Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareCARDIAC BIOMARKERS: PAST, PRESENT AND FUTURE
English0107Rancy Ann ThomasEnglish S. KrishnakumariEnglishCardiovascular (CV) clinical trials are essential to understand the treatment effects and to follow up the natural progression of CV disease. Biomarkers play a pivotal role in understanding the disease state, risk levels, and clinical decision-making. We review the roles that biomarkers have played in CV clinical trials and roles that CV clinical trials have played and will continue to play in the discovery and validation of biomarkers and their implementation in clinical practice. Biomarkers were once the workhorses of patient selection and endpoint definition in clinical trials; more recently, clinical trials have been the proving ground for individual biomarkers. These markers could also reflect the entire spectrum of disease from the earliest manifestations to the terminal stages. In this paper we review recent advances with the use of biomarkers and a glimpse to the history and future of cardiac markers
EnglishCardiovascular diseases, Biomarkers, Clinical trialsINTRODUCTION
Cardiovascular disease (CVD) is a major global cause of mortality in the developed countries. Intravascular thrombogenesis, the main pathogenic mechanism of the coronary artery disease (CAD), is influenced by a complex interplay of procoagulant, anticoagulant, fibrin lytic, endothelial damage/ dysfunction and inflammatory processes [1]. The traditional theory for causation of CAD centers on a complex interplay between genetic and environmental, modifiable and non-modifiable risk factors setting into motion an inflammatory cascade of monocyte migration, lipid oxidation and athermanous plaque formation [2,3]. The term biomarker is an abbreviation for “biological-marker” a phrase first introduced in 1989. In 2001, the definition of biomarker was refined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes or pharmacologic responses to a therapeutic intervention” [4]. Myocardial infarction (MI) can be recognized by clinical features, including electrocardiographic (ECG) findings, elevated values of biochemical markers (biomarkers) of myocardial necrosis, and by imaging, or may be defined by pathology. It is a major cause of death and disability worldwide. MI may be the first manifestation of coronary artery disease (CAD) or it may occur, repeatedly, in patients with established disease [5]. Biomarkers are measurable and quantifiable biological parameters that can have an important impact on clinical situations. Ideal biomarkers are those that are associated with disease clinical endpoints in observational studies and clinical trials, and in some cases, they may even be used as surrogate endpoints. Biomarkers must also be both independent of established risk factors and recognized to be a factor in the disease for which they are a marker [6, 7]. Cardiac biomarkers are protein components of cell structures that are released into circulation when myocardial injury occurs. They play a pivotal role in the diagnosis, risk stratification, and treatment of patients with chest pain and suspected acute coronary syndrome (ACS) as well as those with acute exacerbations of heart failure[8, 9].
Overview of Clinically Relevant Cardiac Markers
Clinical perspectives on biochemical markers for myocardial necrosis evolved during the 1980s and 1990s. In the past, measurement of nonspecific markers such as aspartate transaminase, lactate dehydrogenase (LD), and total Creatine kinase (CK) were performed. Subsequently, measurement of LD isoenzymes and more cardiac-specific enzymes (CK-MB) became available. LD isoenzymes and CK-MB traditionally were measured by labor-intensive electrophoretic techniques. During the 1990s, electrophoretic methods were replaced by CK-MB mass assays using automated immunodiagnostic instruments that could perform testing faster, more frequently, and at lower cost than older methods. Mass assays for CK-MB became the standard of care for cardiac marker testing in the mid-1990s. Subsequently, newer markers of myocardial injury, including CKMB isoforms, myoglobin, and cTnT and cTnI have become available on automated commercial instruments. For the past 40 years, the use of biomarkers has been extremely valuable in the early diagnosis of acute myocardial infarctions (AMI). Sensitivity, specificity and the clinical utility have continued to increase and current research suggests that this trend will continue. This article will review the use of previous and current AMI markers and will conclude with a review of promising new markers.
AMI Biomarker protocol
To detect MI markers, venous blood is routinely drawn from patients with chest pain whoare suspected ofhaving symptoms of acute coronary syndrome (ACS). The marker of interest is presumed to be released from the cardiac tissue which is under ischemic stress and thus may be detected in the blood sample A detected elevation in a particular marker may lead to early diagnosis and treatment and thus improved patient outcome [10]. Characteristics of biomarkers center around three main elements, namely, kinetics of release, sensitivity and specificity. An ideal marker of cardiac necrosis should exhibit the following characteristics: cardiac specificity, early and stable release after necrosis, predictable clearance and be measurable quantitatively using rapid, cost effective methodologies available in clinical laboratories [11, 12] The biomarkers that were proved to predict heart failure could be divided into six categories according to their origin or effects (inflammation, oxidative stress, extracellular matrix remodeling, neurohormones, myocyte injury, myocyte stress), and a seventh category of new biomarkers that have not yet been fully characterized (13). The diagnosis of AMI can be established on the basis of these assays as early as 1.5 to 3 hours after the onset of symptoms. Several biochemical markers for the early detection of myocardial damage have been proposed, of which cardiac troponin T(cTnT), myoglobin and creatine kinaseMB (CK-MB) are the most promising candidates. Serum levels of these markers change rapidly in the early hours after the onset of AMI, therefore, sensitivity and specificity of any particular marker change rapidly over time. Infarct size may influence early sensitivity and specificity of the cardiac marker under study[14]. Certain enzymes (CPK, LDH, etc.,) are released from the heart muscle cells when it is injured (“heart attack”). These enzymes are normally found in the blood at low levels. The abnormal elevation of these enzymes in the blood stream can occasionally be the only indicator that a heart attack (myocardial infarction) has occurred.
Biomarkers Past
Over the years, blood – based biomarkers have played an increasing number of important roles in clinical trials. In addition to refining our understanding of CVD mechanisms, they assist in both identifying study populations and defining intermediate end points (infarct size, suppression of inflammation) in phase 2 clinical trials and in identifying nonfatal clinical end points (e.g., MI) in later-phase work. The earliest blood biomarkers of cardiac injury and disease were activity-based assays to cytosolic myocardial enzymes. These included aspartate aminotransferase (AST) which was the first, lactate dehydrogenase (LDH), and creatine kinase (CK). Beginning in the 1950s, these tests were added to the expanding collection of rapid, automated clinical chemistry assays. These enzymatic assays were found to be of most use as screening tests for ischemic myocardial necrosis brought about by acute myocardial infarction (AMI). These first-generation tests lacked cardiac tissue specificity, being present also in skeletal muscle and other tissues. They furthermore lacked sensitivity, with relatively high baseline values that made interpretation of small increases in serum enzyme activity difficult. These older enzymatic assays performed even worse when used to screen for non-ischemic diseases. An important advance in cardiac biomarkers was the invention and use of monoclonal antibody strategies in the 1980s and subsequent automated immunoassay techniques. Coming from this improvement was the antibody based CK-MB assay and other tests. This began a new generation of cardiac biomarkers that were antibody-based, and resulted in an immediate improvement in the diagnosis of AMI. Again, however, these early immunoassays were still of inadequate sensitivity to be of value for more chronic heart diseases that do not cause substantial myocardial necrosis, such as valvular insufficiency, septal wall defects, and cardiomyopathies [15].
Inflammation
Inflammation is important in the pathogenesis and progression of many forms of heart failure, and biomarkers of inflammation have become the subject of intense inquiry. All stages of plaque development and eventual rupture leading to acute coronary syndromes can be considered an inflam-matory response. The detection of key molecules involved in the atherosclerotic inflammatory cascade therefore offers an attractive approach for detecting cardiac ischemia and predicting outcomes [16].
C-reactive protein
Interest in the presence of inflammatory mediators in patients with heart failure began in 1954, when a crude assay for C-reactive protein, a protein that appears in the serum in a variety of inflammatory conditions, became available. A study published in 1956 reported that C-reactive protein was detectable in 30 of 40 patients with chronic heart failure and that heart failure was more severe in those with higher levels of C-reactive protein [17]. Subsequently, C-reactive protein was described as an acute-phase reactant synthesized by hepatocytes in response to the proinflammatory cytokine interleukin-6.5 The use of C-reactive protein as a biomarker became more common when a low-cost, high-sensitivity test for C-reactive protein was developed [18]. Multivariate analysis indicated that increased C-reactive protein level is an independent predictor of adverse outcomes in patients with acute or chronic heart failure. In the Framingham Heart Study, for example, C-reactive protein (as well as the inflammatory cytokines interleukin-6 and tumor necrosis factor α [TNF-α] was noted to identify asymptomatic older subjects in the community who were at high risk of the future development of heart failure [19]. Further, C-reactive protein has been shown to exert direct adverse effects on the vascular endothelium by reducing nitric-oxide release and increasing endothelin-1 production, as well as by inducing expression of endothelial adhesion molecules [20]. These findings suggest that C-reactive protein may also play a causal role in vascular disease and could therefore be a target of therapy.
Pro inflammatory cytokines
In 1990, Levine et al. described elevated levels of circulating TNF-α in patient with heart failure [21]. TNF-α and at least three interleukins (interleukins 1, 6, and 18) are considered to be proinflammatory cytokines and are produced by nucleated cells in the heart. The cytokine hypothesis of heart failure proposes that a precipitating event — such as ischemic cardiac injury — triggers innate stress responses, including elaboration of proinflammatory cytokines, and that the expression of these cytokines is associated with deleterious effects on left ventricular function and accelerates the progression of heart failure[22]. Proinflammatory cytokines appear to cause myocyte apoptosis and necrosis; interleukin-6 induces a hypertrophic response in myocytes, whereas TNF-α cause left ventricular dilatation, apparently through activation of matrix metalloproteinases. Interleukin-6 and TNF-α levels could be used to predict the future development of heart failure in asymptomatic elderly subjects in one study,[23] though blockade of TNF-α has not resulted in clinical benefit in patients with heart failure.3,[24]. Fas (also termed APO-1) is a member of the TNF-α receptor family that is expressed on a variety of cells, including myocytes. When Fas is activated by the Fas ligand it mediates apoptosis and plays an important role in the development and progression of heart failure. Elevated serum levels of a soluble form of Fas have been reported in patients with heart failure, and high levels are associated with severe disease [25]. The inhibition of soluble Fas in animals reduces postinfarction ventricular remodeling and improves survival [26]. Pharmacologic efforts to reduce Fas levels are still in their infancy but may represent a new direction in the treatment or prevention of heart failure. Indeed, the administration of a nonspecific immunomodulating agent — pentoxifylline[27]or intravenous immunoglobulin[28] — reduces plasma levels of Fas as well as C-reactive protein and is reported to improve left ventricular function in patients with ischemic or dilated cardiomyopathy.
Oxidative stress
Increased oxidative stress results from an imbalance between reactive oxygen species (including the superoxide anion, hydrogen peroxide, and the hydroxyl radical) and endogenous antioxidant defense mechanisms. The imbalance can exert profoundly deleterious effects on endothelial function18 as well as on the pathogenesis and progression of heart failure [29]. Oxidative stress may damage cellular proteins and cause myocyte apoptosis and necrosis. It is associated with arrhythmias and endothelial dysfunction, with the dysfunction occurring through reduction of nitric oxide synthase activity as well as the inactivation of nitric oxide [30]. Inflammation and immune activation, activation of the renin–angiotensin– aldosterone system and the sympathetic nervous system, and increases in circulating catecholamine levels and peroxynitrite formed from the interaction of the superoxide anion and nitric oxide all may increase oxidative stress [31].Since it is difficult to measure reactive oxygen species directly in humans, indirect markers of oxidative stress have been sought. These include plasma-oxidized low-density lipoproteins, malondialdehyde and myeloperoxidase (an index of leukocyte activation), urinary levels of biopyrrins (oxidative metabolites of bilirubin),[32] and isoprostane levels in plasma and urine[33]. The levels of plasma myeloperoxidase [34] and isoprostane excretion correlate with the severity of heart failure and are independent predictors of death from heart failure, even after adjustment for baseline variables[35].The urinary excretion of 8-isoprostane correlates with the plasma levels of matrix metalloproteinases, which at high levels can accelerate adverse ventricular remodeling and increase the severity of heart failure[36]. There is increasing evidence that xanthine oxidase, which catalyzes the production of two oxidants, hypoxanthine and xanthine, plays a pathologic role in heart failure [37]. Uric acid production is elevated in as-sociation with increased xanthine oxidase activity. Elevated levels of uric acid correlate with impaired hemodynamics[38] and independently predict an adverse prognosis in heart failure[39].
Extracellular-matrix remodeling
Remodeling of the ventricles plays an important role in the progression of heart failure [40]. The extracellular matrix provides a “skeleton” for myocytes and determines their size and shape. Normally, there is a balance between matrix metalloproteinase (proteolytic enzymes that degrade fibrillar collagen) and tissue inhibitors of metalloproteinase. An imbalance, with dominance of matrix metalloproteinase over tissue inhibitors of metalloproteinase, is associated with ventricular dilatation and remodeling. An abnormal increase in collagen synthesis may also be deleterious to cardiac function because the resultant excessive fibrosis can impair ventricular function. The propeptide procollagen type I is a serum biomarker of collagen biosynthesis. Querejeta et al [41] observed a positive correlation between the serum level of propeptide procollagen type I and the fractional volume of fibrous tissue determined from cardiac biopsies in patients with essential hypertension. Cicoira et al [42] reported that the level of plasma procollagen type III in patients with heart failure is an independent predictor of adverse outcomes. Thus, elevated markers of increased extracellular-matrix breakdown on the one hand and of excessive collagen synthesis on the other are associated with impaired left ventricular function and adverse clinical outcomes in patients with heart failure. Markers of these processes appear to be important targets of therapy. However, at least 15 matrix metalloproteinase and several forms of procollagen and of tissue inhibitors of metalloproteinase have been identified [43].
Neurohormones In the early 1960s it was reported that patients with heart failure had abnormally elevated levels of plasma norepinephrine at rest and that further elevations occurred during exercise [44]. The urinary excretion of norepinephrine was also increased[45]. These findings suggested that the sympathetic nervous system is activated in patients with heart failure and that a neurohormonal disturbance might play a pathogenetic role in heart failure. Cohn et al [46] subsequently demonstrated that plasma norepinephrine level was an independent predictor of mortality. Swedberg et al [47] made the important observation that the renin– angiotensin–aldosterone system becomes activated in patients with heart failure as well. Subsequently, after its discovery, attention focused on big endothelin-1, a 39-amino-acid prohormone secreted by vascular endothelial cells that is converted in the circulation into the active neurohormone endothelin-1, a peptide hormone 21 amino acids in length. Endothelin-1 is a powerful stimulant of vascular smooth-muscle contraction and proliferation and ventricular and vessel fibrosis and is a potentiator of other neurohormones [48]. The plasma levels of both endothelin-1 and big endothelin-1 are increased in patients with heart failure and correlate directly with pulmonary artery pressure,[49] disease severity, and mortality[50]. The Valsartan Heart Failure Trial (Val-HeFT) investigators compared the prognostic values of plasma neurohormones (norepinephrine, plasma renin activity, aldosterone, endothelin-1, big endothelin-1, and brain natriuretic peptide [BNP]) among 4300 patients [51]. The most powerful predictors of mortality and hospitalization for heart failure, after BNP, were big endothelin-1, followed by norepinephrine, endothelin-1, plasma rennin activity, and aldosterone. However, trials involving several endothelin-1– receptor antagonists have failed to show any beneficial effects on clinical outcomes [48]. In the Randomized Aldactone Evaluation Study (RALES) of patients with severe heart failure, Zannad et al [52] found that administration of the aldosterone blocker spironolactone was associated with a reduction of plasma procollagen type III and clinical benefit, but only in patients whose baseline levels of the procollagen were above the median. Administration of spironolactone in patients with acute myocardial infarction reduced myocardial collagen synthesis, as reflected by plasma procollagen type III, as well as postinfarct adverse left ventricular remodeling [53]. Taken together, these findings suggest that limiting the synthesis of the extracellular matrix might be an important component of the beneficial action of spironolactone in patients with severe heart failure. Arginine vasopressin is a nonapeptide that is synthesized in the hypothalamus and stored in the posterior pituitary gland and that has antidiuretic and vasoconstrictor properties. Excess release of arginine vasopressin intensifies heart failure associated with dilutional hyponatremia, fluid accumulation, and systemic vasoconstriction. Whereas plasma levels of arginine vasopressin are elevated in patients with acute or chronic heart failure [54] and are associated with poor clinical outcomes, blockade of the vasopressin 2 receptor relieves acute symptoms but does not appear to alter the natural history of severe heart failure [55]. Although the various neurohormones are distinct, they have common features. Norepinephrine, angiotensin II, aldosterone, endothelin-1, and arginine vasopressin are vasoconstrictors, thereby increasing ventricular afterload. The facts that blockade of the sympathetic nervous system and of the renin–angiotensin–aldosterone system are cornerstones of current pharmacologic treatment of heart failure support the concept that several of these biomarkers are probably part of the direct causal pathway for heart failure [55].
