Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareEFFECTIVENESS OF USING POWER POINT BASED TEACHING VS. BLACK/WHITE BOARD BASED TEACHING AMONG PHYSIOTHERAPY LECTURERS IN LOVELY PROFESSIONAL UNIVERSITY - A PILOT STUDY
English0105T. S. MuthukumarEnglishAims: The typical undergraduate and post graduate student of today is accustomed to receiving information on a daily basis in a variety of formats, i.e. multimedia channels. This can lead to teachers to update themselves constantly to enrich the students’ knowledge.
Methodology: Physiotherapy lecturers working in Lovely Professional University were participated in this pilot study and convenient sampling method was incorporated. The participants were asked to answer the questionnaires and the responses were collected by the researcher and depicted in a graph.
Results and Conclusion: The overriding conclusion would be that pedagogy must drive educational technology usage rather than the reverse. Since it was a pilot study, the lack of generasibility enables the future research to focus on which instructional devices would be helpful to the physiotherapy teaching community.
EnglishPower point, Black/ white board, Learning management system (LMS)INTRODUCTION
Advances in the development of technology enable teaching profession to explore new methodologies for teaching and learning. These efforts catalyzed the process of integrating technology-mediated tools in education. Such mutually induced supply demand chain greatly influenced different models of teaching and learning, thereby creating an interdependent learning environment.1 Different modes of teaching and learning in the form of online, distance, mobile and network learning environments motivated and to an extent compelled faculty to develop and deliver online teaching materials (Georgiev, Georgieva and Smrikarov, 2006)2 . Physiotherapy is one of the professions that need update in recent years. In earlier days, the Physiotherapy lecturers adopted the black board method of teaching and it helped them to deliver the lectures in an appropriate method. Recently with the introduction of learning management system (LMS) in flexible learning environments, Physiotherapy teachers may develop and deliver course materials for students. According to Quarless (2007), the growing prevalence of LMS is providing more opportunities in tertiary education by mainly exploring design of integrated systems for better suitability in online learning environments and he emphasized the main functions of any LMS such as Course administration and management, Course Pedagogy Teaching and Learning3 . Graves (2001) suggested that there are two main reasons for education providers to adopt e- learning tools4 : 1) To improve the traditional classroom environment with web based technologies with flexibility for access of web based course materials and communication 2) To implement the concept of distance education where there is no traditional class environment and minimize the classroom time. However, it is still a challenge for teachers to adopt the new course delivery formats in spite of the support or training provided by their management (Perreault, Waldman and Zhao, 2002)5 .
There exists a dilemma among the Physiotherapy fraternity that which system of teaching methodologies such as Black board based teaching or Power point based teaching suitable for them. In other words it is older people vs. next gen because the recent Physiotherapy graduates easily transformed themselves to a changing teaching methodology environment. The purpose of this pilot study is to find out the use of black/ white board based teaching and power point based teaching among the Physiotherapy lecturers working in Department of Physiotherapy Lovely Professional University. This study is first of its kind among the Physiotherapy fraternity and it will moot others to go deep into it.
MATERIALS AND METHODOLOGY
The present study was a pilot study in that the participants were selected conveniently among the Physiotherapy lecturers working in department of Physiotherapy, Lovely Professional University. The inclusion criteria was lecturers who were taking Physiotherapy subjects for both undergraduate and post graduate students irrespective of the age, sex, experience and higher qualification and there was no specific exclusion criteria. The size of the population was 15 lecturers. Informed consent was obtained and the participants were asked to answer the questions submitted to them. The questionnaire consists of 10 questions, each question has two options and the respondents were asked to mark or circle the desired answers. The time has given to answer the questions was 15 minutes. The questionnaire has categories like preference of black/white board teaching vs. power point teaching, consuming time and effort, management of large number of students, bothersome/tiring for the preparation of a lecture, coverage of more topics in a lesser time, presenting diagrams, charts, students’ interest, and clear concept of lectures, students’ interaction and students’ performance. The research methodology involved in this study was simple graphical representations of categories that the participants had chosen. In this research, the pilot study had been employed because of estimation of larger number of samples in future research and the feasibility of further research. The concise Oxford Thesaurus defines a pilot project study as an experimental, exploratory, test, preliminary, trial or tries out investigation and investigation designed to test the feasibility of methods and procedures for later use on a large-scale or to search for possible effects and associations that may be worth following up in a subsequent larger study. The data collected from the respondents were graphically illustrated using bar diagrams and the analysis was done at the confidence interval (CI) of 95%.
RESULTS
The findings in this study were inconclusive since it was a pilot study. Most of the respondents about 60% choose preference over black/white board teaching than power point based teaching. The majority of the participants felt more time was consumed to prepare power point presentations. More number of lecturers about 90% preferred power point presentation to teach large number of students rather than black/white board teaching. Many of the participants acknowledged power point presentation was helpful to visualize diagrams, photos videos, better than black/white board teaching. The results were displayed as graphs. The results could not be generalized because of the small sample size. More variables and also the students’ feedback might be needed in future studies.
DISCUSSION
Technology Acceptance Model (TAM)7 originally designed by Davis (1989) has became popular as one of the theories to evaluate any information system’s user understanding and evaluated the decision factors and perceptions about how and when the technology tool is used. Although the initial stages of using and understanding teaching tools such as Blackboard is dependent on its ease of use, it is the usefulness of the system and the support by the organization that have the major impact. In this technology driven educational world, the transformation from black/white board based teaching to power point based teaching has been increasing since most private universities adopt LMS. The present study gave a little idea about the usage of black/ white board teaching or power point teaching among the Physiotherapy lecturers. Out of the 15 respondents, 60% percentage of the people preferred the usage of black/white board teaching because they said that it is easy to use. If compared in terms of time consumption for the preparation of lectures, more than 90% of the participants casted their vote to power point based teaching than black/white board teaching. Majority of the lecturers (99%) preferred power point based teaching to manage the large number of students because they felt that good view of the power point slides using LCD projectors. More than 60% of the participants said that power point consumes more time to prepare for a single lecture and it is tiring. The black/white board based teaching and power point based teaching shared the equal share (more or less) when compared in terms of clear concept of lecture delivery, coverage of more topics in a lesser period of time, interest of students? learning and students? interaction during teaching. It was evident in this study that 95% of the participants had chosen power point based teaching for better delivery of lectures when it requires photographs, pictures and diagrams. Taking into account of the students? performance in test or examinations after the lectures were over, 70% of the participants selected power point based teaching since they believed that it was easily understood by the students and its retention of use during the time of examination preparation. Now-a- days, the Physiotherapy lecturers are updating themselves regarding the new technology available for treatment and also in education field. It is the interest and involvement of the individual to adopt new systems of technology during the course of their life. The study of Landry8 (2003) validated the application of TAM theory in educational environment and identified the influence of external variables such as the instructor’s computer background, computer literacy and perceived ease of use etc Perceived ease of use as defined by Davis (1989) is the degree to which a person believes that using a particular system would be free from effort. Davis (1989) defined PU as “the degree to which a person believes that using a system would enhance his or her job Performance” and referred to the capability of software application to be used advantageously7 . Black/white board based teaching was adopted by numerous teachers in olden days and also recently. They believed that the teaching should be conducted thorough black/white board method only. In course management systems, Blackboard has become a „”glorified toolkit” to meet the demands at the teaching level as “there is the desire to promote active learning and perhaps employ cooperative/collaborative learning strategies and online learning assessments that offer timely feedback to student and instructor alike” according to Quarless, (2007).3 As per Tannenbum9 (1998) power point has all the multimedia components such as sound, video, texts and animations etc. Based on the literatures available regarding the use of power point based teaching, one can get mixed responses. Nunberg10 (1999) stated that PowerPoint is denounced by academics and CEOs for causing detrimental effects on “dialogue, interaction, and thoughtful consideration of ideas.” After a review of these studies, Craig and Amernic11 (2006) concluded that PowerPoint?s effectiveness is contingent upon the discipline, the learning objectives, and learner types. They recommended that faculty study new technology first rather than accepting them blindly and unquestiongly. Hence this study presented all the merits and demerits of both the form of teaching methods. The main limitation of the study was minimal categories we included in the questionnaire and open ended type of questions would have included in the main study.
CONCLUSION
The present study was first of its kind since no research was carried out among Physiotherapy fraternity. Based on the findings, the lecturers preferred black/white board teaching or power point based teaching based on their convenience and other features. It may be concluded that this study was a pilot study and it enables the future research to add more categories in the questionnaire and elaborately study the outcomes of both forms of teaching. In a nutshell it is inconclusive to generalize the preference of usage of black/white board teaching or power point based- teaching among the Physiotherapy fraternity.
ACKNOWLEDGEMENT
Author acknowledges the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The author is so 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 committee Approval: This study has been approved by ethical committee of Lovely
Professional University Funding: There is no source of fund from any external agency Conflict of Interest: There is no conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=226http://ijcrr.com/article_html.php?did=2261. Missula, Saroja, “Staff perceptions of Blackboard as an online teaching tool in tertiary education” (2008). School of Computing and Information Technology Dissertations and Theses. Paper 12.http://www.coda.ac.nz/unitec_scit_di/12.
2. Georgiev, T., Georgieva, E., and Smrikarov, A. (2006). M-Learning - A new stage of e- Learning.Proceedings of International Conference on Computer Systems and Technologies CompSysTech’2004 .Retrieved Nov 25 2010, http://ecet.ecs.ru.acad.bg/ cst04/Docs/sIV/428.pdf.
3. Quarless, D. A. (2007). Redundant features of design in Blackboard (LMS) and user error. SIGCSE Bull, 39(2), 177-179. 4. Graves, W. H. 2001. The new challenges of E-learning. Ubiquity, 1 (43).
5. Perreault, H., Waldman, L., and Zhao, M. (2002). Overcoming barriers to successful delivery of distance-learning courses. Journal of Education for Business, July/August,313-318.
6. Waite M: Concise Oxford Thesaurus Oxford, England: Oxford University Press, 2 2002.
7. Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13, 31-340.
8. Landry, B., J. (2003). Student reactions to web enhanced instructional elements. AnnArbor MI: ProQuest.
9. Tannenbaum, Robert S. 1998. Theoretical foundations of multimedia. New York: Computer Science Press
10. Gregory Krippel, A James Mckee, Janette Moody, Multimedia use in Higher education: promises and pitfalls Journal of Instructional pedagogies. Retrieved Nov 25 2010 http://www. aabri.com/manuscripts/09329.pdf.
11. Craig, Russel J. and Joel H. Amernic. 2006. PowerPoint presentation technology and the dynamics of teaching. Innovation in Higher Education. Vol. 31 147:160.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareEFFECT OF DIFFERENT PROCESSING METHODS ON POLYPHENOLIC CONTENT AND ANTIOXIDANT ACTIVITY OF BROAD BEANS (VICIA FABA)
English0611Pinki SainiEnglish Priyanka SinghEnglish Shreyasi DubeyEnglish and Ayushi SrivastavaEnglishObjective: The effects of processing on total phenolic components and antioxidant activity in commonly consumed broad bean was investigated. Methods: The raw and processed samples were extracted with 70% methanol and analysed for antioxidant components and antioxidant activity.
Results: Processing of legumes caused decrease in total phenolic content when compared to the raw samples. However, the dry heating caused remarkable increase in tannin contents (6.98±0.53 g TAE/100 g extract). The flavanoid and β carotene content was significantly reduced on processing of samples. Raw sample of D. lablab was found to possess the highest DPPH (73.5±2.5%), Reducing power (4.9±0.68 mg ascorbic acid/gm) and Iron chelating capacity than other samples. Conclusion: Maximum retention of antioxidant activity was observed in dry heated samples. Higher correlation was found between phenolic content and chelating capacity (r2=0.945) but a poor correlation with DPPH. Moreover, the content of tannins gave good correlation (r2=0.745–0.913) with Iron chelating and DPPH assays.
EnglishProcessing, Antioxidant, Broad beans, Total phenolics, CorrelationINTRODUCTION
Legumes belong to the family Leguminosae, one of the most important families in Dicotyledons, including around 700 genera and 20,000 species. Legumes are the second most important source of food and fodder, green manures and forages. In comparison of cereal grains, legumes are good source of proteins, dietary fibers, low glycemic indexes, low levels of fat (2-5%) and high amounts of carbohydrates (55- 60%) (Xu et al., 2007). Recently demand for plant based proteins has increased and hence there are more studies on functional proteins from legumes such as chickpea, lentil, cowpea, lupins, pea and broad beans as alternative to soybean. The epidemiological evidence indicates that the consumption of dietary antioxidant such as legume seed proteins provided protective effects for several chronic diseases like cardiovascular diseases, cancer, obesity diabetes and hypercholesterolemia. Broad beans also known as the field bean or fava bean is a species of bean native to North Africa and extensively cultivated in south and south west Asia. In India, it is an important legume used as a pulse and vegetable for human consumption and forage. Broad beans (Vicia faba) are a potential source of protein, dried seeds of bean contain 20–28% crude protein and the amino acids are moderately well balanced with especially high lysine content. They are rich in Ldopa, a substance used medically in the treatment of Parkinson’s disease. L-dopa is also a natriuretic agent, which might help in controlling hypertension. An antifungal protein Dolichin, has also been purified from the seeds of the field bean. Dolichin inhibited Human Immuno-deficiency Virus (HIV) reverse transcriptase, D and E-glucosidases which are glycohydrolases implicated in HIV infection. It had very low ribonuclease and cell-free translation-inhibitory activities (Ye et al., 2000). Further, the dietary protein concentrates of broad beans showed potential hypocholesterolemic effect (Chau et al.,. 1998).
The antioxidant activities and phenolic compounds in fresh legumes have been reported earlier in several communications (Amarowicz et al., 2003; Xu et al., 2007). However the legumes require sufficient processing before consumption. The effects of processing methods on phenolics and antioxidant activities have not been systematically studied. In addition, very little information is available in the literature regarding the changes in antioxidant activity of the processed beans. The aim of the present study is to investigate the effects of processing methods (boiling, drying and pressure cooking) on the phenolic contents and antioxidant activities of broad beans.
