and faculty from departments of Surgery and Anatomy together framed a time table. At the same time the faculty was sensitized regarding such an activity. The interested faculty volunteered to conduct the sessions. Work flow charts and curriculum design: Curriculum committee consisted heads of department of Anatomy and Surgery. Series of meetings were held and the four topics selected for Vertical integrated teaching were Anatomy and Surgery of inguinal canal, mammary gland, venous drainage of lower limb and thyroid gland. The time-table was finalized accordingly. Implementation and execution: 40 students and 19 faculties participated in this project. Pre-test and post-test assessment was carried out for each vertical integrated session. A separate questionnaire was given to students and faculty for their feedback on such integrated teaching methodology.
Observations
The data obtained from the pre and post-test questionnaire and feedback from students and faculties was analysed statistically. The observations were tabulated and results were drawn.
RESULTS
Impact of VIT on Students:Statistical analysis of the pretest and post-test questionnaire was performed to assess the impact of VIT on students at three different levels through separate questionnaires. The following levels were assessed and analysed.
i. Knowledge level
ii. Satisfaction level
iii. Behavioural change
Impact of VIT on Faculty:
The perception of faculty regarding VIT and their feedback was taken through questionnaire and was also analysed. i] Assessment of knowledge level: Statistical analysis of the pre-test and post-testquestionnaire showed that there was a significant improvementin the mean scores of students as well as their knowledge and understandinglevel. The p value was < 0.001 which was statistically highly significant. [Table 1]
ii] Assessment of satisfaction level:
On the basis of the feedback of students itwas seen that 35 % students were highly satisfied and 60 % weresatisfied with vertical integrated teaching program while only 5 % students feltthat it did not matter to them, as shown in Graph1.
iii] Assessment of behavioural change:
The behavioural changes were divided into three categories as follows- those showing no or slight behavioural change, positive change and excellent behavioural change. 65 % students showed excellent behavioural change, 30 % showed positive change while 5 % students showed no behavioural changes. Graph 2
iv] Assessment of faculty:
The response of the faculty was of mixedtype. 35 % responded positively to the exercise of sequential teaching. 64 % faculty revised the basic of Anatomy, Physiology and other subjects prior to thelecture. 94% faculty agreed that Anatomy is a conjoint subject for Surgery. 82% faculty supported the fact that integrated teaching brought about favourable behavioural changes in students, 70 % felt that such teaching sessions made students more inquisitive and 94 % agreed that students’ queries were more relevantafter vertical integrated teaching.
DISCUSSION
Curriculum renewal through integration is promoted by many medical educational organizations. The challenge that we as educationists face today is the successful integration across medical disciplines in order to obtain maximum benefit to our students. [5] Vertical integrated teaching [VIT] involves the combination and correlation of basic sciences knowledge to clinical scenarios so as to deepen the understanding and stimulate advanced learning and problem solving attitude. [6,7] Such an approach might aptly be called as holistic learning as it adds to student perception as well as satisfaction. In our study we have also seen that VIT brings about changes in student’s attitude towards learning and positive changes in their behaviour. In this study while assessing the impact of VIT on knowledge level of the students it was seen that VIT improved the knowledge level and student performance so that it was superior to traditional teaching to some extent. It makes understanding of the topic easier and correlation of clinical cases with basic science knowledge gives clarity of concepts. Though these are the advantages of VIT there are a few shortcomings too. Integration cannot be applied to all topics and many times integration leads to content overload as too much knowledge is given in short period of time. Similar observations are noted by other authors in their studies. [1,3,4] Success of any innovative teaching learning method depends on satisfaction of both the teacher or facilitator and the student or benefactor. In this study we assessed the faculty feedback in relation with the relevance of VIT, the usefulness of integration, change in students’ behaviour and attitude in class as well as their perception in terms of