Myocyte injury
Myocyte injury results from severe ischemia, but it is also a consequence of stresses on the myocardium such as inflam-mation, oxidative stress, and neurohormonal activation. During the past two decades, the myofibrillar proteins — the cardiac troponins T and I — have emerged as sensitive and specific markers of myocyte injury and have improved greatly the diagnosis, risk stratification, and care of patients with acute coronary syndromes. Modest elevations of cardiac troponin levels are also found in patients with heart failure without ischemia[56]. Horwich et al [57] reported that cardiac troponin I was detectable (≥0.04 ng per milliliter) in approximately half of 240 patients with advanced, chronic heart failure without ischemia. In this issue of the Journal, Peacock et al [58] report that troponin measurements are a predictor of outcome in hospitalized patients with acute decompensated heart failure. Other myocardial proteins — including myosin light chain 1, heart fatty-acid binding protein and creatine kinase MB fraction — also circulate in stable patients with severe heart failure. Like cardiac troponin T, the presence of these myocardial proteins in the serum is an accurate predictor of death or hospitalization for heart failure [59]. Future studies should compare the predictive accuracy of troponin measured with a high-sensitivity assay and the predictive accuracy of these other biomarkers of myocyte injury to determine whether the latter add information.
Myocyte stress
Natriuretic Peptides
The precursor of BNP and N-terminal pro–brain natriuretic peptide (NT-pro-BNP) is a pre–prohormone BNP, a 134-amino-acid peptide that is synthesized in the myocytes and cleaved to the prohormone BNP of 108 amino acids. The prohormone is released during hemodynamic stress — that is, when the ventricles are dilated, hypertrophic, or subject to increased wall tension[60]. Prohormone BNP is cleaved by a circulating endoprotease, termed corin, into two polypeptides: the inactive NT-pro-BNP, 76 amino acids in length, and BNP, a bioactive peptide 32 amino acids in length. BNP causes arterial vasodilation, diuresis, and natriuresis, and reduces the activities of the renin–angiotensin–aldosterone system and the sympathetic nervous system. Thus, when considered together, the actions of BNP oppose the physiological abnormalities in heart failure. The natriuretic peptides are cleared by the kidneys, and the hypervolemia and hypertension characteristic of renal failure enhance the secretion and elevate the levels of BNP, especially the NT-pro-BNP[60]. There is also a moderate increase in the level of circulating BNP with increasing age, presumably in relation to myocardial fibrosis or renal dysfunction, which are common in the elderly. Pulmonary hypertension from a variety of causes may increase the plasma level of BNP. The level varies inversely with the body-mass index [61]. Measurement of natriuretic peptides may also be used to screen for acute or late cardiotoxic effects associated with cancer chemotherapy [62, 63]. Two studies have directly compared BNP and NT-pro-BNP[64]. Both found that the N-terminal prohormone was slightly superior to BNP for predicting death or rehospitalization for heart failure. The longer half-life of NT-pro-BNP may make it a more accurate index of ventricular stress and therefore a better predictor of prognosis [65].
Adrenomedullin
Adrenomedullin is a peptide of 52 amino acids and a component of a precursor, pre-proadrenomedullin, which is synthesized and present in the heart, adrenal medulla, lungs, and kidneys . It is a potent vasodilator, with inotropic and natriuretic properties, the production of which has been shown to be stimulated by both cardiac pressure and volume overload [66]. The level of circulating adrenomedullin is elevated in patients with heart failure and is higher in patients with more severe heart failure. The midregional fragment of the proadrenomedullin molecule, consisting of amino acids 45 to 92, is more stable than adrenomedullin itself and easier to measure[67]. Khan et al [58] compared midregional proadrenomedullin and NT-pro-BNP levels in patients after acute myocardial infarction. Both biomarkers were equally strong predictors of cardiovascular death or heart failure. Measurements of midregional proadrenomedullin provided additional prognostic value when combined with those of NTpro-BNP[68].
ST2
ST2, a member of the interleukin-1 receptor family, is a protein secreted by cultured monocytes subjected to mechanical strain. The ligand for this receptor appears to be interleukin-33, which — like BNP and adrenomedullin — is induced and released by stretched myocytes. Infusion of soluble ST2 appears to dampen inflammatory responses by suppressing the production of the inflammatory cytokines interleukin-6 and interleukin-12. Elevated levels of ST2 occur in patients is associated with severe heart failure [69].
Conclusion
Growing evidence has shown that the use of biomarkers reflects different pathologic entities, such as inflammation, oxidative stress, tissue necrosis, and platelet activation. However, no available biomarker offers ideal diagnostic properties for ACS, such as early detection, high sensitivity and specificity, easy availability, and cost effectiveness. Thus, the deployment of new strategies is essential to meet diagnostic, prognostic, and therapeutic needs. With the full use of newly emerging technologies, alone and in combination, novel biomarkers or novel biomarker protein signatures discovery is necessary
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57. Horwich TB, Patel J, MacLellan WR, Fonarow GC. Cardiac troponin I is associated with impaired hemodynamics, progressive left ventricular dysfunction, and increased mortality rates in advanced heart failure. Circulation 2003;108:833-8.
58. Khan SQ, O’Brien RJ, Struck J. Prognostic value of midregional pro-adrenomedullin in patients with acute myocardial infarction: the LAMP (Leicester Acute Myocardial Infarction Peptide) study. J Am CollCardiol 2007;49:1525-32.
59. Konstam MA, Gheorghiade M, Burnett JC Jr. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA 2007; 297:1319-31.
60. Peacock WF IV, De Marco T, Fonarow GC. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008; 358:2117- 26.
61. Vickery S, Price CP, John RI. B-type natriuretic peptide (BNP) and amino-terminal proBNP in patients with CKD: relationship to renal function and left ventricular hypertrophy. Am J Kidney Dis 2005;46:610-20.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareCENTRAL GIANT CELL GRANULOMA PRESENTING AS UNILOCULAR RADIOLUCENCY IN POSTERIOR MANDIBLE - A CASE REPORT
English0812S. Aruleena ShamineyEnglish G. V. Murali Gopika ManoharanEnglishAim: To report a case of Central Giant Cell Granuloma in posterior mandible.
Case Report: In this article, we present a case of Central Giant Cell Granuloma presenting as unilocular radiolucency in posterior mandible.
Discussion: Central Giant Cell Granuloma is a rare benign non-neoplastic lesion of the jaws usually occurring in mandible in young adults. It may be non aggressive or aggressive variety. Aggressive variety has a tendency to recur.
Conclusion: This case helps to demonstrate the wide variation in the clinical and radiological features of Central Giant Cell Granuloma.
EnglishMandible, Central giant cell granulomaINTRODUCTION
Central Giant Cell Granuloma (CGCG) is defined by the World Health Organization as an intra-osseous lesion consisting of cellular fibrous tissue that contains multiple foci of hemorrhage, aggregations of multinucleated giant cells and occasionally trabeculae of woven bone1 .CGCG was first described by Jaffe in 1953.2 Its etiology is unknown and its biological behavior poorly understood3,4. CGCG is a nonneoplastic lesion that is found exclusively in the maxilla and the mandible1 . Central Giant Cell Granuloma generally occurs in children and young adults with a slight predilection for females. The anterior portion of the mandible has been identified as a more common location for Central Giant Cell Granuloma development, with the lesion frequently crossing the midline4,5. The clinical behavior of central giant cell granuloma varies from a slowly asymptomatic swelling to an aggressive lesion that manifests with pain, expansion of cortex and perforation, mobility, displacement and root resorption of adjacent teeth The majority of Central giant cell granulomas present as a radiolucency either unilocular or multilocular with well defined or ill defined margins. Here we report a case of Central Giant Cell Granuloma in the mandible.
CASE REPORT
A 43 year-old female reported to the Department of Oral Medicine and Radiology with a chief complaint of swelling in the inner aspect of the mouth in the lower jaw for the past six months and pain in the same region for the past two months. It started as a painless swelling in the right mandibular molar region and gradually progressed to attain the present size. There was no previous history of trauma. Past medical history revealed that the patient is a known hypertensive under medication. Past surgical history revealed that the patient underwent a surgery in anterior region of lower jaw on right side at her 20th year of age with a histopathological diagnosis of Central Giant Cell Granuloma. Extra oral examination revealed no obvious facial asymmetry(Figure1).On intra oral examination a localised swelling of size 3x3cm present in region of 46,47 extending anteriorly up to edentulous ridge of 46,posteriorly till mesial surface of 48,superiorly upto edentulous ridge of 46 and inferiorly till buccal vestibule, margins were ill defined, overlying gingiva and alveolar mucosa were smooth with color similar to the adjacent normal mucosa. No secondary changes were present in the swelling. (Figure 2) On palpation bicortical expansion was present. The swelling was firm in consistency, tender on palpation with perforation of cortex felt on buccal aspect. No displacement of teeth was associated. Mandibular occlusal radiograph revealed a radiolucency in the region of 45,46,47 with expansion of the buccal and lingual cortex (Figure 3) Panoramic radiograph revealed a well defined periapical radiolucency in 47 with scalloped and corticated borders extending mesially with peripheral extension showing cyst in a cyst appearance (Figure 4). Routine blood and urine investigations were done which revealed no abnormalities. A provisional diagnosis of Central Giant Cell Granuloma was made, since recurrence was suspected. Incisional biopsy from selected area was carried out, histopathological examination of which revealed numerous multinucleated giant cells and areas of hemorrhage in the background of fibrocellular stroma. The diagnosis was compatible with Central Giant Cell Granuloma. Laboratory investigations for serum calcium, phosphorous, and alkaline phosphatase and parathormone were done and the values within normal limits, excluding the brown tumor of the hyperparathyroidism. The patient underwent curettage of the lesion followed by extraction of 47,48.(Figure 5) Histopathological examination of the excised lesion confirmed preoperative diagnosis of central giant cell granuloma.
DISCUSSION
In 1953 Jaffe first described giant cell reparative granuloma as a benign lesion affecting the mandible and maxilla. The etiopathogenesis of the CGCG of jawbones has not been clearly established but it has been suggested that it is the result of an exacerbated reparative process related to previous trauma and intraosseous haemorrhage that triggers the reactive granulomatous process.6, 7. Although CGCGs are benign osseous lesions, some authors separate CGCG into two types, referring to its clinical and radiographic features: (a) Nonaggressive lesion is usually a slow growing and asymptomatic and does not show cortical resorption or root perforation in teeth affected. It is significantly less likely to recur than the aggressive type8 and (b) Aggressive lesions are usually found in younger patients and are painful, grow rapidly. They are larger in size often causes cortical perforation and root resorption and have a tendency to recur9 . To predict the behavior of CGGCs that will exhibit a higher risk of recurrence after treatment has been problematic. The rate of recurrence varies between13-49%. The most reliable factors related to an increased risk of recurrence include clinical activity of lesions (72% of recurrence in the aggressive forms, 3% of recurrence in the nonaggressive forms), younger patients, demonstrated perforation of cortical bone and tumour size10, 11, 12. Variable reports have been published regarding gender predilection, but the CGCG occur more commonly in females with a female-male ratio of approximately 2:1. The 60 % of cases occur before the age of 30 years .In the presently described case also, the patient is a 43 year old female, agrees with the above observations regarding sex. As per the previous literature, the lesions develop twice as often in the mandible with site predilection anterior to the first molar in young patients and there is a tendency to occur in the posterior aspect of the jaw after the first two decades of life. In the case presented here, the lesion occurred in the region of 46, 47 extending till mesial surface of 48.This location is somewhat posterior to its usual occurrence, in young patients and matches with its tendency to occur in the posterior aspect of jaw in older patients. Radiographic appearance of CGCG can be unilocular or multilocular, with either well defined or ill defined margins. Root resorption and tooth displacement may also be evident. In the present case there is well defined unilocular periapical radiolucency in 47 with scalloped and corticated borders. This radiographic appearance is indistinguishable from that of odontogenic cyst, Aneurysmal Bone Cyst (ABC), ameloblastoma, odontogenic myxoma and odontogenic fibroma. Histologically Central Giant Cell granuloma shows cellular fibrous tissue containing multiple foci of hemorrhage, aggregations of multinucleated giant cells and occasional trabeculae of bone. In presently reported case, all the classic histopathological features were noted and diagnosis was made. Numerous lesions such as cherubism, fibrous dysplasia, primary and secondary hyperparathyroidism (brown tumor), anerysmal bone cyst and giant cell tumor (GCT) should be considered in differential diagnosis. GCT is distinctly unusual in the jaw; moreover, giant cells are regularly and uniformly distributed in GCT, while they are clumped in areas separated by virtually devoid areas of central giant cell granuloma. Fibrous dysplasia can be excluded by presence of numerous trabeculae of coarse immature bone showing no relation to functional pattern. Aneurysmal bone cysts show large sinusoidal spaces filled by blood. Both histological and radiological similarities has been reported in brown tumors and CGCG, but normal serum levels of calcium, phospho-rous, alkaline phosphatase and good renal function help in diagnosis of CGCG and excluding the condition of hyperparathyroidism. Cherubism is also histologically similar to CGCG, but it usually occurs in children affecting the jaws, bilaterally, with a hereditary autosomal dominant mode. Management includes simple enucleation, curettage or enbloc resection. Non surgical treatment of CGCG is by intralesional instillation of corticosteroids, subcutaneous calcitonin injections and alpha interferons13. Radiotherapy has not proven to be a statisfactory alternative, because irradiation of giant cells lesions may provoke malignant degradation. The traditional treatment of CGCG is represented by surgical removal via an intraoral approach and the extent of tissue removal ranges from a simple curettage to an enbloc resection. The most aggressive or recurrent lesions can require en bloc bone resection and reconstruction, since it can determine a bone defect and teeth loss. In this case after ruling out the possibility of hyperparathyroidism, the lesion was curetted, along with extraction of 47,48.The patient is under followup(Figure 6).
CONCLUSION
A case of CGCG in a 43 year old female presenting as unilocular radiolucency with scalloped borders in the radiograph posterior to mandibular first molar is reported and its clinical and radiological features are discussed. The pathogenesis and nature of these giant cell lesions still remain enigmatic and therefore further research is needed.
ACKNOWLEDGMENT
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 authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=403http://ijcrr.com/article_html.php?did=4031. Kramer IR, Pindborg JJ, Shear M. Histological Typing of Odontogenic Tumors (2nd Ed). Springer-Verlag; 1999: 31.
2. Jaffe HL Giant cell reparative Granuloma, traumatic bone cyst and fibrous (fibro-osseous) dysplasia of jaw bones, Oral Surg Oral med Oral path 1953; 6; 159-175
3. Cohen MA. Management of a huge central giant cell granuloma of the maxilla. J Oral Maxillofacial Surg 1998; 46: 509-513.
4. Bataineh AB. Thu surgical treatment of central giant cell granuloma of the mandible. J Oral Maxillofac Surg 2002; 60: 756- 761.
5. Ficarra G, Kaban LB, Hansen LS. Central giant cell granuloma of the mandible and maxilla: a clinicopathologic and cytometric study. Oral Surg Oral Med Oral Pathol 1987; 64: 44-49.
6. Ustundag E, Iseri M, Keskin G, Muezzinoglu B. Central giant cell granuloma. Int J Pediatr Otorhinolaryngol 2002; 65:143-6
7. Kauzman A, Li SQ, Bradley G, Bells RS, Wunder JS, Kandel R. Central giant cell granuloma of the jaws: assessment of cell cycle proteins. J Oral Pathol Med 2004; 33:170-6.