MATERIAL AND METHODS
Sample collection and Processing Broad beans were procured from local market of Allahabad city. They were washed, dried and stored under refrigeration. The fresh Broad beans (100g) were boiled using beans: water ratio of 1:5 (w/v) until they became tender. Pressure cooking of samples (100g) was done in a pressure cooker for 20 min with water ratio of 1:3 (w/v). Water was decanted, boiled and pressure cooked samples were dried at 50o C until constant weight reached. Another 100g of sample was dried at 160o C for 15 min in a microwave oven. The fresh, boiled, pressure cooked and dried bean samples were finely powdered using a Willy Mill of 60 mesh size. All the powdered samples were stored separately in a screw capped bottles at a room temperature until further analysis Proximate analysis: All the samples were analysed for proximate composition using AOAC (2005) methods. All the chemicals used were of analytical grade obtained from Merck or Sigma. Preparation of solvent extract: Raw and processed bean powder (100 g) was extracted with 500 ml of 70% methanol (w/v) using a shaker, the sample was shaken occasionally for 24 h. The extracts were centrifuged at 5,000 rpm for 20 min and the supernatants obtained were concentrated with a rotary vacuum evaporator (RV-10, IKA) at 45º C. The resultant extracts were stored in amber vials at 4°C until assayed. The extract recovery percentage of raw, boiled, dry heated and pressure cooked samples of Broad beans were found to be 1.66%, 1.25%, 1.50% and 1.12%, respectively. Estimation of Total Phenolic Content (TPC): Total phenolic content was determined by adopting Folin-Ciocalteu method (Velioglu et al., 1998; Ying et al., 2013). Basically, 0.2 ml of extracts was added with 1.5 ml of Folin-Ciocalteu reagent and mixture was allowed to stand at room temperature for 5 minutes. Then 1.5 ml of sodium carbonate solution (6%) was added into the mixture. Absorbance was measured using spectrophotometer at 725 nm after incubating the sample to stand for 1½ hours at room temperature. Results were expressed as gallic acid equivalent in mg/100 g dry weight (DW). Estimation of Total Tannin Content (TC): Tannin content was determined by the method of Ranganna, 2005. Powdered sample (0.5 g) was boiled with water (75ml) for 30 minutes and centrifuged at 2000 rpm for 20 minutes and the supernatant was collected. Folin Denis reagent and sodium carbonate was added to the sample extract, solution was diluted to 100ml with water and absorbance is taken at 700 nm after 30 minutes. Estimation of Total Flavonoid Content: A colorimetric assay (Kim et al., 2003) with some modification was used to quantify total flavonoid content. Briefly, 25 microliter of diluted sample was added to 125 microliter of double distilled H2 O. Subsequently, 7.5 microliter of 5% NaNO2 was added to the mixture and was allowed to stand for 5 minute thereafter 15 microliter of 10% AlCl3 was added. The mixture was incubated at ambient temperature (25o C) for an additional 5 minute. Following that and 50 microliter of 1 M NaOH was then added to the mixture. The mixture was immediately diluted by addition of 27.5 microliter of ddH2 O and the absorbance of the mixture was measured at 510 nm against a blank prepared with ddH2 O using microplate reader (synergy HT, BioTek instrument, USA). Estimation of Beta carotene: Beta carotene was analyzed by column separation method (Rangana 2005). The absorbance was measured using spectrometer at 452nm. Petroleum ether and acetone mixture was used as blank. DPPH free radical scavenging assay: The free radical scavenging activity of the field bean extracts was measured by measuring the decrease in absorbance of ethanolic DPPH solution at 517 nm in the presence of the extract (Krings and Berger, 2001; Koolen et al., 2013). The initial concentration of DPPH was 0.1 mM and the reading was taken after allowing the solution to stand for 30 min. In cases where the absorbance decreased too much before the 30 minutes period the sample was appropriately diluted. The antioxidant activity was expressed as:- Estimation of Reducing power: The reducing power of the extracts was determined by using potassium ferricyanideferric chloride method (Oyaizu, 1986). Different dilutions of extracts amounting to 1 ml were added to 2.5 ml 0.2 M phosphate buffer (pH=6.6) and 2.5 ml potassium ferricyanide (1%). The mixtures were incubated at 50°C for 20 minutes, after which 2.5 ml trichloroacetic acid (10%) was added. 2.5 ml of the mixture was taken and mixed with 2.5 ml water and 0.5 ml 1% ferric chloride. The absorbance at 700 nm was Chelating Capacity on Fe2+:- Fe2+ chelating capacity was measured by 2, 2′-bipyridyl competition assay (Yamaguchi et al., 2000). The reaction mixture contained 0.25 ml of 1 mM FeSO4 solution, 0.25 ml of sample extract, 1 ml of 0.2 M Tris–HCl buffer (pH 7.4), 1 ml of 2,2′- bipyridyl solution (0.1% in 0.2 M HCl), 0.4 ml of 10% hydroxylamine– HCl, and 2.5 ml of ethanol. The final volume was made up to 5 ml with distilled water. The absorbance at 522 nm was determined and used to evaluate Fe2+ chelating activity using ethyelendiamine tetra acetate (EDTA) as a standard. The results were expressed as mg EDTA equivalent/ g of seed extracts.
RESULTS
Nutritional composition of broad beans: Raw broad beans had crude protein (2.69%) and crude fat (1.02%), ash (2.1%) and crude fibre (1.82%). Raw broad beans had a high protein, crude fibre and calcium content as compared to processed field bean. The phosphorous was highest in boiled broad beans whereas iron content was highest in pressure cooked bean samples. Antioxidant components: Plant phenolics are free radical scavangers and act as antioxidants. The content of polyphenols in broad beans is depicted in Table 2. Total phenolics ranged from 3.33 to 5.65 mg GAE/g extract. The raw broad beans had highest phenolic content followed by dry heated and boiled samples. Tannin content varied from 5.13 to 6.16 mg TAE/g. Raw field bean samples had highest tannin content followed by dry heated and boiled samples. Flavonoid content was in the range of 0.65 to 1.54 mg/100ml (Table 2). Highest flavonoid content was found in raw broad beans which reduced on processing. Maximum reduction was observed in pressure cooked broad beans. The β carotene content varied from 0.31 to 4.41 µg/100g. The highest β carotene content was found in raw field bean samples followed by pressure cooked samples (0.6 µg/100g). Linear correlation coefficient between composition and antioxidant capacity of broad beans has been discussed in Table 4. High correlation coefficient was found between TPC and Iron chelating capacity (r2 =0.945) and FRAP (r2 =0.678), but a poor correlation with DPPH (r2 =0.248). Similarly tannin content showed high correlation coefficient with iron chelating capacity (r2 =0.913) and DPPH (r2 =0.745). A high correlation coefficient was observed between Total Flavanoids and DPPH (r2 =0.945) and Iron chelating capacity (r2 =0.784). β carotene showed a poor correlation with antioxidant assays (r2 =0.086-0.652). Antioxidant activity of broad beans: DPPH was used to determine the free radical scavenging activity of the methanol extracts of raw and processed field bean samples (Table 3). The raw broad beans showed highest DPPH content (73.5%) followed by boiled and dry heated samples. The pressure cooked broad beans had lowest DPPH content (22.8%), Ascorbic acid and BHT were positive controls and exhibited DPPH content as 79.5% and 83.4% respectively. Ferric ion reducing capacity: The reducing properties are related with the presence of reductones, which exert antioxidant action by breaking the free radical chain by donating a hydrogen atom (Shimada et al., 1992). Ferric ion reducing capacity of samples and standards are found to be in following order (Table 3): ascorbic acid (5.1±0.29 mg AA/ gm) > raw (4.9±0.68 mg AA/gm) >BHT (4.3± 0.54 mg AA/ gm) > pressure cooked (3.5±0.34 mg AA/gm) > dry heated (2.6±0.12 mg AA/gm) > boiled (1.2±0.23 mg AA/gm). The dry heated samples had higher reducing power than pressure cooked and boiled samples. Fe chelating: In this study, the chelating ability of the raw and processed seed sample extracts of D. lablab towards ferrous ions were examined (Table 3). All the samples examined showed Fe2+ ion chelating effect and the activity was expressed as mg EDTA equivalent. The raw samples showed a chelating capacity of 70.2±1.05 mg EDTA/g of extract followed by dry heating (67.4±1.12 mg EDTA/g). The boiled broad beans showed minimum Fe capacity (55.2±1.3 EDTA/g).
DISCUSSION
Nutritional composition: The proximate analysis of beans is given Table 1. Raw beans showed a higher nutritional value as compared to processed beans. The decrease in the ash content of processed vegetables could be as a result of processing during which some of the inorganic salt in the vegetables might have leached off (Yaciuk and Sofose 1981). The protein content also showed reduction may be due to the fact that during boiling cellular protein are denatured and the chlorophyll which is bound to protein may be released, such free chlorophyll are highly unstable and are readily converted to pheophytin which is olive green to brown in colour (Komolafe and Obayanju, 2003). Antioxidant components: The polyphenolic and tannin content of broad beans is depicted in Table 2. The results are in accordance with Pascharicha et al. (2014) who also reported total phenolic content of 22.415 GAE equivalents (μg GAE/mg sample) in faba seeds. Siddhuraju (2007) reported that processed samples had lower concentration of phenolic fractions possibly due to the poor extractability by the formation of insoluble tannin- protein and tannin-carbohydrate complexes. The Reduction of phenolic content in broad beans may be due to lixiviation (Siddhuraju and Becker 2003) and the phenols may also bound to other compounds and form insoluble complexes (Fernandez et al., 2003). Similar decrease in phenolics content of broad beans has also been reported by Maheshu et al. (2013). The results are also in accordance with Barroga et al. (1985) who found that boiling and cooking reduced the amount of phenolics in legumes by 75%. However this might be caused in part by diffusion of phenolics from the seed coat to cooking water (Rocha-Guzman et al. 2007). The total flavonoid content (Table 2) of the raw and processed samples was estimated by the aluminium chloride method. It has been recognized that flavonoids show antioxidant activity. The total flavonoid content in the dried faba seeds was estimated to be 7.814 in μg of Catechin equivalents (CE) / mg (Milo, 2004). The β-carotene content of beans was found to decrease on processing. The high sensitivity of β-carotene to light and heat is well recognized and its loss is therefore expected during heat-processing. Some workers have reported losses of β-carotene from vegetables, including spinach, amaranth and fenugreek, during cooking procedures, such as boiling, stewing, frying, blanching and pressure cooking (Yadav and Sehgal, 1995 and Yadav and Sehgal, 1997). The linear correlation between composition and antioxidant capacity of broad beans (Table 4) show that antioxidant activity is not alone dependent on total phenolics. Also the synergistic equation between antioxidants in mixture makes them dependent on concentration as well as on structure and interaction among them (Djeridane et al., 2006). The antiradical and antioxidant activities of beans depend on the amount and composition of the antioxidants they contain. The research conducted by Oomah et al. (2005) with Canadian bean cultivars revealed differences between the cultivars in antioxidant and antiradical activities. Antioxidant activity of Broad beans DPPH content was highest in raw samples followed by boiled and dry heated samples (Table 3). Saini and Singh (2015) have reported that ethanolic extracts of raw spices and herbs show higher DPPH content as compared to other extracts. The antiradical scavenging activity of untreated and treated seed extracts are related to the nature of phenolics, thus contributing to their electron transfer/hydrogen donating ability (Brand-Williams et al. 1995). According to Tsai and She (2006) a change in phenolic compounds after heating might be contributed to a decrease in DPPH-scavenging ability. Ferric ion reducing capacity was found to be higher in dry heated samples as compared to pressure cooked and boiled samples. Higher antioxidant activity of dry heated broad beans might be due to the formation of products from Maillard reaction. Tsai and She (2006) concluded that there was a change in the phenolic compounds after heating which resulted in increase in reducing power. The decrease in reducing power of pressure cooked samples correlates with the low level of phenolic contents since, during cooking, a part of phenolics diffuse from the seed coat to cooking water (Rocha-Guzman et al., 2007). The results of the study show that Fe chelating activity was higher in raw and dry heated samples. Similar results have also been reported in the raw and processed legumes of Macrotyloma uniflorum and D. lablab methanol and acetone extracts (Siddhuraju et al., 2008). The extract of peanut seed testa (Yen et al., 2005) and faba bean (Carbonaro et al., 1996) also showed a significant Fe2+ chelating effect.
CONCLUSION
The raw and dry heated samples of broad beans showed higher antioxidant activity than the pressure cooked and boiled samples. The results indicated that not only the phenolic constituent from raw samples but also the phenolics and Maillard products of processed samples are found to be potent antioxidant suppliers. Therefore, consumers may obtain optimal health benefits along with nutrient assimilation without any negative implications. As dry beans contain compounds other than phenolics that may have significant antioxidant potential, it will be useful to investigate their potential and maximize their use in food industry.
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.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN-0001November30HealthcareITEM ANALYSIS OF MCQS - MYTHS AND REALITIES WHEN APPLYING THEM AS AN ASSESSMENT TOOL FOR MEDICAL STUDENTS
English1216Priya S. PatilEnglish Manisha R. Dhobale English Nitin R. MudirajEnglishMultiple choice questions [MCQs’] form one of the tools for evaluation of medical graduates. The widespread use of MCQs’ raises the question of their validity and authenticity. The present study was focused on MCQ validation with an attempt to highlight the importance of item analysis and discuss the myths and realities of MCQs'. Aim: The aim was to perform Item analysis while probing into myths and realities of MCQ as an assessment tool for first year medical students. A total of hundred students underwent MCQ test as part of their first periodic assessment.
Methodology: A total of hundred students underwent MCQ test as part of their first periodic assessment. A pre-validated MCQ test was given to students and a post-validation was done through item analysis. The indices were calculated using Microsoft excel and various indices compared.
Results: Inspite of using a well-designed MCQ test validated by senior faculty and colleagues, after item analysis the difficulty index of 65 % items and discrimination index of 75 % items was in the acceptable range. The distractor efficacy showed that 9 out of 120 distractors needed revision.
Conclusions: Item analysis must be routinely implemented to validate MCQs’. The myths like shortfalls of MCQ framing, only four options in clinical setting or cueing effect are duly considered and the realities like strict and elaborate protocol for MCQ construction, stimulating critical and lateral thinking of students should be implemented. An integrated approach can help to achieve an ideal assessment tool for the benefit of students.
EnglishMCQ validation, Difficulty index, Discrimination indexINTRODUCTION
Evaluation is an important tool that guides student learning. Multiple choice questions form one of the tools for evaluation and are currently being widely used for assessment of medical graduates.1 Multiple choice questions are particularly useful to assess a large body of material for many students. A multiple-choice question (MCQ) consists of a stem with a question line at its end or underneath it, followed by a number of options. One of the options is correct or best response known as the key, while the others are described as distractors.1 Constructing a valid and effective MCQ is difficult task and needs a different approach. The methodical development of MCQ banks can be an asset which can lead to reliable assessment of students.2 Current widespread use of MCQs’ raises the issue regarding their validity and authenticity.3 Review of literature highlights different views regarding use of MCQ or combined approach of MCQ and free response essay type questions for better assessment of medical graduates. Considering the above issues the present study was focused on MCQ validation through item analysis. The importance of item analysis and the myths and realities concerned with MCQ as an assessment tool for medical students are discussed further.
MATERIAL AND METHODS
The study was conducted in the Department of Anatomy as a part of First Periodic Examination. Hundred First-year MBBS students were voluntarily involved in the study. They were given the MCQ test comprising of forty [40] questions with single best response. The MCQs’ were constructed to assess various levels of knowledge according to Bloom’s Taxonomy.Pre-validation of the MCQs’ was done by the Head of Department and other colleagues in the department. There was no negative marking and the time allotted was forty minutes. Evaluation was done out of forty marks and students were grouped as low, moderate and high achievers. Post validation of the MCQs’ was done by item analysis.4 The scores of all the students were arranged in such a way that there was order of merit.The students were divided into three groups according to their marks. Those students who belonged to the first group were considered as high achievers H [n=30] and those in the third group as low achievers L[n=30]. Each item was analyzed for the following;
• Difficulty Index or Facility value or p value was calculated using the formula p = H + L / N ×100, Where H= number of students answering the item correctly in the high achieving group L= number of students answering the item correctly in the low achieving group1 N= Total number of students in the two groups (including non-responders) Items having p value between 30 – 70% are considered as acceptable, among which items with p value between 50-60% are ideal while items with p value less than 30% (too difficult) and more than 70% (too easy) are not acceptable and need modification.1
• Discrimination index (DI) or d value was calculated using the formula d= H-L× 2/N Where the symbols H, L and N represent the same values as mentioned above. The DI or d value is a measure of the item to discriminate between students of higher and lower abilities and ranges between 0 and 1. In general‘d’ values between 0.20 and 0.35 is considered as good. Items having DI values more than 0.35 are considered to be excellent and those with less than 0.20 are considered poor.