preparation of the topic, efforts and time required and whether such activity could be continued in future. Almost all the faculty involved in this module agreed that integrated teaching required more efforts in planning of the session; it is time consuming and needs devotion to execute it successfully. Hence only enthusiastic and voluntary faculty if involved can do the proper planning, organization and execution of VIT to make the sessions more interesting and rewarding. In the studies by other authors like Vidic et al, Bryhildsen et al have also emphasized on efforts of faculty , need for interdepartmental cooperation and time and effort needed for integrated teaching. [8,9] The students on the other hand were highly satisfied with VIT and 95% students found integrated teaching rewarding. They were happy with the planning and execution of the VIT module and thought that the interaction with the teachers helped them to get their ideas clear. The topics were well balanced, information was relevant and it encouraged their critical thinking. Most of the studies have also agreed that students found such integrated teaching sessions helpful in their bedside clinics.[ 4,5] Interestingly in the present study 95 % of students showed some positive behavioural changes. These were assessed through the questionnaire which highlighted their shift in attitude towards teaching learning. Most of them positively accepted that VIT enhanced their critical thinking, motivated them to modify their method of study and improved their approach to difficult topics. VIT made them more curious to explore topics in depth and this helped to uplift their confidence. Such an aspect of integrated teaching is not dealt with by many authors and it forms an asset of our study. The results of introducing integrated teaching to final year MBBS students are promising as they show some obvious advantages like: a] integration reduces fragmentation and compartmentalization of topics, b] it prevents repetition and c] stimulates students to apply knowledge to clinical concepts. Some of the advantages for the faculty involved are integration promotes interdepartmental collaboration and rationalization of teaching resources. However some difficulties that could be encountered during planning of such sessions are that it requires cooperation of faculty and additional inputs from them. The students also may feel burdened and there is paucity of data on long term benefits of integrated teaching. We are now prepared to introduce such modules for many more topics and more studies in the near future will help us to be ready for a transition from traditional to integrated teaching for undergraduate medical students.
CONCLUSION
We conclude that vertical integrated teaching [VIT] in a medical curriculum is found to facilitate attainment of knowledge and improve the affective and psychomotor domains alongwith creating a positive behavioural change in the students. The present era requires aparadigm shift from independent to interdependent teaching to develop competent medical graduates.VIT is encouraging, so that it can be inculcated in the curriculum and enable a smooth transition from traditional to integrated teaching over the coming years.
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. I sincerely thank the institute as well as all the students, colleagues, office clerk and non-teaching staff for their co-operation during this study. Sources of funding: Nil Conflict of interest: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=192http://ijcrr.com/article_html.php?did=1921. Nazish Rafique. Importance of vertical integration in teaching and assessment ofphysiological concepts. Journal of Taibah University Medical Sciences 2014; 9(4), 282-288.
2. Medical Council of India (1992) Recommendations of the workshop on Need based Curriculum forunder graduate medical education, MCI: NewDelhi.
3. Joglekar S., Bhuiyan, P.S. and Kishore, S.Integrated Teaching–our experience, Journal of Postgraduate Medicine 1994, 40, 4, pp 231-232.
4. Kalpana Kumari M. K., Vijaya V. Mysorekar, Seema Raja. Student’s Perception About Integrated Teaching In An Undergraduate Medical Curriculum Journal of Clinical and Diagnostic Research. 2011 November (Suppl-1), Vol-5(6): 1256-1259
5. David G. Brauer, Kristi J. Ferguson. The integrated curriculum in medical education: AMEE Guide No. 96. AMEE GUIDE 2015, 37: 312–322.
6. Rajan SJ, Jacob TM, Sathyendra S. Vertical integration of basic science in final year of medical education. Int J App Basic Med Res 2016;6:182-5.
7. Vyas R, Jacob M, Faith M, Isacc B, Rabi S, Satish Kumar S, Selvakumar D, Ganesh.A. An effective, integrated learning programme in the first year of the medical course. The National Medical Journal of India. 2008; 21:1-6.