8. Eisenbud L, Stern M, Rothberg M, Sachs SA. Central giant cell granuloma of the jaws: experiences in the management of 37 cases. J Oral Maxillofac Surg 1988; 46:376-84
9. Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg 1986; 44:708-13.
10. Kruse-Losler B, Diallo R, Gaertner C. Central giant cell granuloma of the jaws: A clinical, radiologic, and histopathologic study of 26 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101:346–54. [ Pub Med ]
11. Minic A, Stajcic Z. Prognostic significance of cortical perforation in the recurrence of central giant cell granulomas of the jaws. J Craniomaxillofac Surg. 1996; 24 :104–8. [ Pub Med ]
12. Bataineh AB, Al-Khateeb T, Rawashdeh MA. The surgical treatment of central giant cell granuloma of the mandible. J Oral Maxillofac Surg. 2002; 60 :756–61. [ Pub Med ] 13. Hedge R.J. Central giant cell granuloma in child: A case report Journal of Indian Socie for Pediatric and Preventive dentistry 2004 22 (3); 106-108
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareSTUDY OF CLINICO-PATHOLOGICAL AND BACTERIOLOGICAL PROFILE OF URINARY TRACT INFECTIONS IN GERIATRIC PATIENTS WITH TYPE 2 DIABETES MELLITUS
English1318Bhumika VaishnavEnglish Arvind BamanikarEnglish Pragati MaskeEnglish Vivek Singh RathoreEnglish Vinit KhemkaEnglish Deepshikha SharmaEnglishIntroduction: The elderly with type2 Diabetes Mellitus(DM) have a greater frequency and severity of urinary tract infections(UTIs) due to long duration of DM, its neurovascular complications, long term insulin use, aging and suppression of immune system. The term UTI encompasses asymptomatic bacteriuria (ABU), urethritis, cystitis, prostatitis and pyelonephritis.
Aims: To study the clinical and microbiological profileof UTI in patients more than 60 years of age having type2 DM. To examine whether the presence of diabetes alters the risks and complication profile for UTI’s in elderly.
Materials and Methods: Cross-sectional, analytical study of elderly diabetic patients with UTI diagnosed on the basis of detailed clinical history and investigations.
Results: Out of 60 study subjects, 24 were male and 36 were female with maximum incidence of UTI occurring in 65-69 years of age group. 66.67% of patients had diabetes for more than 10 years and more than 70% were on insulin therapy. HbA1c valu was greater than 8 in 66.67% subjects. Foul smelling urine, dysuria and urgency were the commonest symptoms. Escherchiacoli (E coli) was the commonest pathogen isolated in 70% patients. 26.67% subjects had complicated UTI’s and acute kidney injury was the common complication
Conclusion: E. Coli is the commonest organism causing UTI in elderly diabetics. There was no gender difference in the incidence of UTI. The possible risk factors for UTI in elderly diabetics are long duration of disease (more than 10 years), prolonged insulin therapy and high HbA1c values..
EnglishUrethritis, Asymptomatic bacteriuria, Diabetes mellitus, E. coliINTRODUCTION
Diabetes Mellitus (DM) is a chronic disorder of carbohydrate and fat metabolism having multisystem involvement. Type 2 DM, which is more common, is charactersized by insulin resistance, impaired insulin secretion and increased gluconeogenesis in the liver[1]. Individuals with DM have a greater frequency and severity of infections [2]. Defective migration, phagocytic alterations of chemotaxis in polymorphonuclear leukocytes and impaired cytokine secretion are well documented in type 2 DM[3]. Urinary tract infections (UTIs), both upper and lower tract, are very common in diabetic patients. The term UTI encompasses asymptomatic bacteriuria (ABU), urethritis, cystitis, prostatitis and pyelonephritis. UTIs can be asymptomatic or symptomatic in diabetics. The population most likely to suffer from UTIs is the geriatric diabetic population (60+ years) due to increased duration of disease, long term insulin use, aging, and immune system suppression. Dysfunctional bladders, obstruction in urinary flow, and incomplete voiding are additional factorsin elderly diabetic patients which may cause recurrent UTIs. UTI is twice as common in diabetic females as in non-diabetic females [4][5][6]. UTIs, although uncommon in diabetic men, have higher incidence of complications [7]. Also, as DM is an immunocompromised state, early diagnosis and investigations can prevent dreaded complications such asascending infections including emphysematous pyelonephritis, renal and perirenal abscesses, acute kidney injury and septicaemia in elderly and thus reduce the morbidity[8].
MATERIALS AND METHODS
The study was conducted in the medicine department of a tertiary care hospital. Both inpatients and outpatients were included in the study which was carried out over a period of three months. All patients more than 60 years of age with type 2 DM diagnosed with UTIs (urine showing significant bacteriuria ≥105 CFU/ml of urine) were included in the study. A total of 60 subjects were included in the study. After an informed consent from the patients, they were subjected to a detailed history, physical examination and relevant clinical investigations. Selection criteria for type 2 DM were: a)Fasting blood sugar more than 126 mg/dl OR b) Post-prandial blood sugar more than 200 mg/dl OR c) Patients on drug treatment for diabetes. Patients having age less than 60 years, hypertension, chronic kidney disease, Type 1 DM or known anatomical or surgical defects in the genitourinary tract were not included in the study. Diagnosis of urinary tract infection was made on the basis of clinical history, symptoms and detailed clinical examination. Biochemical investigations of blood and urine were done to confirm the diagnosis. The study subjects, after giving proper instructions, were asked to submit a midstream urine sample which was transported to the microbiology laboratory of the hospital immediately. After ensuring that the urine sample was uncontaminated (by normal vaginal/urethral flora), it was centrifuged and examined under a microscope(×400 magnification). Presence of pyuria (≥ 10 leukocyte/hpf) with a positive leukocyte esterase and/or nitrite tests was considered as a positive urinalysis. The collected samples were then subjected to gram staining and culture testing to identify the species of the pathogens. Significant bacteriuria (SB) was defined as presence of ≥ 105 colony forming units (CFUs) of isolated organisms per millilitre of urine sample in urine culture. Presence of significant bacteriuria with urinary symptoms was diagnosed as UTI. Presence of SB in two consecutive urine samples collected at a seven day interval but without classic urinary symptoms was diagnosed as asymptomatic bacteriuria (AB). Positive history of UTI within past six months was diagnosed as recurrent UTI. Pyelonephritis was diagnosed by presence ofsymptoms of UTI with fever, abdominal pain, leukocytosis and associated with SB. The following investigations were carried out: a)Complete Hemogram - Hemoglobin (Hb in gm/dl); total and differential leukocyte count (TLC, DLC in lac/cumm); erythrocyte sedimentation rate (ESR) (by auto-analyser); b) Urine routine including pH, specific gravity, proteins and albumin, sugar. In Microscopic examination pus cells, epithelial cells, red blood cells, bile salts, bile pigments. c) Urine culture and Blood culture; d) Renal function tests including blood urea (mg/dl), serum creatinine (mg/dl); e)Blood sugar level profile including fasting blood sugar (mg/dl), post prandial blood sugar (mg/dl) (by Glucose Oxidase – Peroxidase method); f) Glycosylated haemoglobin (HbA1C) (by Resin method); g) Ultrasound of abdomen and pelvis and X-ray kidney, ureter, bladder (KUB) as and when required. Data was analyzed using statistical package SPSS version 16. The mean was the primary statistical measure used. The chi-square statistical test was used and a p-value < 0.05 was considered statistically significant.
RESULTS
Out of 60 patients, 24 were males and 36 were females. Maximum incidence of UTI occurred in age group of 65-74 years (60%). The mean age of the study subjects was 68.2 years. Chi-square test showed non-significant relationship between different age groups and gender (Table 1). This shows that UTI occurred with similar frequency in both genders in different age groups. A majority of the study subjects had DM for more than 10 years (Fig. 1) with HbA1c value more than 8(66.67%) (Table 2). There was a non-significant relationship between different levels of HbA1C and gender (p-value >0.05). This shows that both the genders are equally distributed among different levels of HbA1C. At the time of enrolment in the study, 70% subjects were on insulin therapy and remaining 30% were on oral hypoglycaemic drugs. 34(56.67%) diabetic patients had their first episode of UTI whereas 26 (43.33%) had recurrent bouts of UTI in the study. The odds for occurrence of recurrent episodes in females were 1.12 which shows that there is 1.12 times more risk for developing recurrent episodes in females than males. But it was statistically not significant (p> 0.05). 76.67% patients had foul smelling urine, which was the most common presenting symptom, followed by dysuria and urgency (66.67%) (Table 3). Lower UTI i.e. urethritis (36.67%) and asymptomatic bacteriuria (33.33%) were commonly found in the subjects. Urethritis was more common in older females (44.44%) as compared to males (25%). Asymptomatic bacteriuria occurred with equal frequency in both males and females. Cystitis accounted for 13.33% cases of UTI and Pyelonephritis accounted for 16.67% cases. E.coli was the commonest organism isolated from the urine of elderly diabetics accounting for 70% infections, followed by candida species which was found in 13.33% cases. The remaining 16.67% of pathogens were E.faecalis and S.aureus. The difference in incidence of isolation of E.coli in both genders is statistically not significant (Fig. 2). Acute kidney injury was the commonest complication of UTI in elderly diabetics (20%) followed by pyelonephritis (10%) and septicaemia (3.33%) (Table 4). UTI was complicated in 33.33% cases. Mortality rate was 1.67% and cause of mortality was septicemic shock secondary to urosepsis with uncontrolled diabetes mellitus.
DISCUSSION
In this study, 60 diabetic patients above the age of 60 years with symptoms suggestive of UTI were included and investigated. Their clinical profile and laboratory data were analyzed to determine the spectrum of presenting clinical features, complications and common causative organisms for UTI. In the current study, the incidence of UTI in elderly diabetics was the maximum in the age group of 65-69 years (36.67%). 20% of the patients were of more than 75 years of age. A study by Geerlings et al. has shown similar results, i.e. the incidence of UTI increases with ageing in type 2 DM patients.[4] Females (60%) had a higher incidence of UTI than males (40%) in this study. Premenopausal female diabetics commonly have UTIs due to urinary tract contamination by vaginal bacterial flora.[9] But the current study showed that even postmenopausal and elderly diabetic women have a higher incidence of UTI compared to elderly males. Evidence from study by Boyko et al. have shown similar results. [5] Longer duration of type 2 DM (> 10 years in 66.67% subjects), insulin therapy (70% subjects), uncontrolled DM (HbA1C > 8 in 66.67% subjects) were all striking clinical parameters associated with increased incidence of UTI in the study. The findings of a study carried out on south Indian subjects were similar.[10] However, in another study by Schmitt et al., longer duration of diabetes but not glycaemic control (HbA1c values), was associated with higher incidence of UTI.[11] A study by Boyko et al. did not find any significant association between the degree of glycaemic control as assessed by HbA1c level and odds of UTI.[5] Our study also did not find any significant association between HbA1C levels and odds of developing complicated UTI. Thus, the association between glycaemic control as determined by HbA1c levels and UTI among diabetic patients is controversial. In the current study, 43.33% subjects had a history of recurrent UTI with a minor degree of female preponderance. But there was no significant statistical association between DM type 2 and recurrent UTI in elderly females (p>0.05) which was similar to a study by Raz R et al., where DM type 2 was not found to be a risk factor for recurrent urinary tract infections in postmenopausal women.[12] In this study, elderly patients presented with various symptoms but foul-smelling urine was the commonest symptom (76.67%), followed by dysuria, urgency (66.67%) and frequency (56.67%). These findings are in accordance with the observations of a study by Marques et al.[13] A few patients had no symptoms suggestive of UTI and were admitted for uncontrolled diabetes but were found to have asymptomatic bacteriuria on routine examination of urine. Only 40% patients presented with fever in this study showing that in aged diabetic patients, UTI may be present in the absence of fever. Thus, a high index of suspicion for UTI should be kept while evaluating an elderly diabetic with atypical symptoms like urinary retention (13.33%) and incontinence (6.67%) which were also presenting symptoms of a few patients in this study. Urethritis was the commonest form of UTI followed by asymptomatic bacteriuria. However, urethritis occurred with increasing frequency in elderly females compared to males possibly due to shorter urethra and concomitant vaginitis. Complicated pyelonephritis was present in 16.67% patients. This high prevalence of upper UTI can be due to ascending infection, impaired host defences, late presentation of elderly diabetics. Upper urinary tract infections (UTIs) are also a frequent result of bladder colonisation. These findings corresponded well with those of some other studies.[6] As a point of difference, the incidence of pyelonephritis was very high in the current study as compared to the study conducted by Marques et al. where the incidence was only 2.02%. However, the latter study was carried out on community-dwelling elderly women without DM.[13] Thus, type 2 DM is an independent risk factor for developing upper UTI. E.coli was the pathogen isolated in 70% of the study subjects. It occurred with nearly equal frequency in males and females, which is in concordance with other studies.[2,10] Other Gram-negative bacilli like Klebsiella Spp., Proteus Spp., and Citrobacter Spp. were not isolated in the current study. This may be due to the smaller sample size of the current study. In another study from India, it was found that E. coli was the most commonly grown organism (64.3%), followed by Staphylococcus aureus (21.4%) and Klebsiella pneumoniae (14.3%).[14] In a study by Geerlings SE et al., it was noted that increased adherence of E. coli (with type 1 fimbriae) to uroepithelial cells correlated positively with high HbA1C. Higher adherence of E. coli to the uroepithelium was found in patients with poorly controlled diabetes.[15]Candida was isolated from 13.33% subjects in the current study. Prolonged hospitalisation, urethral catheterisation and long term parenteral antibiotic therapy predispose elderly diabetics to candida infections.[16]Gram-positive cocci play a lesser role in UTIs. In the current study, Staphylo-coccus aureus accounted for 10% of UTI. Another common Gram-positive cocci is Staphylococcus saprophyticus which causes UTI in younger females. Complicated UTIs due to Enterococci and S. aureus are quite common, particularly in patients who have received antibiotic treatment or who have undergone instrumentation of the urinary tract. Enterococcus Faecalis was isolated in 6.67% elderly diabetic subjects with UTI in this study. Most of these subjects had a recent history of receiving antibiotic therapy for other infections. Acute kidney injury (AKI), ascending infection to kidneys from lower urinary tract and septicaemia were few complications seen in the study subjects with UTI. However, majority of elderly DM –type 2 patients had an uncomplicated UTI (66.67%). Thus, although UTI occurred with higher frequency in elderly diabetics, the rate of complications was low. AKI was also the commonest complication in a study done by Aswani SM et al.[16]
CONCLUSION
Indiais known as the ‘diabetes capital of the world’ because of Asian-Indian phenotype i.e. high waist to hip ratio. Type 2 DM forms the major burden causing great morbidity due to recurrent infections like UTI and other microvascular and macrovascular complications. India also has a large population of age above 60 years - 8% (according to Census India 2011), many of whom are diabetics. They are prone to recurrent and complicated UTI which causes significant healthcare burden on the society. The current study was aimed at identifying causative micro-organisms of UTI in elderly diabetics and to study their clinical presentation and complications. The results were compared with other similar studies done within and outside India. E.coli was the commonest micro-organism causing UTI followed by candida. Thus, the distribution of organisms found in the urine of patients is similar to that in other populations. There was no statistically significant difference in the incidence of recurrent UTI between male and female subjects in the study. None of the study subjects had HbA1c0.05) Substantial research has been done involving a study group of post-menopausal diabetic female populations. But very few studies have been done on elderly male diabetic subjects. This is the distinguishing feature of the current study. Investigation of asymptomatic or symptomatic bacteriuria in aged diabetic patients for urinary tract infection is important for treatment and prevention of renal complications. However, the sample size in the current study was small and was done for a limited period in a single hospital. Hence, larger study population studied for a longer duration in multiple hospitals will be required to strengthen and confirm our conclusions.
ACKNOWLEDGEMENT
The authors acknowledge the immense help received from scholars whose articles are cited and included in the references to this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=404http://ijcrr.com/article_html.php?did=4041. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J; Diabetes mellitus, Harrison’s principles of internal medicine, 18th edition, chap. 344, pg no.2974.
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3. Brauner AM, Flodin U, Hylander B, Östenson CG. Bacteriuria, Bacterial Virulence and Host Factors in Diabetic Patients, Diabetic Medicine; 1997:10(6), 550–554.