• Distractor Effectiveness (DE) or Functionality of the distractors was calculated by observing how many students used the distractor in an item. If less than 5% of students used the option other than the key then that distractor is said to be a non- functional distractor [NFD]. On the basis of number of NFDs in an item, DE ranges from 0 to 100%. If an item contains three or two or one or nil NFDs then DE would be 0, 33.3%, 66.6% and 100% respectively.6
RESULTS
1] Difficulty Index of items analyzed After individually analyzing the items it was observed that the difficulty index (p value) of 26 items that means 65 % were acceptable. 11 items were too easy and 3 were too difficult hence 14 itemsthat means 35 %could be used after modification. [Table 1] 2] Discrimination index of items analyzed The discrimination index of 30 items [75 %] was acceptable but 10 items [25 %] need revision due to poor index. [Table 2] 3] Distractor efficacy [DE] based on number of NFDs’ As per tables 3, 4 and Graph 1, distractor efficacy was 100% in 24(60%) itemsand was 66.66% in 12(30%) items. So these questions can be added to the MCQ bank. In 3 items distractor efficacy was 33.33% hence their distractors should be modified and in 1 item having distractor efficacy 0%, its distractors should be either changed or the question should be discarded. Hence out of 120 distractors 9 needrevision. It was observed that higher the Difficulty Index, lower was the difficulty of the question. The Difficulty Index and Discrimination Indexwere often reciprocally related. Questions having a high p value (easier questions) discriminate poorly; while those with a low p value were good discriminators.
DISCUSSION
Good teaching is more a giving of right questions than a giving of right answers - Joseph Alberts The selection of an appropriate assessment method for students’ performances remains a daunting task for the teachers. In an attempt to change and upgrade the existing assessment tools MCQs’ are introduced at various levels and are used rampantly for regular assessments as well as important career deciding entrance examinations. A large number of educational research studies have demonstrated poor validity of MCQ’s. Barrows and Tamblyn in their book on Problem Based Learning mention, multiple choice and true/false questions under the heading “reliable evaluation tools with questionable validity”. 5 Item analysis is truly the assessment of the assessment tool itself.1 Post examination analysis of the MCQs helps to assess the quality of individual test items and test as a whole. Poor items can be modified or removed from the question bank. It also helps the teachers to identify the subject content which lacks understanding and need greater emphasis and clarity, by improving or changing the method- ology of teaching. In spite of validating the MCQ items by seniors and colleagues in the current study post validation systematic item analysis showed lacunae. The difficulty index was acceptable in only 65 % items while the discrimination index was acceptable in 75 % items. The distractor effectiveness also reflected need for revision in 9 out of 120 total distractors. Similar results were seen in different studies conducted for item analysis of MCQ. 6 They reveal that though item analysis was traditionally considered as tedious and time consuming task, the use of software applications such as Microsoft Excel has made it relatively easy and effective way to calculate various indices and test the validity of the items.7 Item analysis thus gives an insight and opportunity to revise and improve the MCQ and develop a valid question bank.1 MCQ- Myths and Realities There are many opinions and views of teachers as well as students regarding MCQ assessment and assessment in the form of short essay questions.8 This has led to the following discussion on the myths and realities about MCQs’. • MCQ as guess items assess only factual knowledge: One of the myth we frequently come across regarding MCQs’ is that they are multiple guess items3,6 which are useful to assess only factual recall of knowledge and higher orders of cognitive skills cannot be assessed. However the reality is MCQs’ can be framed and well validated in order to assess higher domains of Bloom’s taxonomy. Developing a good bank of valid and reliable multiple-choicetest items targeting higher cognitive abilities while conformingto item construction guidelines presents a big challenge to theitem developer.2 Yet in reality a dilemma remains during assessment because MCQs’ give four options to the students. Hence we cannot know exactly whether a particular question was answered by rapid retrieval of overlearned content or by purposeful relating of principles.9 • The MCQs’ challenge - Another widely prevalent myth regarding use of MCQ as an assessment tool is that MCQs’ are easy to frame and less time consuming. In reality it is a challenge for the teachers to construct ideal MCQs’ such that all options present as plausible answers. The distractors should be such that they attract students who do not know the answer while who know the right answer ignore them. • Cueing effect - MCQs’ are recently used in most of the entrance examinations at various levels. This has probably led to the myth that they are the best and fast method for assessment in competitive examinations. Multiple studies show that if same group of students are assessed by MCQ and free response tests all students scored higher in objective assessment. The cueing effect of readymade options available was thought to be the major factor.3,10,11 • Integrated approach- If we consider medical professional trainingit is mandatory that more emphasis be given to academic excellence and clinical competency. The medical students should be trained to evolve as problem solvers and not wait for situations with four options. Moreover there are certain clinical scenarios where there is one and only one diagnosis or some other conditions where there are more than four differential diagnoses which cannot be dealt with in an MCQ.The above dilemmas can perhaps be solved by introducing MCQs’ as a part of student assessment in undergraduate examinations more so in pre-clinical subjects. Some of the advantages in doing so are that the MCQs’ can be assessed rapidly with the aid of computers and softwares so can be employed when large number of students are to be assessed along with fast results and less error. They can provide highly structured and clear tasks with easy, objective and reliable scoring where legibility of handwriting doesn’t matter. Such data can be compared from class to class and year to year. Such assessment with MCQs’ can also be applied to certain clinically relevant topics like Paediatrics.12Later in the medical coursewhile using MCQ as an assessment tool for students they should undergo strict protocol for their framing, validation and selection.2 They should be overweighed by free response questions13 and newer ways of assessment to enhance critical thinking of students like case based learning, early clinical exposure, clinical scenarios and problem solving can be introduced. The MCQ test in entrance examinations can be supplemented with well-designed OSCE modules to assess students’ performances.14,15 In studies conducted by various authors16,17 it was seen that most of the students had a consistent performance in both objective and theory assessment. Interestingly it was also noticed that in some cases there was no correlation between MCQ and long essay scores for either the more competent students or the students who received failing grades. Thus, students’ grades determined by an examination format that includes both testing modalities may be different than the grades obtained by using only one of the modalities.18
CONCLUSION
Item analysis enhances the quality of MCQs’ which can help create an authentic and validated MCQ bank which can also assess higher orders of cognitive skills. The myths like shortfalls of MCQ framing, only four options in clinical setting or cueing effect must be considered during the use of MCQ as an assessment tool. The realities like strict and elaborate protocol for MCQ construction, integration with well designed free response and short essay type questions, stimulating critical and lateral thinking of students should be implemented. Sucha perspectivecan help to achieve an ideal assessment tool for the benefit of students at large.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/ editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. 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=228http://ijcrr.com/article_html.php?did=2281. Mehta G, Mokhasi V. Item analysis of multiple choice questions- an assessment of the assessment tool. Int J Health Sci Res. 2014; 4(7):197-202.
2. Sadaf S, Khan S, Ali SK. Tips for Developing a Valid and Reliable Bank of Multiple Choice Questions (MCQs). Educ Health 2012; 25:195-7.
3. Srivastava A, Dhar A, Aggarwal CS. Why MCQ? Indian J Surg 2004; 66:246-8.
4. Bloom, B., Englehart, M. Furst, E., Hill, W., and Krathwohl, D. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York, Toronto: Longmans, Green.
5. Barrows HS, Tamblyn RM. Problem based learning: An approach to medical education. Springer Publishing Company New York 1980.
6. Poulomi Mukherjee, Saibendu Kumar Lahiri. Analysis of Multiple Choice Questions (MCQs): Item and Test Statistics from an assessment in a medical college of Kolkata, West Bengal IOSRJDMS, Volume 2015; 14(12): 47–52.
7. Parag Chavda, Shobha Misra, Bithika Duttaroy. Item Analysis of MCQs’ South East AsianJourn al of Medical Education.2015; Vol. 9 (1):66-68.
8. Agu, A. U., Esom, E. A., Nto, J. N., Anyanwu, G. E., Ezugworie, J. O., Adiri, C. O. and Ozoemena, F. N. Students preference for various types of assessments in anatomy examination. International Journal of Development Research, 2014; Vol. 4 [7]:1377- 1379.
9. Elstein AS. Beyond multiple-choice questions and essays: The need for a new way to assess clinical competence. AcadMed 1993;68:244-9.
10. Baig M, Ali SK, Ali S, Huda N. Evaluation of Multiple Choice and Short Essay Question items in Basic Medical Sciences. Pak J MedSci 2014;30(1):3-6.
11. Walke YSC, Kamat AS, Bhounsule SA. A retrospective comparative study of multiple choice questions versus short answer questions as assessment tool in evaluating the performance of the students in medical pharmacology. Int J Basic Clin Pharmacol. 2014; 3(6): 1020-1023.
12. Duff, Jonathan P., et al. “Development and validation of a multiple choice examination assessing cognitive and behavioural knowledge of pediatric resuscitation: A report from the EXPRESS pediatric research collaborative.”Resuscitation 84.3 (2013): 365-368.
13. Newble DI and Jaeger K (1983). The assessment and examinations on the learning medical students. Medical Education; 17:165-171.
14. Gajjar S, Sharma R, Kumar P, Rana M. Item and test analysis to identify quality Multiple Choice Questions (MCQs) from an assessment of medical students of Ahmadabad, Gujarat. Indian journal of Community Medicine 2014;39:17-20.
15. Walubo A, Burch V, Parmar P, Raidoo D, Cassimjee M, Onia R, et al. A model for selecting assessment methods for evaluating medical students in African medical schools. Acad Med. 2003;78(9):899-906.
16. Singh, T. and Anshu (2012) Principles of Assessment in Medical Education, New Delhi: Jaypee Brothers Medical Publishers.
17. Anbar M. Comparing assessments of students’ knowledge by computerized open-ended and multiple-choice tests. Acad Med. 1991;66(7):420-2.
18. Khan MZ, Aljarallah BM. MEQs and MCQ as a tool for assessing the cognitive skills of undergraduate medical students. Int J Heal Sci.2011;5(1):45-50.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareASSOCIATION OF SERUM MAGNESIUM WITH GLYCEMIC CONTROL AND INSULIN RESISTANCE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
English1723A. VelayutharajEnglish R. SaraswathiEnglish R. ShivakumarEnglish S. SahaEnglish G. NiranjanEnglish R. RameshEnglish AR. SreenivasanEnglishBackground - Context: Magnesium is an essential intracellular cation involved in many carbohydrate oxidation enzyme reactions and in glucose transporting mechanisms besides its involvement in insulin secretion, binding and activity. Body concentrations of Mg++ lowered by poor glycemic control and may predispose for diabetic complications.
Objective: To compare the levels of serum magnesium in type 2 diabetes patients with glycemic control, insulin resistance and lipid profile.
Design, setting and patients: 90 type 2 Diabetes patients who are undergoing treatment protocol were followed by a tertiary care hospital and the correlation of serum magnesium levels assessed against indicators of glycemic control and insulin resistance.
Main outcome: Since hypomagnesemia is a prime risk factor for the development of micro and macro vascular complications, this study was undertaken to find out the association, if any, between hypomagnesemia, glycemic control, lipid profile and insulin resistance.
The results: A plasma Magnesium concentration of 40 (out of 90) type 2 diabetes patients in our study were below the reference range (mean 1.4±0.22 mg %). In patients with hypomagnesemia, the mean Glycated hemoglobin was 9.1±1.4%, which was 130% higher than the mean Glycated hemoglobin value in normomagnesemic patients (6.98±1%) and found significant inverse correlationship between GlycatedHb levels and Serum Magnesium levels at a value of -0.713 with a p value less than 0.01 and also showed significant correlationship with HOM Air values, Fasting blood glucose, and HDL-C levels and TAG levels.
Conclusions: There was a high prevalence of hypomagnesemia in patients with T2DM reduces insulin sensitivity and may increase the risk of secondary complications. And there was a direct correlation between HDL-C and Magnesium levels; hence it is advisable to periodically monitor plasma Mg++ concentrations in diabetic patients, especially those with other risk factors such as alcoholism, familial history of CVD, etc. to reduce future complications.
EnglishSerum magnesium, Insulin resistance, Glucose transporting mechanism, International diabetes associationINTRODUCTION
Diabetes mellitus (DM) is one among the major endocrine disorders that affects South Asians in general and Indians in particular because of the sedentary lifestyle, socio -economic status, ethnicity and the acquired changes in food habits of the Indians. Magnesium is the fourth most abundant cation in the body and plays an important physiological role as a cofactor in various enzymatic reactions involving energy metabolism includes carbohydrate oxidation , glucose transporting mechanism of the cell membrane and also involved in insulin secretion, binding, and activity. Chronic magnesium deficiency has been associated with the development of insulin resistance 1 Homeostatic model assessment for insulin resistance (HOMA-IR) may constitute a useful method for diagnosing insulin resistance as well as to aid the follow-up during the treatment of patients with T2DM and as an indicator of insulin resistance in diabetic patients has been the focus of attention in recent years2 . Glycosylated hemoglobin (HbA1c) measurements are the standard criteria for monitoring longterm glycemic control and reflect control for the previous 3 months. The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), and the International Diabetes Association (IDF) recommend the use of HbA1c assay in the diagnosis of T1DM and T2DM 3 . Hitherto, very few reports are available from South India and more specifically in the region of Trichirapalli, Tamilnadu implicating magnesium levels (in serum) glycemic control, lipid profile and insulin resistance hence we conducted this study. Aim and Objectives: The study aims to estimate the levels of magnesium in serum in patients with type 2 DM and find out any correlation, if any, between magnesium levels in serum, glycemic control and Insulin resistance and lipid profile. Materials and Methods: Patients with Type 2 DM were the subjects for the study. A detailed history of the patient was taken and the duration of the disorder documented. Co morbid status and complications of Type 2 DM were also noted. The patients were divided into three groups based on their glycemic control (Glycated hemoglobin), viz., good control, fair control and poor control (n=30 each). Total number of Cases (n) = 90. After informed consent blood sample for fasting plasma glucose (FPG) and insulin (FPI) serum magnesium, lipid profile and HbA1c (EDTA sample). Biochemical parameters are analyzed in BS380 auto analyzer and HbA1c analyzed by NGSP approved method. HOMA-IR calculated by = Fasting plasma glucose (mmol/l) x Fasting plasma insulin (mlU/l) / 22.5. Inclusion criteria: 90 diabetic patients (Type 2) in three groups (n=30 each) undergoing rationale drug therapy as per the established protocol followed in a tertiary care hospital diabetic clinic. Exclusion criteria: Type 1 DM , gestational Diabetes, specific types of diabetes , patients receiving magnesium therapy, diagnosed cases of osteomalacia, patients who are on diuretic therapy, chronic alcoholics and patients with clinically diagnosed / known micro or macrovascular complications . Results: Basic demographics - The present study included 90 patients, 60 males (66.7%) and 30 females (33.3%). The mean patient’s age was 50 years. The youngest patient was 28 years old and the oldest, 82 years old (Fig.1). The sample population had normal distribution of ages.