8. Vidic B, Weitlauf HM. The horizontal and vertical integration of academic disciplines in the medical school curriculum. ClinAnat 15:233-5.
9. Brynhildsen J, Dahle LO, Behrbohm Fallsberg M, Rundquist I, Hammar M. Attitudes among students and teachers on vertical integration between clinical medicine and basic science within a problem-basedundergraduate medical curriculum. Med Teach 2002;24:286-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcarePERIODONTAL ABSCESS TO PERIODONTAL PROSTHESIS: A MULTI-DISCIPLINARY JOURNEY
English3035Renganath M. J.English Ramakrishnan T.English Anithadevi S.English Manisundar N.English Vidya SekharEnglish Sivaranjani K.EnglishAim: The treatment and long-term retention of mandibular molar teeth with furcation involvement have always been a challenge in periodontal therapy. Root resection has been used successfully to retain teeth with furcation involvement. The term root resection refers to the resection and removal of either of theroots of mandibular molar, which may be affected by periodontal, endodontic, structural deformity. There should be >50% bone support of the remaining roots at the time of the root resection in treating periodontally diseased mandibular molars, which acts as an important factor to obtain good results. In addition, a careful prosthetic plan should be designed to avoid a fracture of resected molars related to biomechanic impairment.
Case Report: This case report of a 23 year old female provides an overview of the feasibility of mesial root resection and bone grafting along with CGF membrane of mandibular right first molar severely affected by perio-endo lesion thus maintaining the function of the teeth.
Discussion: Root resection represents a form of conservative procedure that aims at retaining as much of the original tooth structure as possible thus acting as an alternative to extraction. Root resection of the affected tooth allows the preservation of tooth structure, alveolar bone and maintains the normal function thus being advantageous over other treatment options.
Conclusion: With the results of this case report, the suggested treatment of periodontal abscess with Grade-III furcation by root canal treatment followed by root resection and periodontal flap procedure with bone graft placement along with Concentrated Growth Factor in the furcation defect of the involved tooth could result in successful resolution of infection and excellent healing in the residual defect of furcation which was considered hopeless thus maintaining the function of the dentition.
EnglishPeriodontal abscess, Grade III furcation, CGF, Root resection, Root amputation, Periodontal prosthesisINTRODUCTION
Root resection is the process by which one or more of the roots of a tooth are removed at the level of the furcation while leaving the crown and remaining roots in function.1 It was Farrar, who introduced the root-resection procedure, to treat Grade II and III furcation-involved molars by which, furcation-involved molars can be converted to non-furcated single-root teeth and to provide a favorable environment for oral hygiene for patients as well as clinicians2 . Advances in dentistry, as well as patient’s desire to maintain their dentition, have lead to treatment and retain the teeth that once would have been extracted. In order to carry out this present day scenario, periodontally diseased teeth with severe bone loss at furcation area may well be retained by amputation of the diseased root. This case report describes simple procedure of root resection of periodontally involved mandibular molar and its subsequent restoration to enhance its function with normal dentition.