4. Geerlings SE, Stolk RP, Camps MJ, Netten PM, Hoekstra JB, Bouter KP. Asymptomatic bacteriuria may be considered a complication in Women with diabetes mellitus Utrecht Study Group. Diabetes Care; 2000:23(6), 744-749.
5. Boyko EJ,Fihn SD, Scholes D. Diabetes and the Risk of Acute Urinary Tract Infection Among Postmenopausal Women. Diabetes Care; 2002: 25(10), 1778-1783.
6. Gilbert GG, Donders MD. Lower genital tract infections in diabetic women. Current Infectious Disease Reports; 2002: 4(6), 536-539.
7. Hoepelman AIM, Meiland R, Geerlings SE. Pathogenesis and management of bacterial urinary tract infections in adult patients with diabetes mellitus. International Journal of Antimicrobial Agents; 2003:22(2), 35–43.
8. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am; 1995: 9(1), 25-51.
9. Minardi D, d’Anzeo G, Cantoro D, Conti A, Muzzonigro G. Urinary tract infections in women: etiology and treatment options. Int J Gen Med. 2011; 4: 333–343
10. Janifer J, Geethalakshmi S, Satyavani K, and Viswanathan V. Prevalence of lower urinary tract infection in South Indian type 2 diabetic subjects. Indian J Nephrol; 2009; 19(3): 107–111.
11. Schmitt JK, Fawcett CJ, Gullickson G. Asymptomatic bacteriuria and hemoglobin A1c. Diabetes Care. 1986;9:518– 20.
12. Raz R, Gennesin Y, Wasser J, Stoler Z, Rosenfeld S, Rottensterich E, et al. Recurrent urinary tract infections in post menopausal women. Clin Infect Dis. 2000;30:152–6.
13. Marques LP, Flores JT, Barros Junior Ode O, Rodrigues GB, MourãoCde M, Moreira RM. Epidemiological and clinical aspects of urinary tract infection in community-dwelling elderly women.Braz J Infect Dis: 2012;16(5):436-41.
14. Goswami R, Bal CS, Tejaswi S, Punjabi GV, Kapil A, Kochupillai N. Prevalence of urinary tract infection and renal scars in patients with diabetes mellitus. Diab Res Clin Pract.2001;53:181–6.
15. Geerlings SE, Meiland R, van Lith EC, Brouwer EC, Gaastra W, Hoepelman AIM. Adherence of type 1-fimbriaeted E. coli to uro epithelial cells: More in diabetic women than in control subjects. Diab care. 2002;25:1405–9.
16. Aswani SM, Chandrashekar U, Shivashankara K, Pruthvi BC. Clinical profile of urinary tract infections in diabetics and nondiabetics; Australas Med J.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcarePHYSIOTHERAPY FOR INTERMITTENT CLAUDICATION: A REVIEW ARTICLE
English1924Preeti S. ChristianEnglishPeripheral arterial disease (PAD) mainly occurs due to atherosclerotic stenosis or occlusion of the arteries of the lower limbs, resulting in an impairment of blood flow to the legs. Patients with PAD have a significant reduction in their physical activities like walking due to intermittent claudication. Intermittent claudication is a major symptom of Peripheral arterial disease. It is cramping pain, aggravated by exercise and relieved by rest. It is because of atherosclerosis, fatty deposits blocking blood flow through the arteries, which reduce blood flow to the muscles of leg. Treatments include stopping smoking, starting to physiotherapy, drugs
and surgery. This review of article found that physiotherapy can relieve intermittent claudication for many people. Exercise may be better than angioplasty. Some other types of surgeries are available which are more effective than exercise, but they carry more risks. Nowadays various modes of physiotherapy are available. It is advisable to start physiotherapy treatment with proper guidance.
EnglishIntermittent claudication, Peripheral arterial disease, Atherosclerosis, Physiotherapy.INTRODUCTION
Intermittent claudication is a symptom that describes muscle pain (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest. The pain occurs again when the same amount of exercise is taken. It is classically associated with early-stage peripheral artery disease, and can progress to critical limb ischemia unless treated or risk factors are modified. Peripheral arterial disease (PAD) is characterised by atherosclerotic stenosis or occlusion of the arteries of the lower limbs, resulting in an impairment of blood flow to the legs. Claudication derives from the Latin verb claudicare, “to limp”.1 it is thought that 10% of patients with IC progress to critical limb ischemia and 2% require amputation.2 There are multiple classifications for which to grade the severity of claudication, such as the Fontaine scale: 4
• Stage 1 - No symptoms
• Stage 2 - Intermittent claudication 2a - no resting pain, onset of claudication in more than 200 meters 2b - no resting pain, onset of claudication in less than 200 meters
• Stage 3 - Nocturnal and/or resting pain
Stage 4 - Necrosis (death of tissue) and/or gangrene in the limb Investigation can be done by Ankle brachial pressure index, Exercise tests, Electrocardiography, Angiography.3
TREATMENT AVAILABLE FOR INTERMITTENT CLAUDICATION 3
1. MEDICAL TREATMENT:
• Medications to help control high blood pressure and cholesterol. Other drugs that may help include antiplatelet medications to prevent blood clots.
• In severe cases, procedures may be needed to open blocked blood vessels.
2. PHYSIOTHERAPY TREATMENT:
• Regular exercise, which is essential for patients with mild-to-moderate PAD.
3. OTHER MEASURES:
• Smoking cessation.
PHYSIOTHERAPY GUIDELINES:
Following are the guidelines for the management of patients with lower extremity peripheral arterial disease with complain of IC which is given by American Heart Association and American College of Cardiology (AHA/ACC): 4
• Supervised treadmill or track walking at an intensity that elicits claudication symptoms within 3 to 5 minutes (a score of 1 on the Claudication Pain Rating Scale-Figure 1).4
• Walking until the claudication pain is rated as moderate (a score of 2 on the Claudication Pain Rating Scale- Figure 1), followed by standing or sitting rest to permit symptoms to resolve.4
• Repeating these exercise and rest cycles for 35 minutes of intermittent walking.4
• Increasing the exercise program by 5 minutes per session to 50 minutes, 3 to 5 times per week, for a minimum of 12 weeks.4
DIFFERENT MODES OF EXERCISES:
1. SUPERVISED VS NON SUPERVISED 6, 7
In regular care, exercise therapy is usually prescribed in the form of advice to “go home and walk”, without supervision or follow-up. 6 There is no evidence to support the efficacy of this advice and compliance is known to be low.7 Factors, such as fear of pain, inadequate knowledge and poor general condition, contribute to the difficulty of starting, sustaining and maintaining exercise therapy. Supervised exercise therapy (SET) entails adequate coaching to increase the maximal walking distance. Patients can be gradually transitioned to independent, unsupervised exercise over time if independent exercise is deemed safe by the program staff. At the completion of the supervised training program, patients should be given a home exercise prescription to maintain activity levels because it is expected that exercise training should be continued as a lifelong activity.6, 7
2. LOW VS HIGH INTENSITY 6, 7
Intensity can be guided by an exercise tolerance test with the use of heart rate reserve or oxygen uptake reserve.
3. WEIGHT BEARING VS NON WEIGHT BEARING 47
Weight bearing exercises: treadmill, stepper Non weight bearing exercises: cycling, rowing 4.
UPPER BODY VS LOWER BODY EXERCIS 47
Upper body exercises: Biceps curl, Triceps extension, Overhead press, Lateral raises, Bench press, Lateral pull-down/pull-ups, Bent -over/ seated row Lower body exercises: Leg extensions, curls, press, Adductor/abductor, ankle planter/dorsiflexion, toe flexion/extension
MECHANISM OF EFFECTS OF EXERCISE:
Possible mechanisms, through which exercise may mediate an improvement in intermittent claudication, are described below.
1. Increase Collateral Circulation:
Functional limitation in PAD traditionally has been ascribed to diminished blood flow induced by arterial obstruction from atherosclerotic stenosis. Typical intermittent claudication could theoretically be attributed to ischemia induced by an oxygen demand and supply imbalance. Certainly, fixed atherosclerotic lesions reflected in a diminished ABI are the precipitating event that leads to functional abnormalities in PAD. 8-11 Theoretically, enhanced distal blood flow due to vascular adaptations could underlie the benefits of exercise therapy in PAD. In animal models of arterial insufficiency, available evidence indicates that exercise training augments peripheral arterial supply.8-11 Recent studies demonstrate that exercise stimulates gains in collateral blood flow after femoral occlusion in rodent models through collateral enlargement.8, 12, 13 Collateral growth induced by exercise reflects vascular structural remodelling, a process that depends on both growth factor activity and increased nitric oxide bioavailability via shear stress stimulation of endothelial nitric oxide synthase.8,12,14
2. Improve Endothelial Health:
Normal vascular function depends on a healthy endothelium that elaborates vasoprotective factors, including nitric oxide to regulate arterial flow. Reduced nitric oxide bioavailability in the skeletal muscle microcirculation diminishes the hyperaemic flow response to ischemia and may impede augmentation of blood flow during exercise in PAD.15, 16 Two studies have demonstrated an improvement in endothelial function with exercise training in PAD. A supervised exercise program increased endothelium-dependent flow mediated dilation of the brachial artery by 65% in 19 elderly patients with intermittent claudication.17 In the randomized trial comparing treadmill exercise with lower-extremity strength training and with usual care in PAD, treadmill exercise but not lower-extremity strength training augmented flow-mediated dilation, consistent with improvement in endothelial health. McDermott and colleagues evaluated the effect of each exercise regimen on flow-mediated dilation of the brachial artery.18
3. Enhance Skeletal Muscle Metabolism and Mitochondrial Function: Metabolic dysfunction at the skeletal muscle level superimposed on compromised blood flow has the potential to magnify physical limitation. Episodic ischemia in concert with chronically low physical activity levels alters skeletal muscle phenotype in PAD patients.5 Altered skeletal muscle energetics in PAD has been linked to mitochondrial dysfunction. Abnormal mitochondrial function may interfere with skeletal muscle oxygen utilization and accelerate endothelial damage.19, 20 Decreased calf muscle area and lower type I fiber content are associated with impairments in functional performance measures.21, 22 Exercise training has the potential to enhance skeletal muscle metabolism and mitochondrial function. Interestingly, exercise-induced capillary growth in skeletal muscle also depends on peroxisome proliferators activated receptor-gamma coactivator-1α, suggesting a connection between mitochondrial function and exercise adaptations relevant to PAD.24 In PAD patients, exercise training has been shown to restore carnitine metabolism in association with improved treadmill walking.25, 23
4. Suppressing Inflammatory Activation: Chronic inflammation participates in the atherosclerotic process. Systemic markers of inflammation including C-reactive protein and soluble intercellular adhesion molecule-1 increase the risk of developing PAD.26,27 Higher levels of inflammation are associated with disease progression and with adverse cardiac and lower-extremity outcomes.28-30 Inflammation may accelerate functional impairment in PAD by favouring plaque growth and inducing skeletal muscle injury. Physical activity may have favourable effects in PAD by suppressing inflammatory activation. Extensive epidemiological data demonstrate lower inflammatory marker levels in individuals who participate in regular physical activity compared with those who are sedentary.31A 3-month exercise program ameliorated neutrophils activation after treadmill exercise in 46 PAD patients with claudication.32
DISCUSSION
The earliest suggested therapy for patients with intermittent claudication was exercise therapy. In 1898, Wilhelm Erb first described the results of a patient with intermittent claudication that was successfully treated with exercise.33 The results of the first randomised clinical trial were reported in 1966 by Larsen et al.34 In this study 7 patients were instructed to take a daily walk of at least one hour, besides their normal activities. Patients had to walk until claudication pain forced cessation of exercise and, after a period of rest until the pain disappeared, patients had to repeat the exercise. The 7 patients in the control group were given “medical treatment” in the form of lactose tablets. For the group treated with exercise, a significant increase in maximum walking time was seen, whereas the patients in the control group did not improve their walking distance. Nowadays, exercise therapy is extensively studied, and according to several guidelines the therapy of first choice for patients with complaints of intermittent claudication.35, 36, 37 Housley et al (1988) indicate that “stop smoking and keep walking” has long been the standard first line of management, despite a paucity of adequate studies showing benefits.4 The optimal training program for patients with intermittent claudication should be based on repeated walking until near-maximal pain followed by a short period of rest in a frequency of at least 3 times a week for 30 minutes during a period of at least 6 months.13
SUPERVISED VS NON SUPERVISED EXERCISES: However, the adherence of patients given an oral exercise advice is low. Co-morbidity, lack of specific advice, and lack of supervision are barriers to actually perform walking exercise.39 Supervised exercise therapy (SET) performs better in increasing walking distance compared to an oral exercise advice.38 The Trans-Atlantic Inter-Society Consensus Document on the management of PAD (TASC-II) recommends with ‘level A evidence’ that supervised exercise should be made available as part of the initial treatment for all patients with PAD.40 However, in routine clinical practice most patients only receive an oral advice to increase their walking activities, since supervised exercise programs are not universally available and implemented in daily care for patients with PAD. Supervised exercise programs are more effective than nonsupervised programs in improving treadmill walking distances in patients with IC. The evidence suggests that programs focus on walking at an intensity that elicits symptoms (score of 1 on the Claudication Pain Rating Scale- figure 1) within 3 to 5 minutes, stopping if symptoms become moderate (score of 2 on the Claudication Pain Rating Scale- figure 1), resting until symptoms have resolved, and then resuming walking. The exercise program should be for 30 to 60 minutes of exercise and rest cycles per session, 3 to 5 times per week, for a minimum of 3 months time period.41, 42 A recent Cochrane Review identified a significant improvement in walking distance in patients undergoing a supervised exercise therapy (SET) program compared with those involved in a nonsupervised program, with an increased difference in maximal walking distance of approximately 150 meter after 3 months of time period.43
LOW VS HIGH INTENSITY EXERCISE: Gardner Aw et al conducted a study to find out the effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication. The major finding of this investigation was that PAD patients limited by intermittent claudication who completed a low-intensity exercise program had similar improvements in physical function, peripheral circulation, and health-related quality of life as those patients who completed a high intensity exercise program. In conclusion, the efficacy of low-intensity exercise rehabilitation is similar to high intensity rehabilitation in improving markers of functional independence in PAD patients limited by intermittent claudication, provided that a few additional minutes of walking is accomplished to elicit a similar volume of exercise.44
UPPER VS LOWER EXTREMITY EXERCISE: The results of the randomized controlled trial conducted by Rena Zwierska et al suggested that both upper- and lower- limb weight-supported aerobic exercise training provide an adequate stimulus for evoking improvements in walking performance in patients with PAD. Evidence from the this study suggests that the improvement in walking performance after upper-limb training is due to a combination of central cardiovascular and/or systemic mechanisms in addition to an adaptation in exercise pain tolerance that enables patients to endure a greater intensity of claudication pain before test termination. These findings demonstrate the effectiveness of alternative aerobic exercise interventions for patients with symptomatic PAD. Arm-cranking was very well tolerated by their patient cohort and at high exercise intensities using the interval training regimen. This, and other alternative exercise training modalities such as leg-cranking, and it could be a very useful strategy for improving cardiovascular function and exercise pain tolerance in patients who have become physically inactive due to the discomfort that they encounter during walking, particularly during the early stages of a rehabilitation program45
WEIGHT BEARING VS NON WEIGHT BEARING: Sanderson B et al concluded that however all forms of activity beneficial to Cardio Vascular health and fitness; nonweight bearing was more bearable still weight bearing was better, including 1.9 minutes increased time before onset of claudication. 46
CONCLUSION
Physiotherapy is very effective for patients with intermittent claudication to improve functional capacity and reduce cardiovascular risks. Patient can start with supervised program and then can switch to non supervised home program with proper selection of frequency and intensity. Patients should be encouraged to commence exercise at a moderate intensity, and should stop and rest if claudication pain becomes severe. Walking is most commonly used exercise form by patients. Other forms of exercise like cycling, arm-cranking, strengthening of large muscles of upper/lower body may also are incorporated as tolerated by patients. So physiotherapy treatment with proper guidance is very effective to relieve intermittent claudication.