The normal serum magnesium level was considered to be between 1.7 to 2.7 mg/dl. Serum magnesium levels below 1.7 mg/dl were considered to be hypomagnesemia. In the present study, hypomagnesemia was detected in 40 patients out of 90 (44.4%) which is consistent with earlier reports of the prevalence of hypomagnesemia in diabetic patients (Fig.2). Pham et al had reported hypomagnesemia in 47.7% of non-hospitalized patients with diabetes mellitus4 . Most other studies had reported anywhere from 22 to as high as 43% prevalence.
We subjected the data obtained from our study to a vigorous .spearson correlation analysis using SPSS version 19 (IBM, Chicago, 2010) and found significant and very significant correlations between serum magnesium and other studied parameters. A p Value of less than 0.05 is considered significant and P values less than 0.01 were considered very significant. The low serum magnesium value recorded was 0.9 mg%, while the highest value was 2.40 mg%. The mean serum Mg++ value obtained was 1.77 (±0.38) mg%. Frequency of serum magnesium levels with gender (Fig.3). Glycated Hemoglobin levels measured in the whole study population ranged from 4.8 to 13.3% with a mean of 7.9±1.6 In patients with hypomagnesemia, the mean Glycated Hb was 9.1±1.4%, which was 130% higher than the mean Glycated Hb value in Normomagnesemic patients (6.98±1%). Except for one patient, all the rest had elevated Glycated Hb values above 5% of HbA1c (Fig.4). The mean fasting blood glucose was 156.4±53.7mg% and had a normal distribution over the study sample population (Fig.5). Plasma Insulin levels among patients showed a wide variation in our study with a mean of 14.5 and a standard deviation of as high as 13.57. The insulin levels were used to calculate the homeostatic model assessment (HOMA) indices that quantify Insulin resistance and beta cell function using the following formula: HOMA IR = Fasting Plasma Glucose (mg/dl) X Fasting Plasma Insulin (mu/L) / 22.5 A mean HOMA IR value of 5.4±5.1 mg/dL was obtained from our results (Fig.6) When Plasma Insulin was taken into consideration along with Glycated Hb and Serum Mg++, the correlation was strengthened by a factor of 12%). When HDL levels were correlated with Serum Magnesium, significant direct correlationship was obtained (Fig.10)
DISCUSSION
Hypomagnesemia is an important electrolyte abnormality observed in patients with type2diabetes mellitus. Magnesium depletion is described as the most under diagnosed electrolyte abnormality in current medical practice5 . In fact, the intracellular magnesium deficiency appears to be associated with an impaired function of several enzymes involved in glucose metabolism, which need high energy phosphate bonds and thus require Mg as a cofactor6 and this may lead to an impairment in insulin action and worsening of insulin resistance in diabetic and hypertensive patients 7 . A decreased magnesium status contributes to the development of insulin resistance, which in turn attenuates magnesium uptake in insulin-sensitive tissues. Moreover, low serum magnesium is a strong, independent predictor of the development of type 2 diabetes. In the USA, it has been established that 25 to 39 % of outpatient diabetics have low concentrations of serum Magnesium and several studies have shown lower serum concentrations in type 2 diabetics as compared to healthy controls. The results from the Atherosclerosis Risk in Communities (ARIC) study indicate low serum Magnesium to be a strong, independent predictor of the development of type 2 diabetes8 . Similar to findings from other countries in Europe, Asia and North America 9,10, the mean plasma Magnesium concentration was significantly lower ( overall ) in our study population of overt diabetes. In the present study, the significant correlation between HOMA IR and serum magnesium levels confirms the strong relationship with Insulin resistance (p< 0.05). The striking finding in this population was the high correlation of low plasma magnesium concentrations with high glycated Hb levels among the diabetic subjects. A plasma magnesium concentration of 40 (out of 90) diabetics in our study were below the reference range (mean 1.4±0.22 mg %), a prevalence of low magnesium status that is similar to that reported in type 2 diabetics from outpatient clinics elsewhere11. Senthil et al observed that hypomagnesemia was present in both controlled and uncontrolled diabetic patients12. Magnesium depletion has a negative impact on glucose homeostasis and insulin sensitivity in diabetics as well as on the evolution of complications such as retinopathy, thrombosis and hypertension13. Studies have shown that oral supplementation of magnesium chloride improves insulin sensitivity and glucose homeostasis 14 In human type 2 diabetics, Sheehan (1991) 15 found a significant inverse correlation between serum Mg and hypertriglyceridemia. In our study, there has been a strong positive correlationship between serum Mg++ levels and HDL levels and negative correlation with triacylglycerol levels when taken together attests to the importance of hypomagnesaemia in overall development of metabolic syndrome and future complications. And studies have shown that there is a direct and significant correlation between HbA1c and cholesterol, triglycerides, LDL-C & VLDL-C and inverse correlation with HDL-C16,17. Increased levels of total cholesterol, triglycerides with Hypomagnesemia are responsible for micro- and macrovascular complications in diabetes 18. And in diabetic patients with micro vascular complications had poorer glycemic control than patients without micro vascular complications19. And it is important to note that dietary intake of magnesium from food plus supplements has been associated with a decreased risk for metabolic syndrome, obesity or overweight, elevated blood pressure, and reduced HDL-cholesterol and with lower odds ratios with dietary supplements for elevated HbA1c, increased waist circumference & C-reactive protein.20
CONCLUSIONS
There was a high prevalence of hypomagnesaemia in patients with T2DM in our study population. Hypomagnesemia had shown a significant correlation with age, gender, Glycemic control, HOMA IR, triglycerides and HDL cholesterol in our study. Because of a decrease in magnesium levels reduces insulin sensitivity and may influence the risk of secondary complications, it is advisable in clinical practice to periodically monitor plasma magnesium in diabetic patients, especially those with other associated risk factors such as alcoholism, familial history of CVD, etc. If plasma Magnesium is low, an intervention to increase dietary intakes may be advisable in patients with DM and therapeutic for the prevention of future sequelae due to T2DM.
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. And authors here by declared that no conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=229http://ijcrr.com/article_html.php?did=2291. Chaudhary DP, Sharma R, Bansal DD. Implications of magnesium deficiency in Type 2 Diabetes. Biol Trace Elem Res 2010; May: 119 – 29.
2. Akira Katsuki, MD Yasuhiro Sumida, MD Esteban C. Gabazza, Shuichi Murashima Masahiko Furuta, Rika Araki-Sasaki, Yasuko Hori, Yutaka Yano. Homeostasis Model Assessment Is a Reliable Indicator of Insulin Resistance During Follow-up of Patients With Type 2 Diabetes; Diabetes Care February 2001 vol. 24 no. 2 362-65.
3. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. Jul 2009; 32(7):1327-34.
4. Pham, P.C., P.M. Pham, P.A. Pham, S.V. Pham, H.V. Pham and J.M. Miller, 2005. Lower serum magnesium levels are associated with more rapid decline of renal function in patients with diabetes mellitus type 2. Clin. Nephrol., 63(6): 429-36.
5. Paul Marino: Fluid and electrolyte disorders– Magnesium. The ICU Book, 2nd ed., Philadelphia, Lippincott, Williams and Wilkins 2004; 660-72.
6. Rosolova H, Mayer O, Jr. and Reaven G (1997) Effect of variations in plasma magnesium concentration on resistance to insulin-mediated glucose disposal in nondiabetic subjects. J Clin Endocrinol Metab 82, 3783-85.
7. Paolisso G and Barbagallo M (1997) Hypertension, diabetes mellitus, and insulin resistance: the role of intracellular magnesium. Am J Hypertens 10, 346-55.
8. Kao WH, Folsom AR, Nieto FJ, Mo JP, Watson RL and Brancati FL (1999) Serum and dietary magnesium and the risk for type 2 diabetes mellitus: the Atherosclerosis Risk in Communities Study. Arch Intern Med 159, 2151-59.
9. Nadler JL, Malayan S, Luong H, Shaw S, Natarajan RD, Rude RK. Intracellular free magnesium deficiency plays a key role in increased platelet reactivity in type II diabetes mellitus. Diabetes Care 1992;15:835–41
10. Ma J, Folsom AR, Melnick SL, Eckfeldt JH, Sharrett AR, Nabulsi AA, et al. Associations of serum and dietary magnesium with cardiovascular disease, hypertension, diabetes, insulin, and carotid arterial wall thickness: the ARIC study. Atherosclerosis Risk in Communities Study. J Clin Epidemiol 1995; 48:927–40.
11. Nadler JL, Rude RK. Disorders of magnesium metabolism. Endocrinol Metab Clin North Am 1995; 24:623–41.
12. Senthil Manikandan Thirumanilayur Jayaraman, Kannan Rajendran, Prasanna Karthik Suthakaran, Lal Devayani Vasudevan Nair, Lokesh Rajaram, Rajiv Gnanasekar, Rajendran Karuthodiyil.Study on serum magnesium levels and glycemic status in newly detected type 2 diabetes patients. Int J Adv Med. 2016; 3(1): 11-14
13. Mather HM, Levin GE, Nisbet JA. Hypomagnesemia and ischemic-heart-disease in diabetes. Diabetes Care 1982; 5:452–3.
14. Martha Rodriguez Moran, Fernando Guerrero –Romero .Diabetes care vol.26:4.April 2003 15. Sheehan JP (1991) Magnesium deficiency and diabetes mellitus. Magnes Trace Elem 10, 215-19.
16. Jain Meenu , Jadeja Jayendrasinh M , Mehta Neeta. Correlation between HbA1c Values And Lipid Profile In Type 2 Diabetes Mellitus. International Journal of Basic and Applied Physiology . 2013;Vol. 2 Issue 1;47-50
17. Netravathi Sajjan et al. A study of serum magnesium and dyslipidemia in type 2 diabetes mellitus patients. International Journal of Clinical Biochemistry and Research 2016;3(1):36-41.
18. Asha S Khubchandani*, Hiren Sanghani**Study of Serum Magnesium and HbA1C in Diabetic Patients along with Changes in their Lipid Profiles. Indian Journal of Clinical Practice, Vol. 23, No. 11, April 2013
19. Ramachandra Prabhu .H .D1 , Sruthi Kunche2 . Study of Serum Magnesium and HbA1c in Type 2 Diabetes Mellitus Patients .International Journal of Science and Research (IJSR).2013; Volume 4 Issue 6, June 2015 (2521-24).
20. Papanikolaou Y, Brooks J, Reider C, Fulgoni VL (2014) Dietary Magnesium Usual Intake is Associated with Favorable Diabetes-Related Physiological Outcomes and Reduced Risk of Metabolic Syndrome: An NHANES 2001-2010 Analysis. J Hum Nutr Food Sci 2(3): 1038.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareASSESSMENT OF PHYSICAL ACTIVITY LEVEL IN FEMALE STUDENTS OF RESIDENTIAL COLLEGE USING GLOBAL PHYSICAL ACTIVITY QUESTIONNAIRE: A CROSS SECTIONAL ANALYSIS
English2427Hiral ShahEnglish Hitarthi DhamiEnglish Tarpan ShahEnglishBackground: We are facing a rising trend of NCDs (Non-communicable diseases) associated with sedentary lifestyle. Students who are obese or develop obesity during college years are at increased risk for continued obesity throughout adulthood. Present study was conducted with an objective to study prevalence of sedentary lifestyle among college students and its epidemiological correlates, in particular with the association with hostel residence.
Methodology: Cross-sectional analysis of 50 female residential students of age ranged from 19-22 years was conducted for assessment of BMI and Physical activity level by Global Physical Acivity Questinnaire (GPAQ). Informed consent was obtained prior. From GPAQ questionnaire Physical activity level and BMI data was collected and analysis was done.
Result: Out of 50 subjects 26% subjects were having vigorous PA. 62% subjects were having moderate PA. 12% subjects were having low PA. Out of 50 subjects 42% subjects were in normal categories. 10% subjects were Overweight. 48% subjects were Underweight.
Discussion: In present study, reason for poor physical activity level in 12% students may be physical inactivity during the daily routine and travel domain. They can be encouraged to improve their physical activity level on daily basis. College activities should include compulsory extra-curricular activities to be undertaken by the students such as including sports, athletics, aerobics or yoga.
Conclusion: 12% subjects were found to have low PA. 10% subjects were Overweight. 48% subjects were Underweight. There is still a need to encourage students in residential college to be active on routine basis to prevent shattering burden of non-communicable diseases in society.
EnglishPhysical inactivity, Hostellers, NCDs, BMI, Physical activity level assessment, Physical activity level questionnaireINTRODUCTION AND BACKGROUND
Physical activity (PA) is a health enhancing behavior when practiced regularly, PA reduces the risk for a range of chronic disease. Also among the young, current and future health benefits can be obtained through engaging in physically active lifestyle. It helps building strong bones, healthy joints, a strong heart, a good mental health and prevents today’s major public health concern obesity. 1 College is a time of great change for young adults. Newly found independence allows the college student to make decisions and choices that were often previously made for him or her. One of the most important decisions a college student may make is how to incorporate physical activity (PA) into a busy lifestyle 2. After a decade into the 21st century, we are facing a rising trend of non-communicable diseases associated with sedentary lifestyle. Studies have shown sedentary lifestyles to be associated with an increased risk of cardiovascular diseases (CVD), and all-cause mortality. 1 Physical activity has been defined as ant bodily movement produced by skeletal muscle that results in energy expenditure. 3 Benefits of Physical Activity: Although gaps still exist in the literature, there is evidence that physical activity is an integral component of health and wellness in children. Potential benefits of physical activity include: Chronic disease risk reduction, Obesity risk reduction, Enhanced cognitive function and academic performance, Enhanced body image and self-esteem. 1
Recommended Daily Levels of Physical Activity for Children and Youth
Physical activity guidelines specifically targeted for children and youth are a relatively recent development. Since the early 1990s, recommendations for daily levels of physical activity for children and youth have been developed by a number of different governments, agencies and organizations.4, 5, 6 Some areas of consensus between the differing recommendations include the following: Children and youth should accumulate at least 60 minutes of physical activity on a daily basis. Youth should engage in a variety of different types and intensities of physical activity.Children and youth should be actively encouraged to reduce the amount of time spent in sedentary activities. Extended periods of time spent on sedentary pursuits are associated with decreased physical activity levels and an increased risk of overweight and obesity. Children and youth should participate in activities that are age appropriate.7 Physical Inactivity Studies have shown sedentary lifestyles to be associated with an increased risk of cardiovascular diseases (CVD), and allcause mortality. Some estimates from developed countries indicate that only 15% of the population older than 18 years of age get regular vigorous activity (three times a week for at least 20 min), and 60% report no regular leisure time activity at all, with 25% not active at all.1 Television is unquestionably a sedentary activity, and many studies have hypothesized that increase in television viewing may be partly to blame for reductions in PA.2 The students who are obese or develop obesity during the college years are at increased risk for continued obesity throughout adulthood.8 The apparent protective effect of being more active, and consequently less inactive, was identified first through studies of occupational activity over 50 years ago. Today, there is a significant amount of literature quantifying and qualifying the role of physical inactivity as a risk factor and worldwide interest and efforts to increase levels of participation.9 Obesity, physical inactivity and smoking are of public health concerns due to their association with chronic diseases such as heart disease, hypertension and type II diabetes. Regarding physical consequences, major health organizations have come to an understanding that obesity is linked to serious medical conditions including high blood pressure, high cholesterol, diabetes mellitus, heart disease, stroke, gallbladder disease, arthritis, sleep disturbances, breathing problems and cancer 7, 10, 11 There are many good sources of assessment of physical activity, in both youth and adults. There are many methods that can be used, including pedometer, accelerometers, questionnaires/surveys and diaries.12
Measuring Physical Activity in Youth
Self report instruments are a straightforward means for population health researchers to gather information on the physical activity levels of children and youth in school and colleges, and outside of school as well. These instruents are generally reliable and valid, are relatively simple and inexpensive to administer, and are appropriate for use in population studies.7 One of the subjective measures is GPAQ – GLOBAL PHYSICAL ACTIVITY QUESTIONNAIRE. The global physical activity questionnaire (GPAQ) was developed by World Health Organization (WHO) for PA surveillance in countries.13 GPAQ collects information on PA participation as well as sedentary behavior.14 The present study was conducted with an objective to study the prevalence of sedentary lifestyle amongst college students and its epidemiological correlates, in particular with the association with hostel residence.