CASE REPORT
A 23 years old female patient reported to department of Periodontics with the chief complaint of painful tooth and gums in relation to lower right back region of jaw with the history of food lodgement in between the teeth. On clinical evalu ation, the tooth 45 was tilted distally creating a non-intact proximal relationship with tooth 46 along with an interproximal caries(Class II) involving the tooth 45 with no signs of pulpal exposure. On periodontal examination, there was increase in probing depth of 12mm (UNC-15 probe, GDC™) interdentally distal to 45 and mesial to 46 and Grade III furcation defect exhibiting horizontal involvement 9mm (Nabers probe, GDC™)of 46 both buccally and lingually. Mobility was Grade II on the day of examination. Radiographic examinationrevealed severe bone loss that is oblique to occlusal plane extending from CEJ of 45,46 inferiorly 2mm beyond the apex of mesial root of 46 with a diffuse radiolucency extending along the mesial aspect of mesial root of 46 to the periapical region of both the roots of 46 with loss of lamina dura. A profound radiolucency within the furcation region of 46 can also be appreciated resulting from loss of bone in furcation region and buccal and lingual cortical plates [fig.1]. With the clinical and radiographic findings, it was diagnosed as periodontal abscess in relation to 45 and 46. A treatment plan was formulated to perform endodontic treatment of 46 followed by mesial root resection, since the bone loss was severe involving the mesial root and the surface roughness of mesial root making the periodontal instrumentationas a tough task. Following root resection, the defect was plannedto befilled with bone graft with placement of CGF membrane over it and fabricating periodontal prosthesis made of metal ceramicfor 45 and 46, since there was no sufficient inter-proximal bone to support the tooth following mesial root resection of 46 and also to eliminate food impaction between the two teeth. Emergency treatment included drainage and debridement of the abscess with prescription of antibiotic regimen (Amoxicillin 500mg and Metronidazole 400 mg) thrice a day and analgesic (Acelofenac paracetamol) twice a day for five days. Patient was re-evaluated after five days, as the swelling and inflammation subsided; root canal treatment was initiated at the second appointment [fig.2]. After evaluation of Phase I therapy, the probing depth remained the same as day 1[fig.3] indicating the need for periodontal surgery. Hence, Periodontal regenerative procedure using alloplastic osteoconductive bone graft material (Osseograft™) with CGF was instituted. Under local anesthesia, a full thickness mucoperiosteal flaps was elevated on both buccal and lingually. On surgical debridement, a Grade III furcation involvement of 46 was evident [fig.4] which was undergone root resection and filled with the bone graft material[fig.5]and placed with Concentrated Growth Factor over it which was prepared as membrane [fig.6,7,8]. Flaps were repositioned with Interrupted figure 8 sutures using 3-0 black silk sutures[fig.9] and periodontal dressing (COE Pack™) was applied over the surgical site and post-operative instructions were given.Resected root shown surface roughness with calculus attachment[fig.10] which was clinically a challenging entity for instrumentation. Post-operative medications included Antibiotics and analgesic twice a day for five days. Post-operative healing was good with minimal discomfort and Radiograph was taken a week following mesial root resection [fig.11]. 2 weeks following the Surgery, tooth preparation for the teeth 45 and 46 was done[fig.12] and aperiodontal prosthesis (Porcelain fused to metal) crown was fixed and cemented[fig.13,14,15]. Follow up was done for one week, one month, 6 months[fig.16]. Recall appointments included reinforcement of oral hygiene instructions, scaling if required and periapical radiograph of the involved tooth. Patient revealed no bleeding on probing, no suppuration or episode of abscess and no mobility of tooth as well as no complaint of food impaction. Indicating successful resolution of infection and excellent healing in the residual defect of furcation.
DISCUSSION
The goal of therapy for a periodontal abscess is elimination of the acute signs and symptoms as soon as possible. Treatment considerations includes establishing drainage by debriding the pocket and removing plaque, calculus, and other irritants and /or incising the abscess. Other treatments may include irrigation of the pocket, limited occlusal adjustment, and administration of antimicrobials and management of patient discomfort. A surgical procedure for access for debridement may be considered. In some circumstances extraction of the tooth may be necessary. A comprehensive periodontal evaluation should follow resolution of the acute condition.3 The treatment of the acute periodontal abscess usually includes two stages: the management of the acute lesion; and the appropriate treatment of the original and /or residual lesion, once the acute situation has been controlled.4 If the tooth is severely damaged, and its prognosis is bad, one of the most effective treatments could be tooth extraction.5 Treatment of periodontal abscesses includes, a protocol that has been recommended: drainage through the pocket, scaling of the tooth surface, compression and debridement of the soft tissue wall and irrigation with sterile saline. After therapy, the patient should rinse with warm saline and be examined for the abscess resolution after 24–48 h. 1 week later, the definitive treatment should be carried out.