ACKNOWLEDGEMENT
I am very much grateful to my loving family members and friends for their interest in my academic excellence and also for their encouragement and support. I acknowledge the great help received from the scholars whose articles cited and included in references of this manuscript. I am 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 am grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
ABBREVIATIONS
PAD : Peripheral arterial disease
IC : Intermittent claudication
ABI : Ankle brachial pressure index
SET : Supervised exercise therapy
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6. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams and Wilkins; 2010
7. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. Champaign. IL:Human Kinetics; 2004.
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10. Yang HT, Ren J, Laughlin MH, Terjung RL. Prior exercise train-ing produces NO-dependent increases in collateral blood flow after acute arterial occlusion. Am J Physiol.2002;282:H301– H310.
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13. Yang HT, Ogilvie RW, Terjung RL. Training increases collateral dependent muscle blood flow in aged rats. Am J Physiol. 1995;268:H1174–H1180.
14. Yu J, demuinck ED, Zhuang Z, Drinane M, Kauser K, Rubanyi GM et al. Endothelial nitric oxide synthase is critical for ischemic remodeling, mural cell recruitment, and blood flow reserve. Proc Natl Acad Sci U S A. 2005;102:10999 –11004.
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17. Brendle DC, Joseph LJ, Corretti MC, Gardner AW, Katzel LI. Effects of exercise rehabilitation on endothelial reactivity in older patients with peripheral arterial disease. Am J Cardiol. 2001;87:324 –329.
18. Mcdermott MM, Ades P, Guralnik JM, Dyer A, Ferrucci L, Liu K et al. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial. JAMA. 2009;301:165– 174.
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20. Bauer TA, Brass EP, Barstow TJ, Hiatt WR. Skeletal muscle sto2 Kinetics are slowed during low work rate calf exercise in peripheral Arterial disease. Eur J Appl Physiol. 2007;100:143–151.
21. Mcdermott MM, Hoff F, Ferrucci L, Pearce WH, Guralnik JM, Tian L et al. Lower extremity Ischemia, calf skeletal muscle characteristics, and functional impairment in peripheral arterial disease. J Am Geriatr Soc. 2007;55:400–406.
22. Askew CD, Green S, Walker PJ, Kerr GK, Green AA, Williams AD et al. Skeletal muscle phenotype is associated with exercise Tolerance in patients with peripheral arterial disease. J Vasc Surg. 2005;41:802– 807.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareSCREENING OF SEED OILS FROM FOUR SPECIES OF GENUS IPOMOEA
English2528Mohammed TaufeequeEnglish Abdul MalikEnglish M. R. K. SherwaniEnglishBackground: India depends upon world market to fulfill their industrial and domestic demand of oil, account huge foreign exchange. Since agriculture in India depend upon monsoon, causes uncertainty. In last few decades, there is rapid increase in demand of oil and their oleo chemicals in industries like plasticizers, lubricants, pharmaceuticals, organic pesticides, agro products etc.
Aim: The aim of this study is to explore non-traditional oil sources in order to establish them for various purposes.
Methodology: Seeds from four plant species of genus Ipomoea (I. indica, I. nil, I. pestigridis and I. quamoclit) belonging to convolvulaceae family were subjected to various analytical technique to evaluate their physico-chemical properties. Fatty acid methyl esters (FAMEs) were analyzed using chromatographic and spectroscopic techniques to evaluate their fatty acid compositions.
Results: The results show that the oil yields from the seeds varied from 7.84% to 14.71%. Linoleic and oleic acids were found major fatty acids in all four seed oils. They show high iodine and saponification values. The all four seed oil show high content of polyunsaturated fatty acids (PUFAs) and P/S index more than 1.
Conclusion: Fair oil%, high saponification value and P/S index more than 1, indicated us to use these parameters to establish them as alternate oil sources for various domestic and industrial applications.
EnglishGenus Ipomoea, fatty acid compositions, polyunsaturated fatty acids (PUFAs), Oleo chemicals, P/S indexINTRODUCTION
Genus Ipomoea belongs to convolvulaceae; morning glory family, prominently found in southern, mid-western and western India. Ipomoea is the largest genus of convolvulaceae family; consist over 500 species world wide of which about 60 species are native to India. There are some familiar and economically important examples of this genus; such as Ipomoea batatas (sweet potato), Ipomoea aquatica (water spinach), Ipomoea carnea (mahananda) etc. All four Ipomoea species (I. indica, I. nil, I. pestigridis and I. quamoclit) are climber, common in tropical and sub tropical region. Ipomoea indica (blue morning glory) is a herbaceous twining vine. The plant has laxative property and root paste applied to backaches and sore muscles as a poultice (1). Ipomoea nil is commonly known as Japanese morning glory, seed show hepatoprotective activity (2). The dried seeds are used in anti-inflammatory, Inflammations, Constipation, Dyspepsia, carminative, depurative, Purgative, Vermifuge, Bronchitis, Fever, Skin diseases, Scabies etc. and also used as purgative (3,4). Ipomoea pestigridis (Tigers foot morning glory) leaves extract is administered orally for treatment of intestinal worms (5). Roots are proved beneficial for women in urinary retention, constipation and gynecological disorder and also useful in purgative (3,6). Whole plant along with bread is eaten for healing wounds (7). Ipomoea quamoclit (Cyperus vine) seed is helpful in laxative (8), crushed root with sugar administered orally to cure passing of semen with urine (9). Its leaves are beneficial in ulcer, chest pain (10) and along with stem are helpful in fever, diabetes (11). Hydro-alcoholic extract of its aerial parts show significant radical scavenger activity (11,12). Plant oils are important biomolecules, mostly are in the form of triglycerides (13), they are good sources of usual and unusual fatty acids. In past few decades, production and utilization of oils and fats have grown in size and diversity. Use of Oleo-chemicals have also grown in size in verity of industries such as surfactants, plasticizers, lubricants, pharmaceuticals, soap, detergents, organic pesticides etc. The majority of world oil production depends on few plant species such as soybean, palm, rapeseed, sunflower, ground nut, olive etc. In order to meet the necessary demand of oils and because of different geographical and climatic conditions many plant species have been domesticated and cultivated for centuries for vegetal, medicinal and industrial applications. In our research, we have studied seed oils of genus Ipomoea to evaluate their potential applications for various purposes.
MATERIAL AND METHOD
Sample collection and trans-estrification
Seeds of four species (I. indica, I. nil, I. pestigridis and I. quamoclit) were collected at maturity from arid and semi arid region of western Rajasthan (India). The whole seeds were used for the analyses, were freeze-dried and ground to powder using mortar and analyzed immediately. Oil extraction was performed from grounded seeds of four species with light petroleum ether (40-60o C) using soxhlet extraction technique. The solvent was removed completely under vacuum using rotary evaporator. The analytical values of seeds and seed oils were determined according to American Oil Chemist Society (AOCS) methods (14). Methyl esters of oils were prepared using trans-esterification technique (15).
Analyses of Fatty Acid Methyl Esters
IR spectrums of Fatty Acid Methyl Esters (FAMEs) were recorded using Perkin Elmer RX-I FTIR on KBr cell. The UV-Vis. Spectrum was performed on Perkin Elmer Lambda 15 UV/Vis spectrophotometer. FAMEs were analyzed in Thermo scientific TSQ 8000 Gas Chromatograph- mass spectrophotometer. A capillary column of polysilphenylenesiloxane (BPX 70 TM; length: 25 m; internal diameter: 0.22 mm; thickness of film: 0.25 µm ) was used. Helium was the carrier gas at a flow rate of 1 ml/min. The injector temperature was 250 o C and detector temperature was 260 o C. The oven starting temperature was 80 o C and increased to 200 o C at rate of 8 o C/min, held for 10 min. then increased to 250 o C at rate of 10 o C/min, held for 10 min.
RESULTS
Seed oils of four species from Ipomoea genus were evaluated. They are liquid at room temperature and free from any sediment. The analytical values of seeds and seed oils are given in table I. The oil content of the seeds was 10.39% for I. indica, 7.84% for I. nil, 14.71% for I. pestigridis and 10.37% for I. quamoclit. The protein content in the seeds was varied 13.11% (I. quamoclit) to 23.89% (I. pestigridis). The seed oil of I. quamoclit showed highest saponification value (207.41) and the seed oil of I. indica showed highest iodine value (134.29). The iodine values obtained by experimental procedures are in well agreement with fatty acid composition of seed oils. The IR and UV-Vis spectra of FAME exhibited no absorption band for the presence of any trans unsaturation and conjugation respectively. The oils were examined by GC-MS analysis to the fatty acid content. Fatty acid and their cumulative compositions of seed oils are given in table II. Linoleic acid (ω-6, essential fatty acid) was found to be most abundant fatty acid in I. indica (38.72%), I. pestigridis (37.69%), I. nil (33.50%) and I. quamoclit (29.65%). The second most abundant fatty acid in I. indica, I. nil, I. pestrigridis and I. quamoclit was oleic acid (ω-9, non essential fatty acid) with 23.43%, 23.10%, 25.73% and 20.73% to the total fatty acid respectively. The amount of linolenic acid (ω-3, essential fatty acid) in the seed oils of I. indica, I. nil, I. pestrigridis and I. quamoclit was 13.47%, 9.56%, 9.47% and 13.54% respectively. Amoung SFAs stearic was the most abundant fatty acid in I. indica and I. quamoclit followed by palmitic acid while vice- versa for I. nil and I. pestrigridis. These seed oil were also found to contain lauric, myristic and other acids in trace amount. The seed oil of I. quamoclit was found to contain highest SFAs (36.07%) followed by I. nil (33.77%), I. pestigridis (27.06%), and I. indica (24.39%). In case of PUFAs, the seed oil of I. indica showed highest PUFAs (52.19%) followed by I. pestigridis (47.16%), I. quamoclit (43.19%) and I. nil (43.06%) and on the basis of PUFAs content all of them categorized as semi-drying oils. The P/S ratio of I. indica seed oil was found to be 2.139 followed by I. pestigridis (1.743), I. nil (1.1275) and I. quamoclit (1.197).
DISCUSSION
Since all four seed which were investigated categorized as semi-drying oils on the basis of PUFAs content and contain P/S ratio more than 1, good for paints-varnishes and Oleo chemical industries (16). Except I. nil the other three seed oils showed high saponification values, could be used in soap industries (17,18). The relative amount of SFAs and UFAs in oil is an important parameter for human nutrition and other industrial applications. Since SFAs are desirable for stability of oil (16,19) but became undesirable for human consumption because of the tendency to increase the concentration of low density lipoprotein (LDL)-cholesterol, plasmatic cholesterol and affect the ratio of LDH to HDH (high density lipoprotein) cholesterols level, result into promoting of clotting, vascular smooth proliferation and causes obesity (20-22). Linolenic and linoleic acids (PUFAs) increase the HDL-cholesterol and decrease the LDL-cholesterol while oleic acid (monounsaturated fatty acids; MUFAs) decreases LDL- cholesterol and triacylglicerols blood levels but does not effect HDL-cholesterol level, makes oleic acid more ef-fective in the prevention of heart diseases (21-23). However PUFAs are important to maintain the adequate ratio of LDL and HDL-cholesterol. So for oils, ratio of PUFAs and SFAs (P/S index) has great importance and should be greater than 1 to consider them suitable for human consumption (24). It was established in studies that P/S relation influences the level of nutrient metabolization in the body and as it increases showed lesser deposition of lipids (23).
CONCLUSION
The present study envisage that on accounting high P/S index (more than 1), appreciable amount of oleic acid, adequate content of SFAs and absence of any trans unsaturation and conjugation, the seed oil of all four plant species could be suitable for human consumption. However, not much study on of the seed and seed oil of I. indica has been reported so far whether exhibit poisonous property or not. So the seed oil could be more suitable at industrial scale and oleo chemical industries and needs further investigations to establish as a source for edible purpose. Since the medicinal values of seeds of other three plant species have been reported (2-3,6-7), make them a convenient alternate source for human consumption at low scale (domestic level) and because of moderate protein content it could be proved a local animal feedstock as protein source. The by-product of the seeds after oil extraction could also be useful as bio-mass for various applications. Apart from these parameters there are many other parameters likewise presence of any component in seed oil of I. nil, I. pestigridis and I. quamoclit that could be toxic on consuming at high concentration, their stability at high temperature and resistance against oxidation process should also to be taken in account before establishing as potential source for edible purpose, need further investigations. The result obtained from our study suggested that the above data could be used as base parameter to develop I. indica, I. nil, I. pestigridis and I. quamoclit for domestic and commercial purpose with a sustainable and sustainable manner in southern, mid-western and western region of India.
ACKNOWLEDGEMENT
Authors would like to extend thanks to Head, Department of Chemistry, J.N.V. University for providing necessary facilities and Prof. Pavan Kasera for plants identification. Authors acknowledge the immense help received from the scholars whose articles are cited and included in reference of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=406http://ijcrr.com/article_html.php?did=4061. Whistler WA. Polynesian herbal medicine, Hongkong: Everbest Publications 1992; p. 49,.
2. Babu G, Divya T, Shalima NK, Divya TA, Biju CR. Hepatoprotective activity of ethyl acetate extract of Ipomoea nil (L.) roth seeds on rats. Int J Pharm Pharm Sci 2013; 5(4): 130-133.
3. Sahu PK, Gupta S. Medicinal plants of morning glory: convolvulaceae Juss. of central India (Madhya Pradesh and Chhattishgarh). Biolife 2014; 2(2): 463-469.
4. Seliya AR, Patel NK. Ethnomedicinal Uses of Climbers from Saraswati River Region of Patan District, North Gujarat. Ethnobotanical Leaflets 2009; 13: 865-872.
5. Uma R, Parthipan B. Survey on Medico-Botanical climbers in Pazhayaru river bank of Kanyakumari District, Tamilnadu. JMPS 2015; 3(1): 33-36.
6. Rekha D, Panneerselvam A, Thajuddin N. Studies on medicinal plants of a.v.v.m. Sri pushpam college campus Thanjavur District of Tamil Nadu, Southern India. WJPR 2014; 3(5): 785-820
7. Jagtap SD, Deokule SS, Bhosle SV. Some unique ethnomedicinal uses of plants used by the Korku tribe of Amravati district of Maharashtra. India. Journal of Ethnopharmacology 2006; 107: 463–469.
8. Rani A, Pandey SK, Singh AN. Documentation of medicinal plants from northern coal fields areas, Singrauli, M.P. IJBASR 2014; 1 (1): 12-18.
9. Rahmatullah M, Ferdausi D, Mollik MAH, Azam MNK, TaufiqUr-Rahman M, Jahan R. Ethnomedicinal Survey of Bheramara Area in Kushtia District, Bangladesh. American-Eurasian Journal of Sustainable Agriculture 2009; 3(3): 534-541.
10. Pullaiah T, Chennaiah E. Flora of Andhra Pradesh, 1st ed. Vol. 1. Jodhpur (India): Scientific Publishers; 1997.
11. Hasan SMR, Hossain MM, Raushanara A, Mariam J, Mazumder HEM, Rahman S. DPPH free radical scavenging activity of some Bangladeshi medicinal plants. J. Med. Plant Res 2009; 3(11) :875-879.
12. Uddin N, Islam R, Hasan N, Hossain MS, Roy A, Hossain MM, Rana MS. DPPH Scavenging Assay of Eighty Four Bangladeshi Medicinal Plants. IOSR-JPBS 2011; 6(5): 66-73.
13. Murphy DJ, Storage lipid bodies in plants and other organisms. Prog Lipid Res 1990; 29(4): 299-324.
14. Link W.E. (Ed.), Official and Tentative Methods of the American Oil Chemists Society, 3rd ed., Champaign, IL, USA: AOCS , 1973.
15. Miwa TK, Earle FR, Miwa GC, Wolff IA, Fatty acid composition of Maturing Vernonia anthelmintica (L.) wild seeds. Dihydroxyoleic acid- A possible precursor of Epoxyoleic acid. JAOCS 1963; 40(6): 225-229.
16. McKenzie S, Taylor DC. Seed oils: a new age. Plant Biotechnology 1996; 1: 1-4.
17. Kirsehenbauer HG. Fats and Oil: An Outline of their Chemistry and Technology, 2nd edn., New York : Reinhold Publ Crop; 1965; p.160-161.
18. Amoo IA, Eleyinmi AF, Ilelaboye NOA. Akoja SS. Characterization of Oil Extracted From Gourd (Cucurbita Maxima) seed. Food Agriculture and Environment 2004; 2: 38-39.