MATERIALS AND METHODOLOGY
The study was a cross-sectional analysis of college students studying in college in Kadodara Surat. To have a representation of various academic disciplines, we purposively selected paramedical college students. The sample consisted of a total of 50 female residential students of age ranged from 19-22 years (mean 20 years). Students were approached randomly and were explained about the questionnaire. Students of the college present in the premises were eligible to participate, allowing for voluntary participation. Informed consent was obtained prior to conducting the interviews. To get an adequate representative sample, we targeted a minimum sample size of 50 students from the college.
Global Physical Activity Questionnaire (GPAQ)
The global physical activity questionnaire (GPAQ) was developed by World Health Organization (WHO) for PA surveillance in countries.13 GPAQ collects information on PA participation as well as sedentary behavior. This instrument was mainly developed for use in developing countries. The major strengths of GPAQ include the fact that it is domain specific, which implies that it assesses different types of PA undertaken in three domains plus sitting. The three domains include: Activity at work, travel to and from places and recreational activities.14 Here 50 subjects were taken. Questions were asked to them individually which are included in GPAQ Scale end by it, data was collected. According to it, MET minutes/week PA was calculated for all the participants. For the calculation of physical activity the following MET values are used: 13
RESULTS
Out of 50 subjects 26% subjects were having vigorous PA. 62% subjects were having moderate PA. 12% subjects were having low PA.
BMI
Out of 50 subjects 42% subjects were in normal categories. 10% subjects were Overweight. 48% subjects were Underweight.
DISCUSSION
In this study, 26% subjects were found to have vigorous PA, 62% subjects were having moderate PA. 12% subjects were having low PA. 42% subjects were found to be in normal category of BMI, 10% subjects in Overweight category and 48% subjects were in Underweight category. Using GPAQ scoring for calculating physical activity across the domains of work, transport and recreation, 13 (26%) students were found to have high physical activity, 31 (62%) had moderate while 6 (12%) had low activity level. Previous study comparing physical activity level in day scholers and hostellers has reported hostellers had significantly lesser physical activity compared to the day scholars in the transport domain and recreational domain (pEnglishhttp://ijcrr.com/abstract.php?article_id=230http://ijcrr.com/article_html.php?did=2301. Allison KR, Dwyer JJ, Makin S. Perceived barriers to physical activity among high school students. Prev Med 1999; 28: 608–615.
2. Anderssen N, Wold B. Parental and peer influences on leisuretime physical activity in young adolescents. Res Q Exerc Sport 1992; 63: 341–348.
3. Department of Health and Aging. Australia’s Physical Activity Recommendations for Children and Young People. On-line: Available: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-active-recommend.htm. (Retrieved: February 15, 2005).
4. National Association for Sport and Physical Education. Physical Activity for Children: A Statement of Guidelines for Children 5 - 12, 2nd Edition. On-line. Available at: http://www.aahperd. org/naspe/template.cfm?template=ns_children.html (Retrieved: February 19, 2005).
5. Health Development Agency. Recommended Amounts and Types of Physical Activity. On-line. Available at: http://www. hda.nhs.uk/html/improving/physicalactivity.html. (Retrieved: February 19, 2005).
6. National Centre for Chronic Disease Prevention and Health Promotion. Physical Activity and Health: A Report to the Surgeon General. Online. Available at: http://www.cdc.gov/nccdphp/sgr/ sgr.htm. (Retrieved February 18, 2005).
7. Bar-Or O, Foreyt J, Bouchard C, Brownell KD, Dietz WH, Ravussin E, Salbe AD, Schwenger S, St. Jeor S, Torun B. Physical activity, genetic and nutritional considerations in childhood weight management. Med Sci Sports Exerc 30: 2–10, 1998.
8. Anthsel KM, Anderman EM. Social influences on sports participation during adolescence. J Res Dev Educ 2000; 33: 85–94.
9. American College Health Association. American College Health Association-National College Health Assessment: Reference Group Data Report Spring 2008. Baltimore, MD: American College Health Association; 2008
10. National Centre for Chronic Disease Prevention and Health Promotion. Physical Activity and Health: A Report to the Surgeon General. Online. Available at: http://www.cdc.gov/nccdphp/sgr/ sgr.htm. (Retrieved February 18, 2005).
11. Canadian Association for Health, Physical Education, Recreation and Dance (CAHPERD). Position Statement on Quality Daily Physical Education (QDPE). On-line. Available at: http:// www.cahperd.ca/eng/physicaleducation/about_qdpe.cfm. (Retrieved February 18, 2005)
12. United States Department of Health and Human Services/United States Department of Agriculture. Dietary Guidelines for Americans (2005). On-line. Available at: http://www.healthierus.gov/ dietaryguidelines/. (Retrieved: February 15, 2005).
13. World Health Organization (2006). Global Physical Activity Questionnaire (GPAQ). Geneva: World Health Organization
14. Misra P, Upadhyay R, Krishnan A, Sharma N,Kapoor S. A Community Based Study to Test the Reliability and Validity of Physical Activity Measurement Techniques. Int J Prev Med. 2014 Aug; 5(8): 952–959.
15. Khera R, Sharma R. Physical inactivity among college students is associated with living in hostels: a study from Delhi, India. GJMEDPH, Vol 1(5) September- October 2012
16. World Health Organization. The global strategy on diet, physical activity, and health. World Health Organization; 2012 Available from: http://www.who.int/dietphysicalactivity/goals/en/ Accessed March 10, 2012
17. Kelishadi R, Ghatrehsamani S, Hosseini M, Mirmoghtadaee P, Mansouri S, Poursafa P. (2010). Barriers to physical activity in a population-based sample of children and adolescents in Isfahan, Iran. Int. J. Prev. Med. 1(2): 131–7, 2010
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareTHE ROLE OF DECOY CELLS IN URINE CYTOLOGY IN DETECTION OF POLYOMAVIRUS INFECTION IN POST RENAL TRANSPLANT PATIENTS
English2830Pavithra P.English Praveen S. KumarEnglishObjective: To assess the role of urine cytology as a simple and noninvasive tool in assessment of post renal transplant polyoma virus infection
Case Report: Polyoma virus BK can infect the renal transplant patients on immunosuppressive therapy resulting in progressive renal allograft dysfunction and graft loss. We report a case of 42 year old male who underwent renal transplant six weeks ago followed by immunotherapy, had signs of rejection in the immediate post- transplant period for which he was put on antithymocyte globulin. He now presented with dysuria and urine cytology was done. Viral cytopathic effect in the form of enlarged nucleus with basophilic viral intranuclear inclusions and ground glass chromatin known as “decoy cells” were seen.
Conclusion: Urine cytology can be used as a simple and cost effective screening method for monitoring the renal transplant patients for polyoma virus allograft nephropathy
EnglishPolyoma virus, Decoy, Renal transplant, Urine cytologyINTRODUCTION
Renal allograft recipients are at risk of reactivation of polyoma virus (PV) BK leading to derangement of renal function and allograft loss.[1] Since the pioneering study conducted by Coleman et al, urine cytology has been used as an inexpensive and efficient screening method to detect the cytopathic effect of PV BK in renal transplant patients. [2] The term “decoy cells”was coined for epithelial cells with polyoma viral inclusions in urine cytology specimens to avoid their misinterpretation as malignant cells.[3, 4] We present a case of polyoma viral changes in the epithelial cells of urine in a middle-aged male who underwent renal transplantation.
CASE REPORT
A 42 year old male underwent renal transplantation six weeks ago and was started on immunotherapy with triple immunosuppressants including tacrolimus, mycophenolate mofetil and steroids. Patient presented with signs of rejection in the immediate post- transplant period, for which he was put on antithymocyte globulin (ATG). The patient presented with dysuria and urinary tract infection. Urine samples were collected to rule out possible viral infection. Fresh urine sample was collected, cytospin smears were made, alcohol fixed and stained with Papanicolau stain. Smear showed epithelial cells with high nuclear cytoplasmic ratio, large intranuclear, smudgy ground- glass like viral inclusions characteristic of type I decoy cells ( > 10 decoy cells/ cytospin smear).(Figure 1) No cytoplasmic inclusions were seen. Serological tests for cytomegalovirus and adenovirus were negative. Polyoma virus infection was suspected, following which the dose of immunosuppressants was decreased along with a course of antibiotic and the patient showed improvement.
DISCUSSION
Primary polyomavirus infection occurs in early childhood and the virus remains latent in the urinary tract epithelium.
Three species, BK virus, JC virus and Simian virus (SV40) causes disease in humans. Immunosuppression of the allograft recipient can lead to reactivation of the infection and development of nephropathy resulting in allograft failure in 1- 5% of kidney transplant recipients. When reactivated, the virus proliferates within the nuclei of renal tubular and urothelial cells producing viral cytopathic effect manifested with nuclear enlargement and basophilic intranuclear inclusions. Such cells known as decoy cells can be identified by urine cytology. [5] Four morphological types of “Decoy cells” have been described in literature: Type 1- classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin; Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like; Type 3- multinucleated decoy cells with granular chromatin; Type 4- vesicular nuclei with clumped chromatin and nucleoli.[6] The urine samples can be classified semi quantitatively as: 1-4 infected cells per cytospin (1+), 5-10 infected cells per cytospin (2+), 11 infected cells per cytospin, but still representing a minority of the total cells in sediment (3+), and too many infected cells to count representing the majority of the cells in the sediment (4+).[7] Urine with large numbers of decoy cells (>10/cytospin), inflammatory sediments and biopsy proven PVN have been noted to have significantly greater decay in renal function than patients with no evidence of PVN. [8] Decoy cells should not be mistaken for malignant cells. Decoy cells are medium sized basophilic cells with cytoplasm like tail of a comet and nuclei with clumped ground glass like homogenous chromatin, where as malignant tumor cells have evenly distributed hyperchromatic chromatin with irregular nuclear membrane and little cytoplasm. [9,1] Drachenberg et al. observed that urine samples seem to be the most sensitive and cost effective screening method for PV infection. They also found that immunohistochemical stains are useful to confirm the presence of PV, but do not increase the sensitivity of diagnosis, hence should be used only after detection of decoy cells in urine. [8]
CONCLUSION
Urine cytology can be used as a simple and cost effective screening method for monitoring the renal transplant patients for polyoma virus allograft nephropathy. It can be conveniently used in centres lacking immunohistochemistry and molecular biology services.
ACKNOWLEDGEMENT
We acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. We are also grateful to the authors, editors and 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=231http://ijcrr.com/article_html.php?did=2311. Fogazzi GB, Cantu M, Saglimbeni L. Decoy cells in the urine due to polyoma virus BK infection: easily seen by phase contrast microscopy. Nephrol Dial Transplant 2001; 16: 1496-8.
2. Coleman DV, Mackenzie EF, Gardner SD, Poulding JM, Amer B, Russel WJ: Human polyoma virus BK infection and ureteric stenosis in renal allograft recipients. J Clin Pathol 1978; 31: 334- 8
3. Koss LG. On decoy cells. Acta Cytol 2005;49:233-4. [PUBMED]
4. DeMay RM. Urine: The art and science of cytopathology, Exfoliative Cytology. Chicago: American Society of Clinical Pathologists (ASCP);1996. p. 394-5
5. Vidas Z, Misic M, Pacic A, Jurenec F, Knotek M, Skelin IK. The value of urinary decoy cells finding in patients with kidney transplantation. Coll Anthropol 2010; 34(1): 153-7
6. Colvin RB, Nickeleit V. Renal transplant pathology. In: Jennet JC, Olson JL, Schwartz, Silva FG, editors.Heptinstall’s Pathology of the kidney. 6th ed. Philadelphia: William and Wilkins; 2007. pp. 1441–8.
7. Geetha V, Rao L, Monappa V, Susmitha MS, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr-Jun; 29(2): 133–134.
8. Drachenberg CB, Beskow CO, Cangro CB, Bourquin PM, Simsir A, Fink J, et al. Human polyomavirus in renal allograft biopsies: Morphological findings and correlation with urine cytology. Hum Pathol. 1999;30:970–7.[PubMed]
9. Drachenberg CB, Hirsch HH, Ramos E, Papadimitriou JC: Polyomavirus disease in renal transplantation – review of pathological findings and diagnostic methods. Hum Pathol 2005; 36: 1245-55.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareSTUDY OF OXIDATIVE STRESS PARAMETERS IN TYPE-II DIABETES MELLITUS AND THEIR CORRELATION WITH BLOOD GLUCOSE LEVEL
English3134Prakash P. Malam1English Anand J. Amin2English Ashish C. ZalaEnglish Vipul M. NavadiyaEnglish Dhruv PatelEnglish Dharna A. PatelEnglishObjective: Increasing evidence has underlined the importance of oxidative stress in the pathophysiology of type-II diabetes mellitus and its contribution to the associated complications. However the correlation between oxidative stress parameters and blood glucose levels is not clearly understood.
Method: Present study was done to evaluate the oxidative stress parameters in patients with type-II diabetes mellitus and to check the correlation, if any, between these parameters and blood glucose. Plasma malondialdehyde and superoxide dismutase levels were measured in thirty type-II diabetes mellitus and thirty normotensive subjects. Fasting and post-prandial blood glucose correlation was analyzed by Pearson’s correlation.
Result: Enhanced oxidative stress was observed in type-II diabetes mellitus subjects as denoted by raised plasma malondialdehyde levels and reduced superoxide dismutase levels.
Conclusion: Plasma malondialdehyde correlated positively whereas superoxide dismutase showed negative correlation with blood glucose in type-II diabetes mellitus subjects. No significant correlation was observed between these parameters and blood glucose levels in normotensive controls.