Furcation involvement represent a formidable problem in the treatment of periodontal disease, principally related to the complex and irregular anatomy of furcations. The anatomical characteristics of the areas involved, particularly the size of the furcation entrance, the presenceof root concavities and the uneven surface of the roof of the furcation, make ad-equate instrumentation of the inter-radicular area extremely difficult.6 Concentrated growth factors (CGF) was first developed by Sacco.7 Use of CGF in regeneration shows potential benefits including role on cell migration, cell proliferation and angiogenesis in tissue regeneration phase. CGF barrier is effective to regenerate bone formation associated with grafting procedure. In addition, the mixture of CGF and bone graft could reduce healing time compared to conventional GBR procedure. Success of root resection procedures depends on proper case selection. The morphology of the portion of the tooth remaining after root separation and resection therapy is of primary importance for long term the prognosis of the tooth. In this case, the tooth 46 had sufficient crown: Root ratio, sufficient root length, and thickness to undergo root resection, which would allow the resected remaining segment to bear the occlusal load adequately. Molars that underwent respective procedures due to periodontal reasons had a higher success rate than those due to endodontic causes.8 Clinical prediction of the long-term prognosis is crucial in order to ensure the sequence of therapy and avoiding additional expenditure for the patient. This requires proper diagnosis, treatment planning, and execution by all the clinicians involved in the inter-disciplinary approach. Adequate knowledge of the anatomy of the furcation region is crucial in both planning and execution of the treatment procedure. The degree of success in managing furcation involvement is inversely related to the horizontal probing depth.9 As the furcation invasion progresses, the choice of therapy and the role of inter-disciplinary dentistry becomes more important. Case selection affects the outcome of root resection as a treatment of choice where endodontic complications affecting one root of multi-rooted tooth. Factors such as occlusal forces, tooth restorability and the value of the remaining roots must be examined before treatment.10In the present case, the toothwas able to retain form and function 6months following endodontic therapy,mesial root resection with bone grafting, followed by prosthesis fixation. CONCLUSION Periodontal abscess with secondary endodontic involvement require both endodontic and periodontal therapies. The prognosis of such lesion depends chiefly upon various factors that includes the severity of the periodontal involvement, amount of bone destruction, mobility of the involved tooth, patient compliance and the response to the treatmentadvocated. This article presents a technique to maintain tooth structure in a compromised tooth supporting thefact that the long term success of treating such tooth is largely depending onproper diagnosis, selection of patients who maintained good oral hygiene following phase-I therapy, well planned surgical and restorative management. The suggested treatment of periodontal abscess with Grade-III furcation by root canal treatment followed by root resection and periodontal flap procedure with bone graft placement along with Concentrated Growth Factor in the furcation defect of the involved tooth could result in complete healing of tooth which was considered hopeless. Further studies with series of case reports should be performed to confirm and support the clinical outcome of current case report.
ACKNOWLEDGEMENT
The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to 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=193http://ijcrr.com/article_html.php?did=1931. American Academy of Periodontology. Glossary of Periodontal Terms. Chicago: American Academy of Periodontology; 2001:45.
2. Farrar JN. Radical and heroic treatment of alveolar abscess by amputation of roots of teeth. Dental Cosmos1884;26:79.
3. American Academy of Periodontology. Parameters of Care Supplement Parameter On Acute Periodontal Diseases *. J Periodontol. 2000;71(5):863–6.
4. Ammons W J, Wilson T, Korman. Lesions in the oral mucous membranes. Acute lesions of the periodontium. Fundamentals of periodontics, Singapore: Quintessence eds. K 1996;435–40.