19. Clark WL, Serbia GW. Safety aspects of frying fats and oils. Food Technology. 1991; February: 84-89.
20. Dzisiak D, New oils reduce saturated and trans fats in processed foods. Cereal Foods World 2004; 49: 331-333.
21. Przybylski R, McDonald BE, Development and processing of vegetable oil AOCS; 1995.
22. Sales RL, Costa NMB, Monteiro JBR, Peluzio MG, Coelho SB, Oliveira CG, De Mattes R. Efeitos dos óleos de amendoim, açafrão e oliva na composição corporal, metabolism energético, perfil lipídico e ingestão alimentar de indivíduos eutróficos normolipidêmicos. Revista da Nutrição. Campinas 2005; 18: 499- 511.
23. Lawton CL, Delargy HJ, Brockman J, Smith RC, Blundell JE. The degree of saturation of fatty acids influences post-ingestive satiety. British Journal of Nutrition 2000; 83: 473-482.
24. WHO, World Health Organization, Prevention of coronary heart disease. Geneva. 1982; p. 642.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareKNOWLEDGE AND AWARENESS OF CERVICAL CANCER AMONG WOMEN IN RURAL INDIA
English2932Arunadevi V.English Geetha PrasadEnglishObjectives: To assess knowledge and attitudes about HPV, cervical cancer and its screening among women using a structured questionnaire to obtain information.
Methods: A cross: Section interview based survey was conducted in May 2015. Two hundred women attending a well women clinic were asked to complete a questionnaire assessing cervical cancer awareness and specific knowledge about prevention of the disease.
Settings: Karpaga Vinayaga Institute of Medical Science and Research Centre.
Results: Only 38% of the respondents were aware that cervical cancer is the most common cause of gynecological cancers. 63% were aware that infection is the most common cause of cervical cancer of these 49% said that virus is the cause and 16% of the respondents knew that the virus is Human Papilloma virus(HPV). 78% recognized pap smear as a screening test. In total only 13 out of 200 respondents were aware of HPV Vaccine.
Conclusion: The low screening participation among Indian women may be due to limited awareness and knowledge about cervical cancer screening examinations. The universal application of Pap smears in western communities has lead to drastic decline in the number of invasive cancers of the cervix and higher detection of preinvasive lesions . Identification of factors determining participation, incorporating a comprehensive health education programme prior to screening, personal invitations, proximity of clinics to the target women all help in increasing the compliance.
EnglishConventional cytology, Chronic infection, Sophisticated equipmentINTRODUCTION
Cancer of the uterine cervix is the second most common cancer among women globally. An estimated 550,700 new cases and 286,823 deaths due to cervix cancer are estimated to have occurred in the year 2010. India alone accounts for one-fourth of the global cervix cancer burden.1 . Several tests have been developed to screen women for cervix pre-cancers and cancers. The choice of the test will depend on its technical performance, cost-effectiveness, the available resources and the socio cultural settings in which it is to be used.2 Conventional cytology based screening with pap smear test developed by George Papanicolaou has been the mainstay of cervical cancer prevention worldwide since the 1950’s. Pap test has repeatedly demonstrated good specificity ranging from 86% to 100%.3 . Cytology based screening programmes are labor intensive and logistically burdensome. They require multiple visits by the women for various reasons like screening, obtaining the results follow up investigations and treatment in case of abnormal smears. Thus, despite the low consumable cost, high quality cytology is expensive in absolute terms and may not necessarily be the most cost-effective option for screening.4 Chronic infection with oncogenic HPV is a necessary, but insufficient cause for the development of cervical cancer. Presence of Co-factors such as high parity smoking nutritional deficiency, hormonal contraceptive use and presence of other sexually transmitted infections increases the risk.5 Even today millions of women in the developing countries are never screened for cervical cancer in their entire lifetime. Routine cytological screening should be offered to all women above the age of 21 years who are active for atleast 3 years Screening combined with vaccination can substantially reduce the worldwide cervical cancer mortality. Effective implementation of sustainable cervical cancer screening programmes using sufficiently sensitive and specific tests that covers minimum 70% of the targeted population through screening atleast once in a lifetime along with effective treatment is vital in reducing the burden of cervix cancers.6 The purpose of the study was to assess the level and accuracy of public understanding about cervical cancer and its screening in India.
METHODS
The study was conducted in May 2015. A questionnaire based on the study objectives was designed and administered to 200 women attending a public clinic. The questionnaire consisted of the questions regarding the knowedge and awareness about different aspects of cervical cancer . Open ended questions were asked about the etiology, clinical features and prevention of cervical cancer with multiple responses. This study was approved by ethical committee.
RESULTS AND ANALYSIS
1 KNOWLEDGE ABOUT THE EPIDEMIOLOGY OF CERVICAL CANCER.
The result showed that 38% of the respondents recognized that cervical cancer is the most common malignancy in gynecological cancers, while 28% thought that it is moderately common and 34% thought that it is least common, 36% were aware that it is the second most common gynecological cancer leading to death.
2. Knowledge about the etiology of cervical cancer
63% were aware that infection is one of the causes of cervical cancer, 21.5% said environment and 17% opted for genetics. 19% of the sample said that they “don’t know” the cause of cervical cancer. Of all the respondents who opted for infection 49% said virus is the cause of that infection, Other responses were bacteria (22%), fungus (19%) and parasite (8%). 16% of the study population who opted for virus were aware that HPV is that virus. None of the respondents were aware of the correct technique to detect HPV, which is PCR.
3. Knowledge about the risk factors and clinical features of cervical cancer.
Sexual practice which included unprotected sex was the most common risk factors observed (32%). Most common presenting complaint reported was vaginal bleeding (38%) and vaginal discharge (24%). While few thought lower abdominal pain (15%), swelling of cervix (9%), itching (6.5%) could also be the initial symptoms patients with cervical cancer present with.
4. Knowledge about the treatment of cervical cancer
21% answered the correct treatment option which was “to treat according to the stage of the disease”. 34% were of the opinion that radiotherapy is required to cure cervical cancer, whereas 26% were in favour of surgery and 19% for chemotherapy
5. Knowledge about prevention of cervical cancer
78% of respondents were aware that pap smear is the screening test for cervical cancer. Ultrasonogram (14%), Biopsy(5%), Radiological scans (3%) were few of the incorrect responses observed. Majority of respondents were aware of the correct time to start screening which is after first coitus (62%). In total only 13 out of 200 were aware of the vaccine against HPV Majority of the respondents opted for health professionals (48%) and mass media (41%) as a source through which knowledge concerning cervical cancer, 11% found special lectures and conferences to be a good source to obtain information.
DISCUSSION
In India cancer of the cervix is number one killer cancer among women. It is estimated that during 2008, 134,420 new cases of cancer cervix occured in the country (incidence rate of 7 per lac population) and about 72,825 women died of the disease (mortality rate of 15.2 per lac population). It comes to 23.3 percent of all cancer deaths in women and about 11.4 percent of total cancer deaths in the country.7 . Liquid based cytology (LBC) is more expensive than conventional cytology and requires additional supplies and sophisticated equipment. In a meta-analysis comparing conventional pap with LBC no difference was found in the relative sensitivity. But, a lower pooled specificity was found for LBC when presence of atypical squamous cells of undetermined significance (ASCUS) and above were included (ratio 0.91, 95% CI: 0.84-0.98).8 . The evidence base in support of visual based screening methods has emerged from several studies conducted in different developing countries demonstrating comparable or greater sensitivity of visual inspection of the cervix with naked eye (after application of acetic acid (VIA) or lugol, s iodine (VILI) than that of cytology. The test characteristics of VIA have been evaluated from several cross sectional studies in India, Africa and china, wherein the sensitivity range from 67% to 79% and the specificity range from 49-86% 9 . The sensitivity and specificity in a pooled analysis of eleven cross – sectional studies were 76.8%(range, 56.1-93.9%) and 85.5% (range 74.2-93.8%) for VIA and 91.7% (range, 76.0-97.0%) and 85.4% (range, 73.0-91.3%) for VILI respectively.10 VIAM (performing VIA under low magnification) has similar sensitivity and specificity as compared with VIA and does not have any added benefit over VIA.11. The results of cluster randomised controlled trial in southern India, after a single round of screening using VIA followed by treatment in the same visit, when appropriate, show a significant 25% reduction in cervical cancer incidence and a significant 35% reduction in cervical cancer mortality at the end of seven years of follow up.12 Another cluster randomised controlled trial of cervix cancer screening in Mumbai, India, demonstrated a significant down staging of cervix cancers in the intervention arm.13 Though a single round of VIA screening did not show decrease in the incidence of advanced cervical cancer and significant mortality reduction after eight years of initiation of the osmanabad trial14, the same may be evident after few more years of follow-up. The Mumbai cross-sectional study concludes that parallel testing with both VIA and VILI should be considered where good quality cytology is not feasible and that the sensitivity of cytology and HPV testing can be significantly increased by adding the visual test.15. Visual tests are not reliable in postmenopausal women because of changes in the transformation zone of the cervix the area in which precursors of cervical cancer arise.16,17. Genital HPV infection is the most common viral sexually transmitted infection (STI) and affects roughly 80% of sexually active people. In most cases HPV infection is cleared by the cell mediated immune system within 1-2 years of exposure.18. The median time of clearance of HPV infections detected during screening studies is 6-18 months.19. The small proportion (about 10%) of carcinogenic infections persisting for several years is strongly linked to a high absolute risk of diagnosis of precancer.20.
CONCLUSION
More than 85% cases and 88% deaths from cervix cancer occur in developing countries, where women often lack access to cervical cancer screening and treatment. Choosing a suitable screening test with good efficacy and one which is replicable, affordable, feasible for implementation with respect to available technical expertise and manpower is an important aspect of a screening program . Highly effective HPV prophylactic vaccines are now available for prevention of cervix cancers. Hence, early detection and treatment needs to be continued for millions of women who are already infected and who may not receive vaccination in the near future.
ABBREVIATIONS:
HPV- Human Papilloma Virus
STI- Sexually Transmitted Infections
VIA- Visual Inspection of Acetic acid
VILI-Visual Inspection of Lugol’s Iodine
VIAM- Visual Inspection of Acetic acid under low Magnification
ICUD-Intra Uterine contraceptive Device
OCP- Oral contraceptive Pills
LBC- Liquid Based Cytology
ASCUS- Atypical Squamous Cells of Undetermined Significance
ACKNOWLEDGEMENT
Author acknowledges the enormous help received from the scholars whose articles have been cited and incorporated in references. Author is also grateful to authors/editors/publishers of all those articles journals and books from where the literature for this articles has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=407http://ijcrr.com/article_html.php?did=4071. Farley J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: Lyon, France,: International Agency for Research on Cancer ; 2010.
2. Kitchener HC, Castle PE, Cox JT. Chapter 7: Achievements and limitations of cervical cytology screening, Vaccine 2006; 24,3: S63-S70.
3. Nanda K, McCrory D, Myers E et al. Accuracy of the papanicolaou test in screening for and follow up of cervical cytological abnormalities: a systematic review. Ann Intern Med 2000 ; 132:810-9.
4. Goldie SJ, Gaffikin L, Gold haber – Fiebert JD, et al. Cost – effectiveness of cervical , cancer screening in five developing countries. N Eng J Med 2005:353:2158-68.
5. Munoz N. Castellsague X, de Gonzalez AB, Gissmann L, Chapter 1: HPV in the aetiology of human cancer. Vaccine 2006 ; 24,3:S3/1-10. Epub 2006 Jun 23.
6. Gravitt PE, Belinson JL , Salmeron J ,et al. Looking ahead a case for human papillomavirus testing of self sampled vaginal specimens as a cervical cancer screening strategy, Int J cancer 2011:129:517-27.
7. GLOBOCAN 2008, India Fact sheet, 2010 Section of Cancer Information International angency for Research on cancer, Lyon, France.
8. Arbyn M , Bergeron C, Klinkhamer P, etal. Liquid compared with conventional cervical cytology; a systematic review and meta analysis. Obstet Gynecol 2008:111:167-77.
9. Sankaranarayanan R, Gaffikin L, Jacob M, et al. A critical assessment of screening methods for cervical neoplasia. Int J Gynaecol obstet. 2005:89:84-12.
10. Sankarnarayanan R, Basu P, Wesley RS, et al . Accuracy of visual screening for cervical neoplasia. Results from an IARC multicentre study in India and Africa. Int J cancer 2004:110:907- 13.
11. Sankaranarayanan R, Shastri SS , Basu P, et al. The role of low level magnification in visual inspection with acetic acid for the early detection of cervical neoplasia, Cancer Detect Prev 2004 :28:345-51.
12. Sankaranarayanan R, Esmy PO, Raj Kumar R, et al, Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu , India :a cluster-randomised trial, Lancet 2007;370;398-406.
13. Mittra I , Mishra GA, Singh S, et al A Cluster Randomized controlled Trial of Cervix and Breast Cancer Screening in Mumbai, India; Methodology and Interim Analysis after Three round of Screening. Int J Cancer 2010; 126; 976-84.
14. Sankaranarayanan R, Nence BM , Shastri SS, et al HPV screening for cervical cancer in rural India , N Engl J Med 2009; 306;1385-94.
15. Shastri SS, Dinshaw KA, Amin G, et al Concurrent evaluation of visual , Cytological and HPV testing as screening methods for the early detection of cervical neoplasia in Mumbai , India. Bull world Health organ 2005; 83; 186-94.
16. Colposcopy and Treatment of cervical Intraepithelial Neoplasia : A Beginner, s Manual , Edited by sellors JW and Sankaranarayanan R. IARC 2003-04.
17. Sherris J, Wittet S, Kleine A, et al Evidence – Based, Alternative cervical Cancer Screening Approaches in Low – Resource settings. Int. Perspect Sex Reprod Health 2009;35;147-52.
18. Stanley M. Immune responses to Human Papillomavirus, Vaccine 2006; 24 ;S16-22
19. Plummer M, Schiffman M, Castle PE, et al A 2-Year Prospective study of HPV persistence among women with ASCUS or LSIL cytology, J Infect Dis 2007; 195; 1582-9
20. Schiffman M, Herrero R, Desalle R et al The carcinogenicity of human papilloma virus types reflects viral evolution, Virology 2005; 337; 76-84.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareMEDICATION ADHERENCE AND ITS CORRELATES AMONG DIABETIC AND HYPERTENSIVE PATIENTS SEEKING CARE FROM PRIMARY HEALTH CENTER, INDIA
English3340Pruthu ThekkurEnglish Mahendra M. ReddyEnglish Gomathi RamaswamyEnglish Bijaya Nanda NaikEnglish Subitha LakshminarayananEnglish Ganesh Kumar SayaEnglishIntroduction: Low adherence to prescribed medication in patients with non communicable diseases (NCDs) increases risk of hospitalization and premature mortality. Assessing adherence to medications and its correlates among NCD patients can help in delivering targeted interventions.
Objectives: To assess the level of low adherence to prescribed medications and associated factors among diabetic and/or hypertensive patients registered in NCD clinic at a Rural Health Center in South India.
Methodology: A facility based cross-sectional study was conducted in a RHC of Puducherry, India. All the patients who registered and attended clinic for follow up in August 2014, with either hypertension and/or diabetes and received drug for more than four weeks prior to contact were included in study and adherence was assessed using Morisky Medication Adherence Scale (MMAS-8) questionnaire. The data was entered in Microsoft Excel and was analyzed using SPSS version 20.
Results: Of the 281 included in the study the mean (SD) age was 57.4 (11.9) years and 169 (59.8%) were females. Among these 281, 155 (55.1%) had only hypertension, 46 (16.4%) had only diabetes and 90 (28.5%) had both hypertension and diabetes. Low adherence to medication was seen in 47 (16.7%) participants. In the model factors like education of 1-5years (OR-2.68, CI-1.03–6.98)), education of >6 years (OR-3.50, CI-1.34–9.14), having only diabetes (OR-3.78, CI-1.28-11.17) and tobacco use (3.51, CI-1.24–9.96) were independently associated with low adherence.
Conclusion: Around one-sixth of the patients with either diabetes and/or hypertension were found to be less adherent to prescribed medication. Higher education levels, use of tobacco and having only diabetes were identified independently as risk factors for low adherence.