EnglishOxidative stress, Type-II diabetes mellitus, Correlation, Malondialdehyde, Superoxide dismutaseINTRODUCTION
Type 2 diabetes is caused by a combination of genetic and environmental factors. There are two main pathological defects in the disease, insulin resistance(a decreased ability of the peripheral tissues to respond to insulin) and b-cell dysfunction(an inability of the pancreas to provide sufficient insulin to compensate for insulin resistance)(1).Oxidative stress is currently suggested as a mechanism underlying diabetes and diabetic complications (2).Enhanced oxidative stress and changes in antioxidant capacity, observed in both clinical and experimental diabetes mellitus, are thought to be the etiology of chronic diabetic complications (3). Oxidative stress is defined as a state of imbalance between oxidants and antioxidants in favour of the oxidants, potentially leading to cellular damage(4).Oxidative stress in the pathogenesis of diabetes is suggested, not only by oxygen free-radical generation,but also due to nonenzymatic protein glycosylation,alteration in antioxidant enzymes(5),In addition to GSH, there are other defense mechanisms against free radicals like the enzymes superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (CAT) whose activities contribute to eliminate superoxide, hydrogen peroxide and hydroxyl radicals (6). Some study suggest that glipizide, metformin and rosiglitazone reduce some oxidative stress parameters in Type-II DM patients (7).Nevertheless,the available data is not conclusive and the association between human blood glucosee and oxidative stress remains to be elucidated.So the present study was undertaken to assess malondialdehyde and SOD activities in randomly selected normotensive and type-II diabetes mellitus subjects and to study the relationship, if any, between blood glucose levels and these biomarkers of oxidative stress.
MATERIALS AND METHODS
Cross sectional design was used for this study. The study protocol was approved by Institutional Ethics Committee.
Subjects
The study included thirty newly diagnosed type-II diabetes mellitus patients never treated previously for type-II diabetes mellitus.All patients were between the ages of 45 to 65 years. Thirty normotensive healthy volunteers served as controls. After explaining the study details, informed consent was obtained from all the participants.Patients with cerebrovascular or coronary artery disease, congestive heart failure, hypertensive, renal or liver disease and any active viral or bacterial infection were excluded from the study. Smokers, alcoholics and subjects taking any medication known to affect oxidative stress were also excluded.
Samples
After enrollment, 5 ml venous blood sample was collected in Na-EDTA (1 mg/ml) tubes from each subject and entrifuged immediately at 3000 rpm for 15 minutes. The separated plasma was used for estimation of MDA. Cells were washed with normal saline three times and RBCs were subjected to lysis by adding 3 ml ice cold distilled water. Hemolysate was then precipitated by adding 1 ml ethanol and 0.6 ml chloroform. The mixture was mixed thoroughly on vortex and centrifuged at 3000 rpm for 15 minutes. Supernatant was used for estimation of SOD activity.
Methods
Plasma MDA was estimated as per the method described by Ohkawa,(8) 0.5 ml plasma, 0.5 ml of normal saline, 1 ml of 20% trichloroacetic acid (TCA) and 0.25 ml TBA reagent were added in a test tube and kept in a boiling water bath at 95?C for one hour. The tube was centrifuged at 3000 rpm for 10 minutes and optical density of supernatant was measured in a spectrophotometer at 535 nm. MDA level was expressed in terms of nmol/ml of plasma. SOD activity was measured by method of Marklund and Marklund (9) with some modifications described by Nandi and Chatterjee.(10) Briefly, 50 μl hemolysate was added to 1ml of air equilibrated Tris-HCl buffer (pH 8.2) in a cuvette and allowed to incubate at room temperature. The reaction was started by adding 10 μL of freshly prepared 2.6 mM pyrogallol solution (252 mg pyrogallol and 10 μM HCl added to 100ml distilled H2O). The rate of increase in the absorbance was recorded for a period of 2 minutes, from 1 minute 30 sec to 3 minute 30 sec at 420 nm. The 50% inhibition of autooxidation of pyrogallol was measured and activity of SOD was expressed as U/gHb.
Statistical analysis
Data were expressed as mean ± SD. Student t test was used to assess statistical differences between the groups. Blood glucose and their parameters was anlyesed by pearson’s correlation . Differences were considered statistically significant at p < 0.05.
RESULTS
Thirty type-II diabetes mellitus and thirty age matched normotensive controls were included in the study. Baseline characteristics of both groups are shown in table 1. In type-II diabetes mellitus group, FBS and PP2 BS were significantly higher than the control group (p < 0.001) (Table 1). Levels of oxidative stress biomarkers in both groups are shown in Table 2. Plasma MDA was increased significantly in type-II diabetes mellitus group compared to controls (p < 0.01). The activity of SOD was significantly lower in type-II diabetes mellitus group (p < 0.01).
We further studied the relationship between these two parameters and blood glucose levels in both groups. Pearson correlation coefficients between the different parameters assessed and FBS and PP2 BS. Plasma MDA correlated positively with FBS and PP2 BS in type-II diabetes mellitus subjects (fig. 1b). SOD showed negative correlation with FBS and PP2 BS in type-II diabetes mellitus subjects (fig 2b). No correlation was observed between any of these parameters with FBS and PP2 BS in controls (fig 1a and 2a).
DISCUSSION
The present study was done to evaluate the oxidative stress parameters in the patients with type-II diabetes mellitus and to assess the relationship, if any, between these parameters and blood glucose levels. We observed that malondialdehyde levels were significantly raised in the patients of essential type-II diabetes mellitus and there was concomitant reduction of antioxidant enzymes superoxide dismutase. Increased production of free radicals together with increased lipid peroxidation and decreased antioxidant enzymes in type-II diabetes mellitus was demonstrated in previous studies.13,14 It is suggested that in type-II diabetes mellitus, activation of enzymes involved in free radical synthesis leads to overproduction of superoxide anion, hydrogen peroxide and other reactive oxygen species.(11) Due to their highly reactive nature and nonspecific binding, ROS can attack almost all biomolecules including lipid membranes. MDA is a product of long chain fatty acid peroxidation that accumulates due to increased oxidative stress. MDA further accelerates peroxidation itself by synergizing with free radicals.16 Superoxide dismutase and catalase are among the primary antioxidant defense against oxidative stress. Augmented expression of these enzymes may be expected in face of increased production of reactive oxygen species in type-II diabetes mellitus . However, the decreased level of antioxidant enzymes observed in the present study may be explained by the fact that excessive ROS inactivate these enzymes and also suppress the expression of genes encoding for these enzymes.(12) The present study showing statistically significant increase in MDA and concomitant decrease in antioxidant enzyme levels in type-II diabetes mellitus patients confirms the results of previous studies. However whether oxidative stress is the cause or the consequence of type-II diabetes mellitus is not clear and it needs further evaluation. We further examined the possible relationship between these parameters and FBS and PP2 BS levels. Positive correlation was observed between plasma malondialdehyde and blood glucose levels in typeII diabetes mellitus subjects. A negative correlation was observed between antioxidant enzyme levels and blood glucose in type-II diabetes mellitus subjects. These results suggest that the generation of free radicals increases proportionately with rise in blood glucose levels above normal. These findings point to the fact that severity of oxidative stress parallels the degree of rise in blood glucose in patients with type-II diabetes mellitus . The correlation observed in this study assumes a great importance due to the fact that oxidative stress contributes to the complications of type-II diabetes mellitus including retinopathy, neuropathy and nephropathy. Thus it seems logical that normalization of blood glucose may considerably check oxidative stress and reduce the complications of type-II diabetes mellitus.17 In view of their ability to decrease the vascular oxidative stress in addition to their blood pressure lowering effect these agents may prove beneficial in long term treatment of type-II diabetes mellitus .
CONCLUSION
Oxidative stress is increased in patients with type-II diabetes mellitus as videnced by the significant changes in the levels of oxidative stress parameters. Moreover, these parameters correlate with the blood glucose in type-II diabetes mellitus . Thus attempts to lower blood pressure could prove beneficial in such patients by reducing the oxidative stress related long terms complications. Funding: No funding sources Conflict of interest: None declared Ethical approval: The study was approved by the Institutional Ethics Committee
ACKNOWLEDGMENTS
We thank the medical record in charge and staff of hospitals for their co-operation and support during the study and also patient who participate in this study
Englishhttp://ijcrr.com/abstract.php?article_id=232http://ijcrr.com/article_html.php?did=2321. Hales CN. The pathogenesis of NIDDM. Diabetologia. 1994 Sep;37 Suppl 2:S162-8. PubMed PMID: 7821732. Epub 1994/09/01. eng.
2. Gutteridge JM, Halliwell B. Comments on review of Free Radicals in Biology and Medicine, second edition, by Barry Halliwell and John M. C. Gutteridge. Free Radic Biol Med. 1992;12(1):93-5. PubMed PMID: 1537574. Epub 1992/01/01. eng.
3. Baynes JW. Role of oxidative stress in development of complications in diabetes. Diabetes. 1991 Apr;40(4):405-12. PubMed PMID: 2010041. Epub 1991/04/01. eng.
4. Sies H. Oxidative stress: introductory remarks. Oxidative stress. 1985:1-8.
5. Strain JJ. Disturbances of micronutrient and antioxidant status in diabetes. Proc Nutr Soc. 1991 Dec;50(3):591-604. PubMed PMID: 1809968. Epub 1991/12/01. eng.
6. Soto C, Recoba R, Barron H, Alvarez C, Favari L. Silymarin increases antioxidant enzymes in alloxan-induced diabetes in rat pancreas. Comp Biochem Physiol C Toxicol Pharmacol. 2003 Nov;136(3):205-12. PubMed PMID: 14659454. Epub 2003/12/09. eng.
7. Baynes JW, Thorpe SR. Role of oxidative stress in diabetic complications: a new perspective on an old paradigm. Diabetes. 1999;48(1):1-9.
8. Ohkawa H, Ohishi N, Yagi K. Assay for lipid peroxides in animal tissues by thiobarbituric acid reaction. Anal Biochem. 1979;95(2):351-8.
9. Marklund S, Marklund G. Involvement of the superoxide anion radical in the autoxidation of pyrogallol and a convenient assay for superoxide dismutase. Eur J Biochem. 1974 Sep 16;47(3):469-74. PubMed PMID: 4215654. Epub 1974/09/16. eng.
10. Nandi A, Chatterjee I. Assay of superoxide dismutase activity in animal tissues. J Biosci. 1988;13(3):305-15.
11. Rolo AP, Palmeira CM. Diabetes and mitochondrial function: role of hyperglycemia and oxidative stress. Toxicol Appl Pharmacol. 2006 Apr 15;212(2):167-78. PubMed PMID: 16490224. Epub 2006/02/24. eng.
12. Lipinski B. Pathophysiology of oxidative stress in diabetes mellitus. J Diabetes Complications. 2001 Jul-Aug;15(4):203-10. PubMed PMID: 11457673. Epub 2001/07/18. eng.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareCLINICO-EPIDEMIOLOGICAL PROFILE OF PATIENTS PRESENTING WITH ACUTE POISONING
English3541Shreya M. ShahEnglish Pratik D. AsariEnglish Anand J. AminEnglishObjectives: The present study was conducted with aim to generate the clinico-epidemiological data of Acute Poisoning cases presented at hospital which in turn would be helpful in planning rational use of available resources for prevention and management of poisoning cases.
Methods: Observational cross-sectional study was carried out from October, 2013 to March, 2014. Patients of either sex of above 12 years of age of acute poisoning admitted in medicine emergency ward were included. Obtained data were analyzed using descriptive statistics and results were expressed as percentage and mean.
Results: Of 340 cases, male and female patients were 216(63.53%) and 124(36.47%) respectively. Male: female ratio was 1.74:1. Most of the cases belonged to the age group of 21-30 years (38.82%). Ingestion was the most common route of exposure (71.47%). Intentional (suicidal) poisoning was recorded in 62.06% cases followed by accidental poisoning (37.94%). Common causes of poisoning were poisonous bites (25.88%) followed by organophosphate (19.41%) and unknown compound (19.41%) ingestion. Commonly observed symptoms were vomiting, local symptoms in cases of bites, altered sensorium, giddiness and breathing difficulty. Average number of days of hospitalization was 5.39 days. Complete recovery and mortality were seen in 66.47% and 16.47% cases respectively.
Conclusion: Acute Poisoning is one of the leading causes of hospital admissions and mortalities. High costs of treatment and intensive care burden makes poisoning an important area for further research. The current study has managed to contribute substantial additional information regarding the epidemiology and outcome of poisoning in a tertiary care hospital at a district level.
EnglishAcute Poisoning, Clinico-epidemiological profile, Medicine emergency, PoisoningINTRODUCTION
Acute Poisoning is a common medical emergency. Poison is a substance that causes damage or injury to the body and endangers one’s life due to its exposure by means of ingestion, inhalation or contact.1 Acute poisoning due to accidental and suicidal exposure causes significant mortality and morbidity throughout the world.2 According to World Health Organization (WHO) estimates, in 2004, 346,000 people died worldwide from unintentional poisoning of which 91% occurred in developing countries.3 Easy availability of poisonous substances and sparse medical facilities result in a high fatality rate in the developing world. According to recent data from National Crime Bureau of India, accidental poisoning accounted for 17.9% of all causes of un-natural deaths while consuming of poison (26%), was observed for committing suicidal death during the year 2014.4 Acute poisoning cases account for 2-3% of all hospital admissions in India.5 Cases of poisoning are more common in India than the west countries, owing to the ease with which poisons can be obtained, increasing use of chemicals for industrial and domestic purpose, quack remedies containing poisonous drug and frequent occurrences of bites by venomous snakes.6 In India, due to wide geographical variation and vast differences in socio-economic status and cultural practice, the type of poisoning cases encountered in clinical practice differ in different states. So there is a need to collect accurate data on different aspects of acute poisonings. The present study was conducted with aim to generate the clinico-epidemiological data of Acute Poisoning cases pre sented at hospital which in turn would be helpful in planning rational use of available resources for prevention and management of poisoning cases.
MATERIAL AND METHODS
An Observational cross-sectional study was carried out to assess the clinico-epidemiological data of acute poisoning cases admitted in emergency ward of a tertiary care teaching hospital attached to Medical College in Gujarat during October, 2013 to March, 2014. Approval of the institutional ethics committee was obtained before initiating the study. All patients of either sex of acute poisoning admitted in medicine emergency ward, who were above 12 years of age, were included in this study after taking patient’s/ relatives’ verbal consent. Patients of 12 or less than 12 years of age and cases where diagnosis was uncertain were excluded from the study. Data of total 340 acute poisoning cases were collected and were entered in prechecked proforma. These cases were evaluated and observed in the medicine emergency ward, Medical Intensive Care Unit (MICU) and followed up in respective medicine unit wards till their discharge or fatal outcome, as applicable. The data included name and age of the patient, date of admission and discharge, case history, investigations, diagnosis, ongoing treatment and outcome. The data obtained were subsequently analyzed using descriptive statistics and the results were expressed as percentage and mean.