5. Smith R G, Davies R M. Acute lateral periodontal abscesses. British Dental Journal 1986;161:176–8.
6. DeSanctis M, Murphy KG. The role of resective periodontal surgery in the treatment of furcation defects. Periodontol 2000 2000;22:154-68.
7. Sacco L. Lecture, International academy of implant prosthesis and osteoconnection, 2006. 12. 4.
8. Park SY, Shin SY, Yang SM, Kye SB. Factors influencing the outcome of root-resection therapy in molars: A 10-year retrospective study. J Periodontol 2009;80:32-40.
9. Santana RB, Uzel MI, Gusman H, Gunaydin Y, Jones JA, Leone CW. Morphometric analysis of the furcation anatomy of mandibular molars. J Periodontol 2004;75:824-9.
10. Green EN.Hemisection and root amputation. J Am Dent Assoc1986;112(4): 511-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241818EnglishN2016September21HealthcareBROAD SPECTRUM ANALYSIS OF URINARY CRYSTALS: A CLINICOPATHOLOGICAL AND MICROBIOLOGICAL STUDY
English3639G. BhuvaneshwariEnglish Sonti SulochanaEnglishAim: The aim of this study is to evaluate the association between urinary crystal and urinary tract infection (UTI) in patients attending Saveetha Medical College and Hospital.
Method: A cross-sectional study was conducted with 1500 urine specimens. A total of 1500 urine specimens received to microbiology and pathology laboratory were included in the study. Urine with crystals were analysed for culture positivity. Urine routine examination was done for urine crystals analysis. Semi-quantitative method (standard loop technique) was done for analyzing significant bacteriuria. The correlation between the urinary crystal and urinary tract infection were analysed by odds ratio.
Results and Conclusion: A cross-sectional study was conducted with 1500 urine specimens. A total of 1500 urine specimens received to microbiology and pathology laboratory were included in the study. Urine with crystals were analysed for culture positivity. Urine routine examination was done for urine crystal analysis. Semi-quantitative method (standard loop technique) was done for analyzing significant bacteriuria. The correlation between the urinary crystal and urinary tract infection were analysed by odds ratio. Out of 1500 urine sample, 155 were found to be crystal positive, in which bacterial isolation rate was more from uric acid crystal positive samples. Escherichia coli was the maximum yield from the crystal positive samples with the colony forming unit (cfu) of 10000 cfu per mL (less than significant bacteriuria of 1,00,000 cfu/mL). Other organisms isolated were Klebsiella spp, Pseudomonas spp, Citrobacter spp, Enterobacter spp, Acinetobacter spp. and Proteus spp. Their resistance pattern was also analysed.
EnglishBacteriuria, Crystal positivity, Routine examination, Standard loop technique, Urinary tract infectionINTRODUCTION
Crystals in the urine is known as crystalluria. Sometimes crystals are found in healthy people and other times they are indicators of organ dysfunction, the presence of urinary tract stones of a like composition (known as urolithiasis), or an infection in the urinary tract. Some of these disease processes that are associated with these crystals will be the focus of this lesson. Urinalysis is not only used for the diagnosis of urologic conditions such as calculi, urinary tract infection (UTI), and malignancy. It also can alert the physician to the presence of systemic disease affecting the kidneys. A large number of people (up to 20% of the population worldwide) are suffering from urinary stone problem. The majority of stones are composed of oxalates, calcium salts, and phosphates. Among phosphates, magnesium ammonium phosphate hexahydrate (MAPH; MgNH4PO4•6H2O), known as struvite, is the predominant crystalline component. Struvite crystallization is related to urinary tract