EnglishDiabetes Mellitus, Hypertension, Medication compliance, Non communicable diseases, Primary health careINTRODUCTION
Non Communicable Diseases (NCD) mainly comprises of cardiovascular diseases (CVD), chronic respiratory diseases, cancer, diabetes and mental illness. By 2020, NCD’s are expected to contribute to 60% of the global disease burden and 73% of the total mortality.[1] Developing countries like India are undergoing epidemiological transition from communicable to non-communicable diseases.[2] NCD account for 53% of all deaths in India and are estimated to increase up to 67% in 2030.[3] Hypertension and diabetes are the common chronic morbidities which can lead to life-threatening complications like CVD.[4] Systematic review and meta-analysis on prevalence of hypertension in India, 2014 shows overall prevalence of 29.2% in adults aged more than18 years and 27.6% and 33.8% in rural and urban respectively.[5] With 66.8 million affected by diabetes, India ranks second globally.[6] In India, urban and rural divide in non-communicable disease prevalence is reducing and is expected to diminish very soon.[7] With increasing NCD burden in India, Ministry of Health and Family Welfare has launched a national program namely, National Program for Prevention and control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in the year 2010. It was initiated in 100 backward and remote districts in 21 states as a pilot phase and it is proposed to cover all the districts in the country in a phased manner by the end of 12th five year plan. Under NPCDCS, NCD clinics are functioning in Primary Health Centers (PHC) where investigations and treatment are provided free of cost.[8] Though such facilities are provided in PHC, monitoring of patient’s adherence to health advice plays an important role in determining the outcome of these chronic conditions. Adherence is defined as “the extent to which a person’s behavior such as taking medication, following a diet and/or executing lifestyle changes corresponds with the agreed recommendations from a health care provider”.[9] Among these factors, adherence to treatment is an important factor in prevention of complications. Non-adherence to treatment plays a major role in increasing the all-cause hospitalization, mortality and out of pocket expenditure among patients with diabetes and/ or hypertension.[10] A study conducted at a tertiary care hospital in South India among diabetic in-patients showed that only 49.3% were adherent to prescribed medications.[11] Similarly, a study among hypertensive patients in South India showed that 45.8% were having low adherence.[12] In India, studies assessing adherence to medication among patients with diabetes and hypertension are mostly limited to patients attending tertiary care facilities.[11-13] But, it is important to assess adherence to treatment and its correlates in those patients attending PHCs as most of them are yet to develop complications. Identifying the non-adherent patients and factors associated with non-adherence will help in guiding targeted interventions in future among these patients to improve adherence and avert complications that may arise due to non-adherence. With this background, the present study was conducted among patients with either diabetes and/or hypertension registered in NCD clinic at a Rural Health Center (RHC), to assess a) the adherence to prescribed medications and b) socio-demographic and treatment factors associated with low adherence.
METHODOLOGY
Study setting: During the month of August 2014, a facility based cross-sectional study was conducted among patients with either hypertension and/or diabetes seeking healthcare from the NCD clinic, Rural Health Center (RHC), Ramanathapuram. The RHC is a Primary Health Center located in Puducherry, India and is 16 kilometers away from the Puducherry main town. It is attached to a tertiary care research institute and is also functioning under the Government of Puducherry. It caters to the health needs of 9852 individuals residing in four socio-demographically and economically similar villages namely Ramanathapuram, Thondamanatham, Thuthipet and Pilayarkuppam. Majority of people in these villages have low economic status, low education status and are dependent on agriculture for living as is the scenario in most of the Indian villages. People here mainly depend on RHC for their health needs. RHC, Ramanathapuram provides round the clock health services which include OPD services from 9 am to 4.30 pm and emergency services in remaining hours. Special clinics for Non Communicable Diseases (NCD), Antenatal care and Well Baby care are scheduled on Wednesday, Thursday and Friday respectively. The study was carried out among patients attending NCD clinic at RHC, Ramanathapuram. Patients with at least one chronic disease condition like hypertension, diabetes mellitus, coronary heart disease, rheumatic heart disease, asthma, thyroid disorders, epilepsy and psychiatric disorders are registered in NCD clinic. The registered 415 patients are divided into batches of around 105 and each batch visits RHC for consultation and follow-up once in a month. Consultation, drugs for 28 days and necessary laboratory services are provided free of cost during this monthly follow-up visits. Patients are reviewed every Wednesday by trainee doctors under the supervision of medical officer in charge of RHC. During each monthly visit, the details on management are updated in the comprehensive patient case sheets by attending medical doctor. The patients are advised regarding need for regular follow-up visits and lifestyle modifications to combat non communicable disease. The pharmacist educates patients regarding dose and regimen of the prescribed medication to be followed during the course of next four weeks.
Study population: We included all the patients with either diabetes and/or hypertension who are already registered and attending NCD clinic at RHC, Ramanathapuram during the month of August 2014 and had received drugs for at least past four weeks. The patients were interviewed after obtaining a verbal informed consent during their visit to NCD clinic.
Study tool and Study variables: Pretested, semi-structured interview schedule was used to collect information. Pre testing was done in four patients who had both diabetic and hypertension and in three patients who had diabetes alone. It was done in those who attended NCD clinic at a tertiary care hospital. No major changes noted during pre testing of questionnaire. The interview schedule had three components socio-demographic details, details of treatment received and adherence to medication. The component of socio-demographic details included age, gender, village, education, occupation, marital status and also lifestyle behaviors like alcohol use and tobacco use. The treatment details had variables like type of morbidity, duration of treatment, number of drugs received and dosage. The details of treatment received were extracted using patient case sheets. The adherence to medication was captured with the eight-item Morisky Medication Adherence Scale (MMAS-8) which has eight questions and was graded as low adherence, moderate adherence and good adherence. MMAS-8 is validated in India and other parts of world in different languages with reliability value (α) of 0.83. MMAS scores can range from 0 to 8, with low adherence defined as MMAS scores less than 6; moderate adherence as scores of 6 to less than 8, and good scores as a score of 8.[14-16] The questions were translated and back translated to Tamil and English respectively by two separate bi-linguistic persons for content verification. The interview schedule was administered by trained MBBS interns who were well versed in local language Tamil. The study protocol was approved by the concerned clinic administration panel.
Operational Definitions:
Adherence to medication: Patients having a score of 8 were considered to have good adherence. Patient with scores of 6-7 were considered to have moderate adherence. Patient with scores of 6 years (OR-3.50, CI-1.34–9.14), having only diabetes (OR-3.78, CI-1.28-11.17) and tobacco use (3.51, CI-1.24–9.96) were independently associated with low adherence (Table 3).
Duration of Disease: Duration of either diabetes or hypertension whichever was detected first in the patient. For ex: Patient is having Hypertension and Diabetes since two years and one year respectively, then duration of disease is considered as two years.
Dosage: Patients dosage is considered Once Daily, Twice Daily or Thrice Daily if he/she is consuming at least one drug once in a day, two times a day or three times a day respectively.
Number of drugs: Total number of different drugs that the patient has been prescribed by attending medical doctor to consume per day.
STATISTICAL METHODS
The data was entered in Microsoft Excel and was analyzed using IBM developed SPSS version 20. The continuous data like age, duration of disease and number of drugs received were converted into categorical data according to relevance. All the categorical data were presented as percentages. The association between low adherence and categorical variables like age group, gender, education status, occupation, type of disease, duration of disease, dosage and number of drugs was tested using univariate logistic regression. The variables with P value less than 0.1 in univariate logistic regression were taken for multivariate logistic regression and considered as significant when P value was less than 0.05.[17] The strength of association was mentioned in terms of odds ratio.
RESULTS
Out of 305 registered patients with either hypertension and/ or diabetes, eight patients were put on treatment during month of August and 16 patients did not attend clinic during month of August. Hence, 281 patients were included for assessing adherence to medication and its correlates. Of the 281 participants, mean (SD) age was 57.4 (11.9) years and 169 (59.8%) were females. Among participants, 165 (58.7%) were uneducated and 129 (45.9%) were homemakers. Of the total, 36 (12.8%) and 29 (10.3%) participants reported current use of alcohol and tobacco respectively. Socio-demographic details of study participants are shown in Table1. Of the participants, 155 (55.1%) had only hypertension and 90 (28.5%) had both hypertension and diabetes mellitus. Diabetes mellitus alone was found in 46 (16.4%) of the study participants. Mean (SD) duration of the treatment was 5.2 (4.7) years. The duration of treatment ranged from one month to 30 years. Asthma, epilepsy or hypothyroidism in form of comorbidity was present in 19 (6.8%) of the participants. Of the total, 114 (40.6%) were consuming drugs only once in a day and around 164 (58.4%) had to consume two to three drugs per day. Morbidity profile of study participants are shown in Table 2. High, moderate and low adherence to medication was seen in 100 (35.6%), 134 (47.7%) and 47 (16.7%) participants respectively. The proportion of low adherence was found to be higher in those having only diabetes (27.7%) compared to those having only hypertension (17.4%) or having both disease conditions (8.8%) and was found to be statistically significant. Lesser age, higher education, being housewife, tobacco use and having only diabetes were significantly associated with low adherence to medication on univariate logistic regression. Variables like age, gender, education, occupation, alcohol use, tobacco use, type of morbidity and duration of morbidity had p value 6 years (OR-3.50, CI-1.34–9.14), having only diabetes (OR-3.78, CI-1.28-11.17) and tobacco use (3.51, CI-1.24–9.96) were independently associated with low adherence (Table 3).
DISCUSSION
Our study conducted among patients with either hypertension and/or diabetes followed up in a rural PHC showed that 16.7% of the study participants had low adherence to medication. Patients with better education, using tobacco and having only diabetes were found to be independent risk factors for low adherence to prescribed medication in our study. Arulmozhi and Mahalakshmy, in a study from Puducherry using MMAS-8 scale reported low adherence to medication in 39% patients.[11] Age Englishhttp://ijcrr.com/abstract.php?article_id=408http://ijcrr.com/article_html.php?did=4081. World Health Organization. 2008-2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases. WHO. Available from: http://www.who.int/nmh/publications/9789241597418/en/. [Last accessed on 2015 Sep 05]
2. World Health Organization. Health Transition. WHO. Available from: http://www.who.int/trade/glossary/story050/en/. [Last accessed on 2015 Sep 05]
3. Reddy K. Srinath and Sailesh Mohan. Chronic diseases in India: Burden and implications. Chronic Diseases in India. Swiss Re - Center for Global Dialogue 2014. Available from: http://cgd. swissre.com/global_dialogue/topics/Cardiovascular_risks_in_ HGM/Chronic_Diseases_in_India_Burden_and_Implications. html. [Last accessed on 2015 Sep 05]
4. Cade WT. Diabetes-Related Microvascular and Macrovascular Diseases in the Physical Therapy Setting. Phys Ther 2008;88(11):1322–35.
5. Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32(6):1170–7.
6. IDF Diabetes Atlas update poster, 6th ed. Brussels, Belgium. International Diabetes Federation;2014.
7. Ramachandran A, Shetty AS, Nandhitha A, Snehalatha C. Type 2 diabetes in India: challenges and possible solutions. Available from: http://www.apiindia.org/medicine_update_2013/chap40. pdf. [Last accessed on 2015 Sep 05]
8. National Program for Prevention and Control of Cancer, Diabetes, Cardio Vascular Diseases and Stroke (NPCDCS): Operational Guidelines (Revised: 2013-17). Directorate General of Health Services Ministry of Health and Family welfare Government Of India;2013:22.
9. World Health Organization. Adherence to long term therapies: Evidence for action. Geneva, Switzerland: WHO;2003:135-45.
10. Ho PM, Rumsfeld JS, Masoudi FA, McClure DL, Plomondon ME, Steiner JF, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Archives of internal medicine 2006;166(17):1836–41.
11. Arulmozhi S, Mahalakshmy T. Self Care and Medication Adherence among Type 2 Diabetics in Puducherry, Southern India: A Hospital Based Study. J Clin Diagn Res JCDR 2014 Apr;8(4):UC01–3.
12. Kumar N, Unnikrishnan B, Thapar R, Mithra P, Kulkarni V, Holla R, et al. Factors associated with adherence to antihypertensive treatment among patients attending a tertiary care hospital in Mangalore, South India. Int J Curr Res Rev 2014;6(10):77–85.
13. Hema K, Padmalatha P. Adherence to medication among Hypertensive patients attending a tertiary care hospital in Guntur, Andhra Pradesh. Indian J Basic Appl Med Res 2014;4(1):451–6.
14. Morisky DE, Ang A, Krousel-Wood M, Ward H. Predictive Validity of a Medication Adherence Measure for Hypertension Control. Journal of Clinical Hypertension 2008;10(5):348-354.
15. Krousel-Wood MA, Islam T, Webber LS, Re RS, Morisky DE, Muntner P. New Medication Adherence Scale Versus Pharmacy Fill Rates in Seniors With Hypertension. Am J Manag Care 2009;15(1):59-66.
16. Morisky DE, Di Matteo MR. Improving the measurement of self-reported medication nonadherence: Final response. J ClinEpidemio 2011; 64:258-263
17. Mickey RM, Greenland S. The impact of confounder selection criteria on effect estimation. Am J Epidemiol 1989;129(1):125– 37.
18. Sankar UV, Lipska K, Mini GK, Sarma PS, Thankappan KR. The adherence to medications in diabetic patients in rural Kerala, India. Asia Pac J Public Health 2015;27(2):NP513–23.
19. Venkatachalam J, Abrahm SB, Singh Z, Stalin P, Sathya GR. Determinants of Patient’s Adherence to Hypertension Medications in a Rural Population of Kancheepuram District in Tamil Nadu, South India. Indian J Community Med 2015;40(1):33–7.
20. Lee GKY, Wang HHX, Liu KQL, Cheung Y, Morisky DE, Wong MCS. Determinants of Medication Adherence to Antihypertensive Medications among a Chinese Population Using Morisky Medication Adherence Scale. PLoS One 2013;8(4). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636185/.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareASSESSMENT OF NUTRITIONAL STATUS AMONG ADOLESCENT BOYS (10-19 YEARS) OF SECONDARY SCHOOLS IN AN URBAN AREA OF DISTRICT ROHTAK, HARYANA
English4146Vikas GuptaEnglish Debjyoti MohapatraEnglish Vijay KumarEnglishBackground: Census 2011 estimated that there are approximately 253 million adolescents in India, constituting about 20.9% of the total population. Adolescence is an important stage of growth and development in the lifespan. Adolescent is a tender stage which is not only marked by rapid physical growth, but also accompanied by sexual and hormonal turbulence. Inadequate nutrition not only hamper the physical growth but also delay pubertal changes in the body.
Methods: This cross sectional study was conducted in the field area of an urban health center, Rohtak, Harayna during the months of January to March 2015. The participants involved were school going adolescent boys 10 to 19 years). The participants were classified as thinness as their under-nutritional status depending upon the Z-score value (WHO growth standards, 2007) of their respective BMI.
Results: A total of 649 boy participated in study. Overall mean age of study participants was 15.5 years. The proportion of adolescents who were undernourished based on BMI Z Score came out as 36.7% (13.3% severely undernourished and 23.4% moderately undernourished). Mothers education status was found to have a significant impact on nutritional status of adolescent (P = 0.017).
Conclusion: Nutritional status of the studied children is not impressive among adolescent boys, there is a need for health promotion activities in school children by providing an enabling environment and improving nutritional status of the adolescents will go a long way in maintaining the health of the country..