RESULTS
Of 340 cases, male patients were 216 (63.53%) and female patient were 124 (36.47%) with male: female ratio 1.74:1. Most of the cases belonged to the age group of 21-30 years (38.82%) followed by 31-40 years (20.29%) and 13-20 years (18.53%) [Table1]. In this study, the youngest patient was of 15 years of age while the oldest patient was 85 years old. 31.95 + 12.86 years was mean age of all patients. Mean + SD of age of male and female patients were 31.17 + 11.79 years and 33.3 + 14.50 years respectively. Among various routes of exposure for poisons, ingestion was the most common route of exposure (71.47%) followed by dermal (in cases of bites) (25.88%) and inhalation (2.65%). Intentional (Suicidal) poisoning was recorded in 62.06% cases followed by accidental poisoning in 37.94% cases. Out of 340 cases, 25.88% cases were due to poisonous bites which included snake bite, honey bee sting, scorpion bite, nevla bite and unknown bite. Organophosphates and unknown compounds were causative agents in 19.41% cases each. Different causative agents observed during study were as shown in Table 2. Commonly observed symptoms among 340 poisoning cases were as shown in Table 3. Average number of days of hospitalization was 5.39 days per cases. Maximum 38 days of hospitalization was observed in a case of acid compound poisoning. For all patients who were discharged or who died within 24 hours of admission, hospital stay was counted as 1 day [Figure 1]. Complete recovery was seen in 66.47% of cases. Mortality (death) was seen in 16.47% of cases. Other outcomes of poisoning were Discharge against Medical Advice (DAMA) (10.59%), Absconded (5.88%), and Discharge On Request (DOR) (0.59%). Out of 56 death cases, 51 cases were of due to suicidal poisoning and 5 were due to accidental poisoning. Deaths occurred due to different causative agents as shown in Table 4.
DISCUSSION
Of total 340 cases included in this study, male patients were 63.53% and female patients were 36.47% which is similar to findings of B. Maharani et al. (2013) [61.33 % male, 38.63% female] and Peshin SS et al. (1999-2012) [62.19% male, 37.80% female].2,7 Similar male preponderance was seen in other published studies also.8-12 Male preponderance found in the poisoning cases may be because of more exposure to stress in a daily routine life and also because of more occupational hazards than female. However, in few studies, more female patients compared to male patients of poisoning were reported.13, 14 In present study, most of the cases were between 13-40 years of age (77.64%), among which 38.82% patients belonged to 21-30 years of age group. Srivastava A et al.(2005) in their study observed highest incidence of acute poisoning in 14-40 years of age group.15 In a study done in Yavatmal, Vaidya and Hulke et al. (2012) reported maximum poisoning cases in 21-30 years age group (34.50%) followed by 24.53% cases in 31-40 years and 23.23% cases in 11-20 years age group.14 Similar trend of age group distribution of poisoning cases was reported in different studies carried out in Nepal, Sri Lanka and Uganda.14 This trend of highest number of cases in 21-40 years of age group is due to more work pressure, family problems, economical stress and other life settlement problems in this age group.
Ingestion was the most common route of exposure (71.47%) followed by dermal and inhalation. Dermal exposure was seen only in cases of poisonous bites in present study. Similar pattern of route of exposure was reported in study by Srivastava A et al. (2005)15 [88% oral route] and also in other studies.2, 16, 17
Intentional (Suicidal) poisoning was recorded in 62.06% cases followed by accidental poisoning (37.94%). Ramesha KN et al. reported 78% patients of intentional poisoning and 22% patients of accidental poisoning.18 Result of data analysis of poisoning cases reported to the National Poisons Information Centre, New Delhi showed that nearly half (47%) of poisoning cases were accidental (1-70 age group).15 Accidental poisoning is more common in pediatric age group which we have excluded from this study. This may be a possible reason for less accidental poisoning cases in present study compared to national data for India in which cases of all age groups were reported. Out of 216 male patients intentional poisoning was observed in 67.12% male patients; while for female patients, it was 53.22%. Intentional poisoning was more in males in present study. This finding was similar with other studies done by Sharma et.al(2002), Dash et al. (2005) and Singh et al. (1984) but contradicts the study done by Pokhrel et al.(2008) in which incidence was high among females.2 While analyzing data for causative agents for poisoning, we found that 1/4th (25.88%) of all cases were due to poisonous bites and 19.41% cases were of Organophosphate poisoning, which is parallel to findings of the study by Banerjee I et al. (31.90% snake bite, 21.84% organophosphorus compounds).13 In the study conducted by Ramesha KN et al., majority of poisoning cases were due to OP compounds (36%) followed by snake bite in 16.2%.18 In studies carried out at different centers in South India, organophosphate compounds were found to be the commonest causative agents for poisoning, while the incidence of aluminium phosphide poisoning was found to be high in North Indian studies.2 Higher incidence of snake bite cases in present study can be because of geographical location of our tertiary care hospital where snake bite incidence is high. Another possibility for this can be the fact that the study period was harvesting season. Providing symptomatic and specific antidote treatment and supportive care for the patient was the mainstay of management in the majority of poisoning cases observed during study. Days of hospitalization in present study ranged from 1 to 38 days with an average of 5.39 days per patient. In the study conducted by Vaidya and Hulke et al., observed duration of hospital stay varied from 1 to 5 days.14 Mortality (death) was recorded in 16.47% of patients. In studies by Vaidya and Hulke et al., Ramesha KN et al. and Singh S et al. overall mortality were found to be 20%, 15.4% and 17.3% respectively.14, 18, 19 Incidence of death as high as 16.47% observed in this study can be result of one or more factors operating in individual patients like time lapsed between consumption of poison and hospital admission and lake of information of the poison consumed/ingested. Many patients were referred from private hospital when their conditions became worse. Recovery in 2/3rd of patients (66.47%) is a result of good emergency and intensive care management at our hospital set up. Few of the limitations of the present study were poor documentation of data mainly because of scarcity of better trained staff and exclusion of poisoning cases in children less than 13 years age. Also, as the study was conducted at a single hospital for a short duration, results cannot be generalized.
CONCLUSION
Acute Poisoning is one of the leading causes of hospital admissions and mortalities. High costs of treatment and intensive care burden makes poisoning an important area for further research. The current study has managed to contribute substantial additional information regarding the epidemiology and outcome of poisoning in a tertiary care hospital at a district level. Educational programs with emphasis on preventive measures are necessary to create awareness among the general public.
ACKNOWLEDGMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Funding and support: None. Conflict of interest: None.
Englishhttp://ijcrr.com/abstract.php?article_id=233http://ijcrr.com/article_html.php?did=2331. Thomas W F, John H D, Willium R H. Stedman’s medical dictionary. 28th edition. Lippincott William and wikins, Newyork. (2007)2004.
2. B. Maharani and N. Vijayakumari., Profile of poisoning cases in a Tertiary care Hospital, Tamil Nadu, India. J App Pharm Sci. 2013; 3 (01): 091-094.
3. World Health Organisation. International Programme on Chemical Safety. Poisoning prevention and management. Available from: http://www.who.int/ipcs/poisons/en.
4. New Delhi: National Crime Records Bureau Ministry of Affairs; 2014. Accidental Deaths and Suicides in India 2014. Available from: http://ncrb.nic.in/ADSI2014/adsi-2014%20full%20report.pdf
5. Chadha IA. Poisoning. Indian J Anaesthesia 2003;47(5):402- 411.
6. Subrahmanyam BV. Poisons and there medico legal aspects. In: Modi’s Medical Jurisprudence and Toxicology. 22nd edition. New Delhi: Lexis Nexis Butterworth Tripathi Publication; 2002. edition New Delhi :48 Peshin SS, Srivastava A, Halder N, Gupta YK. Pesticide poisoning trend analysis of 13 years: a retrospective study based on telephone calls at the National Poisons Information Centre, All India Institute of Medical Sciences, New Delhi. J Forensic Leg Med. 2014 Feb;22:57-61
7. Lall, S.B., S.S. Al-Wahaibi, M.M. Al-Riyami and K. Al-Kharusi, 2003. Profile of acute cases presenting to health centres and hospital in Oman. Eastern Mediterranean Health J., 9:944-954.
8. Kanchan, T. and R.G. Menezes, 2008. Suicidal poisoning mortalities in southern India: gender differences. J. Forensic, Leg. Med., 15:7-14.
9. Al-Barraq, A. and F.Farahat, 2011. Pattern and determinants of poisoning in a teaching hospital in Riyadh, Saudi Arabia. Saudi Pharma. J.,19:57:63.
10. Rajanandh M. G., Santhosh S., Ramasamy C. Proospective Analysis of Poisoning Cases in a Super Speciality Hospital in India. Journal of Pharmacology and Toxicology.2013;8(2):60-66.
11. Rajanandh M. G., Santhosh S. Retrospective Assessment of Poisoning Cases in a Multi Specialty Hospital in Tamilnadu. Journal of Pharmacology and Toxicology. 2014;9(2):105-109.
12. Banerjee I, Tripathi SK, Roy AS. Clinico-epidemiological profile of poisoned patients in emergency department: A two and half year’s single hospital experience. Nt J Crit Illn Inj Sci. 2014 Jan-Mar; 4(1): 14–17.
13. Vaidya YP, Hulke SM. Study of trends of poisoning in the cases reported to government hospital, Yavatmal. Chron Young Sci 2012;3:63-7.
14. Srivastava A, Peshin SS, Kaleekal T, Gupta SK. An epidemiological study of poisoning cases reported to the National Poisons Information Centre, All India Institute of Medical Sciences, New Delhi. Hum Exp Toxicol. Jun 2005;24(6):279-85.
15. Jesslin j, R. Adepu, S churi. Assessment and Prevalence and mortality incidences due to poisoning in south indian tertiary care hospital. Indian J. Pharm sci.2010;72;5,587-591.
16. Anthony L, Kulkarni C. Patterns of poisoning and drug overdosage and their outcome among in-patients admitted to the emergency medicine department of a tertiary care hospital. Indian J Criti Care Med 2012; 16: 130-5.
17. Ramesha K.N., Krishnamurthy B. H. Rao, Ganesh S. Kumar. Pattern and outcome of acute poisoning cases in a tertiary care hospital in Karnataka, India. Indian J Crit Care Med. July-September 2009 ;13(3):152-155.
18. Singh S, Shama B K, Wahi P L, Anand B S, Chugh K S. Spectrum of acute poisoning in adults(10 year experiences). Journal Assoc. Physician India. 1984; 32: 561-563
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareSYNTHESIS AND APPLICATIONS OF SUGAR FLUORINATED NUCLEOSIDES
English4249Mohamed Ibrahim ElzagheidEnglishIn this review, different methods that have been used for the synthesis of 1’-, 2’-, 3’-, 4’- and 5’-sugar fluorinated nucleosides and their analogous are presented and different fluorinating agents are listed. Highlighted examples of the sugar fluorinated nucleosides that make a great impact on chemistry, biochemistry, and drug discovery are also elaborated. This review has shown that introduction of a fluorine atom in different positions within the sugar structure of the nucleoside improves their reactivity and properties.
EnglishNucleosides synthesis and applications, Sugar fluorinated nucleosides, Fluorinating agentsINTRODUCTION
Fluorinated nucleosides attracted many medicinal chemists because of their promising medicinal applications. They play a major role in interrupting the replication of cancer cells or viruses [1-3].A great intention was given by chemists to the introduction of fluoro group into sugars and nucleosides and different methods for the formation of fluorine carbon bond have been developed [4-7]. It is believed that the inherited biological activity of the fluorine incorporated nucleosides may be due to the electronegativity of fluorine and the strength of the carbon-fluorine bond. Strong electronic character of fluorine can alter the electronic properties of the nucleosides and induce interesting biophysical properties to the sugar-fluorinated nucleosides [8]. They can also be used as building blocks in oligonucleotides [9]. The synthesis of fluorinated nucleosides (by introduction of fluorine atom at 1’, 2’, 3’, 4’, and 5’ positions) can be achieved, by different fluorinating agents (Figure 1), through selective fluorination of nucleosides or by glycosylation of nucleic acids bases (nucleobases) with fluoro-sugar derivatives [10-14]. There are six reported methods for the synthesis of sugarfluorinated nucleosides (Figure 2). These are:
1. Epoxide cleavage by fluoride ions: This reaction has been used for the synthesis of 9-(3-deoxy-3-fluoro-β- D-xylofuranosyl) adenine 1 [15], and 9-(3-deoxy-3- fluoro-β-D-arabinofuranosyl) adenine 2 [16].
2. Displacement of sulfonyloxy group by fluoride ions: This reaction has been used for the synthesis of 5’-fluronucleosides because displacement of 5’-sulfonates with fluorine is more easily achieved than the same reaction with 2’- or 3’-sulfonates. A good example is the synthesis of 9-(3, 5-dideoxy-5-fluoro -β-D-ribofuranosyl) adenine 3 [17].
3. Fluorine anhydro ring opening: This reaction has also been used for the introduction of fluorine in 2’- and 3’-postitions: A good example is the synthesis of 1-(2-deoxy-2-fluoro-β-D-ribofuranosyl) uracil 4 [18] and 1-(3-deoxy-3-fluoro-β-D-ribofuranosyl) uracil 5 [18].
4. One step exchange of hydroxyl group by fluorine: This has been achieved by treating desired sugar with diethylaminosulfurtrifluoride, DAST, or [bis (2-methoxyethyl)-amino] sulfurtrifluoride, MAST, then coupling the brominated fluorosugar with the nucleobases [10]. A good example is the synthesis of 9-(2-deoxy-2-fluoro-β-D-arabinofuranosyl) purine 6 [10].
5. Sequential photo-bromination and fluorination: In this method desired sugar was treated with N-bromosuccinimide, NBS, followed by fluorination with silver tetrafluoroborate (AgBF4 ) [19]. A good example here is the synthesis of 4’-fluoroadenosine 7.
6. Electrophilic fluorination of the nucleoside 1’-position: in this synthesis treatment of the 1’-lithium enolate, prepared from the 2’-ketoderivative, with N-fluorobenzenesulfonimide (NFSI) or 1-Chloromethyl-4-fluoro-1, 4-diazoniabicyclo [2.2.2] octane bis (tetrafluoroborate) (Selectfluor) , followed by reduction of the 2’-keto-moeity gave the 1’-fluorouridine derivatives [20, 21]. A good example is the synthesis of 1’-fluorouridine 8 (unprotected nucleosides was not successfully isolated because of the instability.
Although excellent reviews on the synthetic aspects of the fluorinated nucleosides have been published [12, 22],some of them were long and sometimes confusing. Our present review is short, clear and to the point. We tried here to put more emphasis on synthetic methodology and applications of the sugar fluorinated nucleosides.
DISCUSSION
1’- Fluorinated nucleosides
Almost all hydrogens attached to carbons have been substituted by fluorine atoms. However, substitution at 1’-carbon is rarely reported. This is may be due the feeling that 1’-nucleosides are difficult or unstable to synthesize. Recently the synthesis of protected 1’-fluoronucleosides (Scheme 1) was reported by Shuto group [20, 21]. In this synthesis, treatment of 2’-ketouridine 9 with Lithium bis (trimethylsilyl) amide (LiHMDS) and N-F fluorination agents such as Selectfluor or NFSI gave anomeric mixture of the 1’-fluoro-2’-ketouridine derivatives 10 and (Arabino type congener) in 57-88 % yield. Reduction of the 2’-keto group of 10 by diisobutylaluminiumhydride (DiBAL-H) followed by acetyl protection of the resulted hydroxyl group with acetic anhydride (Ac2 O) and 4-dimethylaminopyridine (DMAP) gave the 1’-fluorouridine derivatives 11 and 12 (8:9=1:4) in 68 % yield. This method has three drawbacks:
1. Only protected 1’-fluorouridine derivatives 11 and 12 were isolated and neither isolation nor deprotection and purification of the free 1’-fluoronucleoside was successful. This is may be due to the instability of the deprotected 1’-fluoruridine.