infections by microorganisms producing urease. Infection-induced urinary stones form as a result of a urinary tract infection by urease-producing bacteria. Infection stones make up approximately 15% of urinary stone diseases and are thus an important group. The basic precondition for the formation of infection stones is a urease positive urinary tract infection. Urease is necessary to split urea to ammonia and CO2 . They are mainly the microorganisms from species of Proteus, which are isolated in the case of 70% of the so-called infectious stones. Proteus species, the motile, Gram-negative bacteria within the Enterobacteriaceae that cause urinary tract infections, primarily in patients with long-term urinary catheters in place or structural abnormalities of the urinary tract. Proteus infections are known to be frequently persistent and difficult to treat and can lead to several complications such as acute or chronic pyelonephritis. Additionally, these species are the most common bacilli associated with the formation of bacteria-induced bladder and kidney stones. Urease is the essential virulence factor of these bacteria involved in stone formation. Ammonia, produced by the enzymic hydrolysis of urea, elevates urine pH, causing super saturation and crystallization of magnesium and calcium ions as struvite (MgNH4PO4.6H2O) and carbonate apatite [Ca10(PO4)6.CO3], respectively. It has been found that, in addition to urease activity, bacterial exopolysaccharides contribute to stone formation. Polysaccharide produced by bacteria may aggregate precipitated urine components to form a stone. When these crystals deposit themselves infection stones form. If these infections are not treated and the stones are not removed, the kidney will be damaged. Thus recurrent urinary tract infection and crystal formation should be analysed promptly and correlated in order to avoid infection induced urinary stones. Thus, the goal of this study is to correlate the urinary tract infection and urine crystal, in order to find the bacteria commonly associated with the crystal positive cases, their significance and also to find their antibiogram.
MATERIALS AND METHODS
A cross-sectional study to analyse the crystal positivity and culture positivity was conducted in the Department of Microbiology at Saveetha Medical College and Hospital after obtaining the university scientific review board approval and ethical committee clearance. A total of 1500 urine specimens received to microbiology and pathology laboratory were included in the study. Urine samples were processed by standard urine route examination and standard loop technique as follows. Microscopic Urinalysis: To prepare a urine specimen for routine examination, a fresh sample of 10 to 15 mL of urine were centrifuged at 1,500 to 3,000 rpm for five minutes. The supernatant then is decanted and the sediment resuspended in the remaining liquid. A single drop is transferred to a clean glass slide, a cover slip is applied and observed under 40X. Standard loop technique: Specimens arriving at the laboratory were inoculated onto a blood agar plate and a MacConkey by using a 0.001-ml calibrated loop. The well-mixed urine was sampled with the calibrated loop and plated onto the surface of the blood agar plate. A single streak of the inoculum was spread across the center of the plate, and the inoculum was then spread perpendicular to the primary streak to ensure a semiquantitative colony count. MacConkey agar plate was also inoculated in the same manner. Plates were incubated at 37°C and examined once at 18 to 24 h. If no growth was observed or if the colony count was less than 10 CFU per plate, the plates were kept for an additional 24 h and read again. Positive cultures and obviously contaminated cultures were reported at 24 h.
RESULT
Out of 1500 urine sample, crystal positivity was found more in male in-patients (68%) of age group 41-50(17%). The agewise, sex-wise and IP-OP distribution was shown in table 1. Among the 1500 urine specimens, 155(10%) was found to be positive for urinary crystals. Out of which calcium oxalate were 109(70%), uric acid 24(16%), Triple phosphate 14(9%), Amorphous phosphate 5(3.2%) and Amorphous urate 1(0.6%). The bacterial isolation was higher (67%) from the uric acid crystal positive samples. Patients infected with uric acid crystal yielded higher frequency of Escherichia coli (44%) that too of 10000 colony forming unit per mL in 22% cases. Out of which, 56% were found to be ESBL producers, 1.2% were found to be multi-drug resistant and 0.5% was Pan-drug resistant organism. The relation between crystal positivity and culture positivity and their sensitivity, specificity, positive predictive value and negative predictive value is shown in table 2. The distribution of crystal positivity and culture positivity was shown in table 3. The antibiotic resistance of those culture positive cases was shown in Figures 1,2,3 and 4.\
DISCUSSION
A large number of people (up to 20% of the population worldwide) are suffering from urinary stone problem [9]. The majority of stones are composed of oxalates, calcium salts, and phosphates. Among phosphates, magnesium ammonium phosphate hexahydrate (MAPH; MgNH4PO4•6H2O), known as struvite, is the predominant crystalline component [10,11]. Formation of infectious urinary calculi is the most common complication accompanying urinary tract infections by members of the genus Proteus. The major factor involved in stone formation is the urease produced by this bacteria.7 It has been found that, in addition to urease activity, bacterial exopolysaccharides contribute to stone formation. Polysaccharide produced by bacteria may aggregate precipitated urine components to form a stone which is also said to be infection induced urinary stones.8 In our study the findings of 1500 urine samples are, 155 cases (10%) were found to be crystal positive. Out of which 19 were out-patient and 136 were in-patients. Out of 155, 104 (67%) were male and 51 (33%) were found to be fe-male. Another study done by Naseri et.al., revealed that, out of 183 patients, 130 cases (71%) were female and 53 patients (29%) male. Most of the patients (61.9%) were between 2 years of old. In our study, 27 crystal positive samples were between the age group of 41-50. 3 In our study crystal positivity is still 48%. In a study done by Yousefimashouf et.al., 28% of tested samples had positive culture. From the positive cases, Staphylococcus epidemidis (40.4%), Acinetobacter baumannii (10.6%) and Escherichia coli (8.5%) were the most common isolates. In our study Escherichia coli were the majority isolates from uric acid crystal positive samples. The similar views have been expressed by David et.al., that the majority of UTI are caused by Escherichia coli.1 Out of 40 Escherichia coli strains, 56% were found to be ESBL producers, 1.2% was found to be multi-drug resistant and 0.5% was Pan-drug resistant organism. The most rate of sensitivity of Escherichia coli was against to gentamicin and Psuedomonas aeruginosa to ciprofloxacin in a study done by Yousefimashou et. al., The data revealed that the bacteria isolated from crystal positive urine specimens had multidrug resistance. Yousefimashouf et.al., also reported the same. Among all chemical compositions, calcium oxalate (in either pure or mixed form) was the most common and found in 64 and 75% of the stone formers with and without bacterial isolates, respectively in a study done by Ratree Tavichakorntrakool et al., Nevertheless, limitations of our present study should be noted. Bacteria found in urine might promote formation and growth of these crystals. But it has to be confirmed with stone matrices and crystals culture. Therefore, extensive investigations of crystals are required to address this concern. In summary, our data indicate that the prevalence of UTI associated with crystal positivity is still high (48%). In addition, UTI are frequently associated with almost all chemical types of kidney stones, not only struvite, and Escherichia coli, not urea splitting bacteria, is the most common causative microorganism found in urine.
CONCLUSION
Hence in our opinion it is mandatory to check the urine complete analysis along with the urine culture and sensitivity. If not so, at least with the crystal positive urine samples culture has to be done in order to control infection induced urinary stones.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of Funding: nil Conflict of Interest: nil
Englishhttp://ijcrr.com/abstract.php?article_id=194http://ijcrr.com/article_html.php?did=1941. Johnson, D.E., Lockatell, V., Russell, R.G., Hebel, J.R., Island, M.D., Stapleton, A. Comparison of escherichia coli strains recovered from human cystitis And pyelonephritis infections in transurethrally challenged mice. infection and immunity. July 1998, p. 3059–3065 vol. 66, no. 7
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3. Naseri, M, Alamdaranm, SA. Urinary tract infection and predisposing factors in children doi:10.1136/archdischild-2012-302724.0890.
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5. Tavichakorntrakool, R, Prasongwattana V, Sungkeeree S, Extensive characterizations of bacteria isolated from catheterized urine and stone matrices in patients with nephrolithiasis. Nephrol dial transplant (2012) 27: 4125.
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