2. This method gives anomeric mixture of protected 1’-fluoruridines and that leads to low yield of the preferred β-anomer.
3. This method was not applied to purine nucleosides.
2’- Fluorinated nucleosides
More attention was given to the synthesis of 2’-β-Dfluoronucleosides (araF-nucleosides) over the 2’-α-D-fluoro nucleosides (riboF-nucleosides). This is because of the interesting antiviral activity shown by introducing a fluorine atom at the 2’-β-positions of the nucleosides and nucleoside analogs rather than at 2’-α-positions. Reichmann et al. [23] and Watanabe et al. [24] developed a synthetic method, in two steps, to obtain 2-deoxy-2-fluorD-arabinose 14a and 1-bromo-2-deoxy-2-fluoro-D-arabinose 14b from a readily available D-glucose derivative 13 (Scheme 2). Arabinose sugars 14a-b were used to synthesize series of fluorinated nucleosides 15-18 in a large scale for biological evaluation. Straightforward method for the synthesis of FIAC and FMAU nucleosides was also developed by Tann etal. [25]. For example, 1-(2-deoxy-2-fluoro-β-D-arabinofuranosyl)- 5-iodocytosine (FIAC, 15), 1-(2-deoxy-2-fluoro-β-Darabinofuranosyl)-5-methyluracil (FMAU, 16), 1-(2-fluoro2-deoxy-β-D-arabinofuranosyl)-5-iodo uracil (FIAU, 17), and 1-(2-fluoro-2-deoxy-β-D-arabinofuranosyl)-5-ethyl uracil (FEAU,18) have shown potent activity against Herpes Simplex Virus (HSV), and excellent activity against hepatitis-B virus (HBV) and cytomegalovirus (CMV). FMAU, 16 have also shown significant activity against murine leukemia [22]. Chu’s group [26, 27] has also reported an efficient procedure for the synthesis of 1- (2-deoxy-2-fluoro-β-Larabinofuranosyl)-5-methyluracil 21 from sugar 19 (Scheme 3). Another interesting approach is the synthesis of the 2’-fluorinated nucleosides, namely 2’-deoxy-2’-fluoro arabinonucleosides (araF-nucleosides) [28, 29]. They are used as building blocks for the synthesis of 2’-deoxy-2’-fluoro arabinonucleic acid (2’-F’ANA), [30-33] a very promising antisense oligonucleotides. Here the 2’-fluoro nucleosides were prepared via condensation of the silylated nucleic acids bases such as silylated N-acetyl cytosine or silylated thymine or N-benzoylated adenine with 2-deoxy-2-fluoro-3, 5-di-Obenzoyl-α-D-arabinofuranosyl bromide 22. Deprotection of the produced nucleosides, followed by 5’-tritylation and N-benzoylation give araF- nucleosides 23-25 in high yield (Scheme 4). The black sheep of this family of 2’-fluoro nucleosides is the 9-(2-deoxy-2-fluoro-β-D-arabinofuranosyl) guanine (araFG) because the above mentioned procedure yields araF-G in low yields. An efficient synthesis of araF-G has been reported by Elzagheid et al. [29]. It involves coupling of 2-deoxy-2-fluoro-3, 5-di-O-benzoyl-α-D-arabinofuranosyl bromide 22 with silylated 2-chloro hypoxanthine 26 to afford 2-chloro-β-araF-I 27 that was transformed in araF-G 28 by treatment with methanolic ammonia in high yield (Scheme 5). Another efficient approach for the synthesis of araF-G 28 was reported by Sivets [34]. The synthesis involves reaction of potassium salts of 2-amino-6-chloropurine with 2-deoxy2-fluoro-3, 5-di-O-benzoyl-α-D-arabinofuranosyl bromide 22. In addition to methanolic ammonia, 2-mercaptoethanol and sodium methoxide in methanol was also used to convert the masked nucleoside to araF-G. In addition to the above mentioned syntheses, a novel synthesis and evaluation of the 5-ethyl analogs of the 2-deoxy-2-fluoro- β -D-arabinofuranosyl nucleosides was reported by Shakya et al. [35]. Among the tested fluorinated nucleosides, the 1-(3-bromo-2, 3-dideoxy-2-fluoro-β-Darabinofuranosyl)-5-ethyluracil has showed promising activity against Mycobacterium tuberculosis and Mycobacterium bovis with no cellular toxicity upto the highest concentration tested (CC50 > 100 µg/mL). A linear synthesis of 2’-deoxy-2’, 2’-difluorocytidine (Gemcitabine) was also reported by Brown et al. [36]. Gemcitabine under the trade name Gemzar, by Lilly Company, was widely used as anticancer drug. This linear synthesis involves conversion of 3, 5-di-O-benzoyl-2-deoxy-2, 2-difluororibose to corresponding glycosyl urea followed by conversion to cytosine base thru the uracil derivative.
3’- Fluorinated nucleosides
Carbon-3’-fluoronucleosides have shown a wide range of biological activity [37]. Among them, 3’-deoxy-3’-β-Dribofuranosides of adenine, guanine and their 2-deoxy analogs have shown potent antiviral and cytostatic activities [38]. Synthesis of 3’-fluorinatednucleosides such as 9-(3-deoxy3-fluoro-β-D-xylofuranosyl) adenine 1 [15] and 9-(3-deoxy3-fluoro-β-D-arabinofuranosyl) adenine 2 [16](Figure 2) by reacting 1-(5-O-benzoyl-2,3-epoxy-β-D-lyxofuranosyl) adenine with tetraethylammonium fluoride and 1-(5-O-benzoyl2,3-epoxy-β-D-ribofuranosyl) adenine with potassium hydrogen fluoride respectively are subject to few drawbacks. Vigorous reaction conditions are required for the ring opening and strictly anhydrous conditions are needed for the reagent and also to avoid formation of side products. Epoxide ring opening is relatively easy with HF in the presence of tetrahydrofuran or dioxane. This is because of the increased dissociation of the hydrofluoric acid [39]. An alternative route has been reported by Pankiewicz and Watanabe [40] for the synthesis of 9-(3-deoxy-3-fluoro-β- D-ribofuranosyl) adenine 33. This involves the treatment of the nucleoside triflate 29 with sodium acetate to give 3’-Oacetyl derivative 30. Mild hydrolysis of the later nucleoside in triethylamine-methanol-water mixture gave nucleoside 31 in good yield. Further treatment with DAST [(diethylaminosulfurtrifluoride, Et2 NSF3 ] gave the desired 3’-fluorosubstituted nucleoside 32 in high yield. Acidic treatment of 32 with acid gave nucleoside 33 (Scheme 6). Another interesting approach is the synthesis of 3’-fluorinated purine nucleosides 35-37 (Scheme 7) from 3’-fluorinated pyrimidine nucleosides 5 and 34 with the application of recombinant T. thermophilus pyrimidine nucleoside phosphorylase (TtpyNP) and E-Coli purine nucleoside phosphorylase (EcPNP) [41]. Another straightforward synthesis of 2’, 3’-dideoxy-3’- β-fluoronucleosides was reported by Khalil et al.42 The 5’-acetyl-3-nitro-2’-deoxynucleodies 38a-b were reacted with DAST in anhydrous dichloromethane-pyridine mixture to give the corresponding 3’- β -fluoronucleosides. Deprotection of the 3-nitro group was achieved by tributyltin hydride (Bu3SnH) in dry toluene in the presence of α, α’- azoisobutyronitrile (AIBN). Removal of the 5’-acetyl with methanolic ammonia afforded nucleosides 39a-b (Scheme 8).
4’- Fluorinated nucleosides
Another class of the fluoronucleosides that has attention of late is the 4’-fluoronucleosides. They are expected to have significant values in a variety of biochemical studies. A fruitful procedure has been reported by Lee et al. [19] where various 4’-fluorinated nucleosides 42-44 have been prepared in three steps via sequential bromination and fluorination of the ribofuranose 40. Glycosylation of the 4-fluoro-β-Dribofuranose 41 with N, O-bis-(trimethylsilyl) trifluoroacetamide and trimethylsilyl triflate followed by debenzoylation gave the desired fluoronucleosides in good yield (Scheme 9).
5’- Fluorinated nucleosides
Four approaches for the synthesis of 5’-fluoronucleosides 45-48 (Figure 3) have been reported. These include:
1. Nucleophilic displacement of sulfonates by fluoride ions: This reaction is carried out in either mesylates or tosylates with potassium fluoride in ethylene glycol or with tetrabutylammonium fluoride in dimethylformamide (DMF). However, the use of hydrofluoric acid in dioxane has been reported to give better yields [17].
2. Opening of the O2 , 5’-bond of anhydronucleosides: these anhydronucleosides can serve as good starting materials but they are rarely used [43].
3. Reaction of a free 5’-hydroxyl group with DAST. This reagent has been successfully applied for the replacement of hydroxyl group by a fluorine atom [44].
4. Displacement of iodine as leaving group: In this approach silver fluoride in pyridine has been used for introduction of fluorine atom at 5’-position of the 5’-iodouridine [14].
CONCLUSIONS
In this review, a highlighted number of important synthetic methods of biologically active fluorinated nucleosides have been covered. A fluorine atom, as a mimic of hydrogen or hydroxyl group, that has been introduced in different positions in the sugar moiety of the nucleoside has surely improved their pharmacological and biological properties.
ACKNOWLEDGMENT
Author acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241813EnglishN2016July12HealthcareIMMUNOHISTOCHEMISTRY STUDY FOR HER-2/NEU EXPRESSION IN LESIONS OF UTERINE CERVIX
English5057Pramod SarwadeEnglish Sunita PatilEnglish Rajan BinduEnglishObjectives:
1. To study expression of HER-2/neu in lesions of uterine cervix by immunohistochemistry.
2. To correlate expression of HER-2/neu with histological type, grade and stage of cervical malignancy.
Methods: Total 50 cases were included during the period from October 2013 to October 2015. Immunohistochemical studies were done on formalin-fixed paraffin embedded tissue blocks with HER-2/neu antibody.
Results: Out of fifty cases, 10 cases (20%) of adenocarcinoma (ADC), 1 case (2%) of adenosquamous carcinoma, 4 cases (8%) of CIN, 3 cases (6%) of chronic cervicitis, 2 cases (4%) of chronic cervicitis with squamous metaplasia, 30 cases (60%) of squamous cell carcinoma of cervix (SCC). And It Amongst 9 cases of poorly differentiated SCC cases, 2 cases showed 1+ positivity, 2 cases showed 2+ positivity, 1 case showed 3+ positivity. Out of 16 cases of moderately differentiated SCC, 4 cases showed 1+ positivity, 4 cases showed 2+ positivity, 2 cases showed 3+ positivity. Among 5 cases of well differentiated SCC, 2 cases showed 1+ positivity. Out of 10 cases of adenocarcinoma of cervix, 2 cases of well differentiated adenocarcinoma showed 1+ positivity. Each 2 cases of moderately differentiated adenocarcinoma showed 1+ and 2+ positivity. Cervical carcinoma cases with involvement of lymph node and parametrium showed stronger HER-2/neu staining.
Conclusion: Higher HER-2/neu expression was noted in malignant lesion as compared to benign lesions. Stronger HER-2/neu expression was noted among higher stage tumors and those with parametrial and lymph node involvement.
EnglishHER-2/neu expression, Immunohistochemistry, Cervical lesionsINTRODUCTION
According to the global cancer statistics for 2012, cervical cancer is the fourth most common cancer affecting women worldwide and it is also the fourth most common cause of cancer death in women worldwide. Almost 70% of the global burden falls in areas with lower levels of development and more than one fifth of all new cases are diagnosed in India.[1] Carcinoma cervix is one of the common malignancy in women in India with an incidence of 9 to 44 per 100,000 women.[2] Current treatment is failing to cure locally advanced disease. Therefore next step in treatment is testing of molecular targeted therapies to improve outcome of cervical cancer patients. [3] The c-erbB-2 proto-oncogene, also called HER-2/neu, is located on Chromosome 17q21 which encodes 185kDa transmembrane glycoprotein with tyrosine kinase activity. Overexpression leads to constitutive activation of tyrosine kinase residues.[4] The epidermal growth factor receptor (EGFR/HER) family of receptors has been associated with aggressive biological behavior and metastatic potential.[5] The expression of HER family members in gynaecological cancers and their relationship with disease stage, grade and response to treatment controversial.[6] HER2/neu expression is not limited to cervical cancers but is also seen in other tumors like breast, stomach, ovary, uterine serous endometrial carcinomas, colon, bladder, lung, head and neck and esophagus.[7]
MATERIALS AND METHODS
A total of 50 cases of cervical tissue were obtained from October 2013 to October 2015. The study consists 10 cases (20%) of adenocarcinoma, 1 case (2%) of adenosquamous carcinoma, 4 cases (8%) of cervical intraepithelial neoplasia (CIN), 3 cases (6%) of chronic cervicitis, 2 cases (4%) of chronic cervicitis with squamous metaplasia, and 30 cases (60%) of squamous cell carcinoma of cervix. Routine Hematoxylin and eosin stained slides were screened to obtain the best section for immunohistochemistry with HER-2/ neu antibody. 3-5 micron sections were cut on poly L-lysine coated slides. Antigen retrieval was done by heating the sections in citrate buffer at pH 6.0 using microwave oven. 100 µl prediluted primary antibody HER2/neu (Monoclonal, Immunogen: A synthetic peptide corresponding to residues near the C-terminus of human HER2, Clone: EP1045Y, Species: Rabbit, Ig class: IgG, Protein Conc.: 50mg/ml, Catalog no.: AN471-5ME, BioGenex, USA) were applied so as to cover the tissue sections. Standard Streptovidin-biotin peroxidase method is used. A golden brown membrane and cytoplasmic staining was taken as a positive reaction. Intensity of HER-2/neu expression was graded according to the 2014 ASCO/CAP guidelines[8] as complete intense circumferential membrane staining within >10% of tumor cells (3+); circumferential staining that is incomplete and/ or weak/moderate within >10% of tumor cells or complete intense circumferential membrane staining within 10% of tumor cells (1+) and no staining is observed or shows membrane staining that is incomplete and is faint/barely perceptible and within Englishhttp://ijcrr.com/abstract.php?article_id=235http://ijcrr.com/article_html.php?did=2351. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 23rd July 2014.
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6. Reyes HD, Thiel KW, Carlson MJ, Meng X, Yang S, Stephan J, et al. Comprehensive profiling of EGFR/HER receptors for personalized treatment of gynecologic cancers. MolDiagnTher. 2014;18(2):137-51.
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9. Gupta N, Singh S, Marwah N, Kumar S, Chabra S, Sen R. HER2/neu expression in lesions of uterine cervix: Is it reliable and consistent?. Indian J PatholMicrobiol. 2009;52:482-5.
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12. Joseph T and Raghuveer CV. HER-2/neu expression in cervical intraepithelial neoplasia and cervical carcinoma. International Journal of Biomedical and Advance Research 2015; 6(01):47- 52.
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17. Mandai M, Konishi I, Koshiyama M, Komatsu T, Yamamoto S, Nanbu K, et al. Altered expression of nm23-H1 and c-erb B-2 proteins have prognostic significance in adenocarcinoma but not in squamous cell carcinoma of the uterine cervix. Cancer. 1995;75:2523-9.
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