EnglishUnder-nutrition, BMI, AdolescentsINTRODUCTION
The World Health Organization (WHO) defines adolescents as individuals aged 10-19 years. The term adolescent is derived from the latin word “adolescere” meaning “to grow up”. As per World Population Prospects, the 2012 revision, there are around 699 adolescents worldwide, comprising 17.3 % of the global population. Every fifth person in the world is an adolescent. Census 2011 estimated that there are approximately 253 million adolescents in India, constituting about 20.9% of the total population. Adolescence is an important stage of growth and development in the lifespan. Adolescent is a tender stage which is not only marked by rapid physical growth, but also accompanied by sexual and hormonal changes. This period is very crucial since these are the formative years in the life of an individual when major physical, psychological, hormonal and behavioural changes take place. Adolescent period may represent a window of opportunity to prepare an adolescent for a healthy adult life. (Tanner) Unfortunately these group of individuals are the most neglected as they are neither children nor adults. Yet they experience a variety of health and social problems like early marriage, teenage pregnancy, sexually transmitted diseases, drug abuse, juvenile delinquency, injuries, learning disabilities, mental illness and malnutrition. (Kathleen M Kurz) Nutrition is the foundation for good health and development. Malnutrition denotes impairment of health arising either from deficiency or excess or imbalance of nutrients in the body. Generally there are two forms of malnutrition one is under-nutrition and other is over-nutrition. In India nearly 44-47% of adolescents are abnormally thin. (Parasuraman 2009) Inadequate nutrition in adolescence can potentially retard growth and sexual maturation, although these are likely consequences of chronic malnutrition in infancy and childhood. Adolescence is also a period of catch-up growth for previously undernourished children. (op ghai) Calculation of BMI(weight/height2 ) remains a valid tool for epidemiological studies to assess the nutritional status of adolescents. (World Health Organization Physical Status) A large number of national nutritional programs have been implemented to combat the menace of malnutrition, but the gap remains the same. (DK Taneja). There is paucity of studies being conducted among adolescent boys hence this area needs to be further explored. There is also a need to investigate the various socio-demographic and lifestyle factors affecting nutritional status of adolescents and such observations could be utilized into the formulation of programmes and policies. Also at anganwadi centres more priority is given to adolescent girls, keeping more often adolescent boys neglected. Keeping this all in view, the present study was conducted among adolescent boys to assess their nutritional status and to evaluate the associated various factors associated with it.
MATERIALS AND METHODS
Study design and the participants: This cross sectional study was conducted during the months of January to March 2015 in the service area of an urban health center, Rohtak which also happens to be field practice area under the aegis of department of Community Medicine, PGIMS, Rohtak, Haryana;. The participants involved were school-going boys (10 to 19 years). All government and private secondary schools were listed and the school principals were approached to obtain permission for conducting the study. Only two government schools provided permission for conducting study and following which interview dates of study were fixed. Both school granted permission to conduct study only from ninth standard onwards. The line listing of students from 9th standard to 12th standard was done for both the schools, total students were about 840. Out of 840 participants, 660 students were included in the study using consecutive sampling. Written informed consent from the parents and assent from the student was obtained.
Data collection: A pretested, predesigned questionnaire was used by the investigator to interview study participants. Information regarding socio-economic profiles was obtained from parents through telecommunication.Assessment of age is most essential for conducting growth studies. The accurate age of the adolescent boys was recorded from the school registration books. The anthropometric measurements of children were done using WHO guidelines (1995). The weight was measured in kilogram (Kg) using bathroom scale with minimum clothing and without shoes having precision of 0.5 kg. It was calibrated against known weights regularly. The zero error was checked for and removed if present, every day. Height in centimetres (cm) was marked on a wall with the help of a measuring tape. All boys were measured against the wall without foot wear and with heels together and their heads positioned so that the line of vision was perpendicular to the body. A glass scale was brought down to the topmost point on the head. The height was recorded to the nearest 1 cm. The body mass index (BMI) was calculated as weight in kg divided by the square of height in meter (m). Students suffering from an acute illness on the day of study or within a period of 2 weeks prior to the study were excluded. The prevalence of thinning among Indian adolescents in the observation of Parshuranam et al. was around 44%, so sample size was calculated using prevalence as 40% with allowable error as 10% of prevalence and non-response as rate as 10%, total sample size calculated was 660. Sample size calculation= (1.96)2 *p*q / (d)2 , where p is prevalence = 0.4, q is 1-p = 0.6, d is allowable error which is 10% of prevalence = 0.04. The participants were classified as thinness as their under- nutritional status depending upon the Z-score value (WHO growth standards, 2007) of their respective BMI, which was calculated using WHO Anthro plus software. If Z-score < -2 = moderately thinning, Z-score < -3 = severely thinning. This cutoff point has been utilized by several recent studies worldwide on under-nutrition among adolescents. The socio-economic status was obtained using modified B.G. Prasad socioeconomic status classification (revised for year 2014, CPI 2001 as base). There are five classes under this upper class (I) (>Rs.5,357), upper middle class (II) (Rs.2652- 5356), middle class (III) (Rs.1570-2651, lower middle class (IV) (Rs.812-1569), and lower class (V) (Rs.811). (Modified B.G Prasad, Base year 2014)The responses to schedule by each participant were entered into excel sheet and data was tabulated and for statistical analysis using SPSS 16.0, we calculated percentages and applied the Chi-square test wherever necessary and required.
RESULTS
Present study was conducted in two government schools with a total of 649 participants studying in 9th to 12th standards. Overall mean age of study participants was 15.5 years (Table 1).The mean height and weight were calculated for each class group and for all groups together mean height and weight came out as 163.5 cm and 50.4 kg. BMI derived from height and weight was also sorted for individual class groups and it was noticed that for 9thstandard, mean value of BMI(17.9) was lowest and was highest for 12th standard (19.5), and this difference was statistically significant (ANOVA test F-value = 8.9, P Englishhttp://ijcrr.com/abstract.php?article_id=409http://ijcrr.com/article_html.php?did=4091. Chandramauli C. Adolescents and Youth in India - Highlights from Census 2011. Proceedings of the Conference commemorating on World Population Day 2014 jointly organized by ORGI and UNFPA; 2014 July 17; Vigyan Bhawan, New Delhi.
2. World Population Prospects: the 2012 revision. United Nations: New York; 2012.
3. India - Population and Housing Census 2011. Office of the Registrar General and Census Commissioner India; Ministry of Home Affairs, Government of India.
4. Tanner JM. Growth at adolescence (2nd ed.) Oxford: Blackwell Scientific Publications, 1992.
5. Kathleen M Kurz; Symposium on Adolescent Nutrition – Are we doing enough? ; University of Aberdeen; July 1995.
6. World Health Organization. Adolescent Nutrition: a review of the situation in selected South-East Asian Countries. New Delhi: Region of South East Asia, WHO; 2006.
7. Ghai OP, Gupta P, Paul VK. Ghai essential pediatrics, adolescent health and development. Pediatrics 2006;6:66.
8. Taneja DK. Health policies and programmes in India. 11th ed. Delhi: Doctors publications; 2013. p. 98-107.
9. World Health Organization. Physical status: the use and interpretation of anthropometry: Report of a WHO Expert Committee. Technical Report Series No. 854. Geneva: World Health Organization; 1995.
10. Verma R. Manual of practical community medicine. 2nd ed. Chandigarh: Saurabh Medical Publishers; 2014. p. 7.
11. De Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 2007;85:660-7.
12. Banerjee S, Dias A, Shinkre R, Patel V. Under-nutrition among adolescents: a survey in five secondary schools in rural Goa. Natl Med J India 2011;24:8-11.
13. Saluja N, Bhatngar M, Garg SK, Chopra H, Bajpai SK. Nutritional status of urban primary school children in Meerut. Int J Epidemiol 2010;8:1-7.
14. Dasgupta A, Butt A, Saha TK, Basu G, Chattopadhyay A, Mukherjee A. Assessment of malnutrition among adolescents: can BMI be replaced by MUAC. Indian J Community Med 2010;35:276-9
15. Iyer UM, Bhoite RM, Roy S. An exploratory study on the nutritional status and determinants of malnutrition of urban and rural adolescent children (12-16) years of Vadodaracity. Int Appl Biol Pharm Technol 2011;2:102-7.
16. Kanade AN, Joshi SB, Rao S. Under nutrition and adolescent growth among rural Indian boys. Indian Pediatr 1999;36:145– 56.
17. Das B, Bisai S. Prevalence of undernutrition among Telaga adolescents: an endogamous population of India. Inter J Biolog Anthr 2008;2:123-9.
18. Deshmukh PR, Gupta SS, Bharambe MS. Nutritional status of adolescents in rural Wardha. Indian J Pediatr 2006;73:139-141.
19. Haboubi GJ, Shaikh RB. A comparison of the nutritional status of adolescents from selected schools of South India and UAE: a cross-sectional study. Indian J Community Med 2009;34:108- 111.
20. Gupta R, Rastogi P, Arora S. Low obesity and high undernutrition prevalence in lower socioeconomic status school girls: a double jeopardy. Human Ecol 2006;14:65-70.
21. Bhattacharyya H, Barua A. Nutritional status and factors affecting nutrition among adolescent girls in urban slums of Dibrugarh, Assam. Natl J Community Med 2013;4:35-9.
22. Deka MK, Malhotra AK, Yadav R, Gupta S. Dietary pattern and nutritional deficiencies among urban adolescents. J Family Med Prim Care 2015;4:364-8
23. Rajaretnam T, Hallad TS. Nutritional status of adolescents in northern Karnataka, India. J Fam Welf 2012:58:11-4.
24. Ahmed F, Zareen M, Khan MR, Banu CP, Haq MN, Jackson AA. Dietary pattern, nutrient intake and growth of adolescent school girls in urban Bangladesh. Public Health Nutr 1998;1:83–92.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareDIGITAL DERMATOGLYPHICS IN CARCINOMA BREAST
English4752Vaishali ParanjapeEnglish Ashwini KundalkarEnglish P. Vatsala SwamyEnglish Yashwant KulkarniEnglishCarcinoma breast is the second most common cancer amongst Indian women. Environmental factors, abnormal genetic background, mutations, hormones and changing lifestyle along with genes 17q21: BRCA1 and 13q21:BRCA2 have strong impact on in its etiopathogenesis. Dermatoglyphic patterns are determined by multiple genes and has multifactorial inheritance. Patterns are unique for every individual, remain unaltered throughout life, easy to record and can be studied by non invasive techniques.
Methods: Digital dermatoglyphics of 100 histopathologically proven cases of Carcinoma breast were recorded, classified and compared with dermatoglypic patterns of 100 subjects not suffering from any clinically obvious genetic disease.
Objective: To evaluate dermatoglyphics as a noninvasive anatomical marker of carcinoma breast. To find patterns most commonly associated with carcinoma breast.
Results and Conclusions: Presence of an ulnar or radial whorl or an arch on six or more than six fingertips coupled with absence of a radial loop and central whorl is strongly associated with carcinoma breast. The most common pattern found in cases (49.70%) as well as controls (64.40%) was Ulnar loop (X2= 18.94, p< 0.001). Stastically significant decreased intensity of ulnar loops in patients with carcinoma breast was compensated by stastically significant increased intensity of ulnar whorls (26.90%) radial whorls (6.90%), Arches (7.4%). Fingertips of controls showed stastically significant increased frequency of central whorl
(10%) Radial loops (3.2%).
EnglishDigital dermatoglyphics, Carcinoma Breast, Loops, Arches, WhorlsINTRODUCTION
Breast cancer is one of the most common and severe diseases encountered in clinical medicine. It is second most common cancer amongst Indian women; and an increasing trend in its incidence has been observed in most of metropolitan cities. 1 Population based epidemiological studies have shown that up to 10% of women all over the world will develop breast carcinoma in their life time. Further, the risk of developing breast carcinoma is increased up to 3 fold if a first degree relative is affected and up to 10 fold if more than one first degree relatives are affected.2There are other predisposing factors also,3 such as early menarche, late menopause, increased frequency in nulliparous than in multiparous, increased risk when the age at first child birth is over 30 years,4 obesity, intake of diet with high lipid content,5 exposure to exogenous estrogens, oral contraceptives,6 and also moderate alcohol consumption7 . Though the exact aetiopathogenesis of the breast cancer is not yet clear, the environmental factors (carcinogens) and hormones, along with an abnormal genetic background, seems to be the most common and possible explanation.2 Breast cancer is a genetic disease. This view is supported by (a) its familial tendency (b) identification of various mutations in tumor cells, for example mutation in gene –BRCA-1and BRCA-28 . Untreated cancers are always and invariably fatal. Hence early diagnosis (at in situ stage) and prompt treatment are important. Identification of people at increased risk of cancer before its development is an important objective of any cancer research8 and the study of dermatoglyphic patterns may provide a noninvasive and economical method to identify such people. This view is supported by Fuller (1973). He studied malignancy in general9 ; Ciovirnache M. et al (1986) 10, Edelstein J. et al (1991)11 have studied dermatoglyhphics in carcinoma thyroid patients and acute lymphocytic leukaemia respectively. Seltzer MH et al (1982)12 (1990)13 ; Abhilasha S et al (2014)14 studied the association between carcinoma breast and dermatoglyphics and strongly feel that dermatoglyphics may have a guiding future role in identifying carcinoma breast patients and also for those women who are at increased risk of its development. Considering these factors current study was undertaken with following aims and objectives: 1. Analysis and classification of the digital dermatoglyphic patterns in patients with carcinoma breast. 2. Compare it with normal subjects. 3. Correlate with previous studies. 4. Evaluate dermatoglyphics as a non invasive anatomical marker of carcinoma breast. 5. To find patterns most commonly associated with carcinoma breast.
MATERIAL AND METHODS
100 patients with carcinoma breast (The cases (gr-A)) were obtained from the Department of Surgery, BJ Medical college and Sasson General Hospital Pune. The diagnosis of all the cases of carcinoma breast was confirmed histopathologically. The control group (gr-B) consisted of 100 normal and healthy, perimenopausal and postmenopausal females less than 60 years of age; without any known genetic disorders, not giving history of cancer in the family, not suffering from hypertension, diabetes, schizophrenia, mental retardation or any other clinical illness having a genetic background. The detail case history was recorded in both the groups. The purpose of study was explained. Then proper information regarding the procedure and purpose of recording prints was given to members of both the groups who agreed for the study. After their consent, finger prints were taken. Fingerprints of both hands were taken using ink and pad method as described by Cummins and Midlo. After taking the prints, fingertip pattern were studied according to Bhanus (1991)15 classifications of digital patterns as follows:
Fingertip pattern
Loops: Series of ridges enter the pattern area on one side of the finger and exit from the same side. If the ridges enter and exit on the ulnar side of the finger it is an-ulnar loop (UL) and those from radial side of the finger are radial loops (RL). Loop has one triradius (ie : meeting point of three ridge lines). (Fig- Radial loop, Ulnar loop) Arches: Series of ridges enter the pattern on one side and exit from opposite side .At the centre of the pattern the ridges are slightly arched. Such pattern is called an arch. (Fig- Arch) Whorls: Ridges are arranged in the series of concentric rings. Whorls have two or more triradii. Whorls are further classified as radial, ulnar and central/median. If we consider left hand and trace the ridges from the centre of concentrically arranged pattern to periphery and the tracing shows clockwise alignment of ridges, it is an ulnar whorl (UW). If the alignment is in anticlockwise direction it is radial whorl (RW). Another way to classify a whorl, as radial, ulnar or median is by counting ridges. The centre of triradius and centre of whorl (core) are joined .The ridges crossing the line are counted from centre of the whorl to the triradius present on ulnar, as well as on the radial side of the finger. For example, If the ridge count is 10, from the centre to the triradius present on ulnar side and 15 from the centre to the triradius present on radial side, it is an ulnar whorl .If it is less on radial side than on ulnar side, it is radial whorl. If the count on both the sides (ulnar and radial) is similar, it is central /median whorl (C /M W). (Fig- Ulnar whorl, Radial whorl, Central/ Median whorl)
Statistical Methods:
Chi square test is used to assess the stastical significance of the data as fingertip pattern is a qualitative variable.
RESULTS
DISCUSSION
Ulnar loop is the most common pattern seen in less than 50% of the cases with carcinoma breast (49.7%) as compared to (64.4%) the controls. Ulnar whorls (26.9 %) are the second most commonly encountered pattern seen in carcinoma breast cases followed by Arches (7.4%). Radial whorl (6.9%), Central whorl (5.9%), Radial loops (3.2%) are the patterns encountered in decreasing order of frequency in women suffering from carcinoma breast. The highest frequencies of Patterns significantly associated with each fingertip in patients with carcinoma breast are as follows. (Table 2)
Dermatoglypic pattern seen on left middle finger of cases and controls does not show stastically significant difference. (Table 2) Observation of six or more whorls is seen in the studies conducted by Seltzer MH et al (1982)12 and (1990)13, Sakineh Abbasi et al (2006)16, Chintamani et al (2007)17, J. Lavanya et al (2012) 18, Abhilasha S (2013) 14. Sakineh Abbasi et al (2006) 16, quotes that “In 616 Iranian females studied, we have found a stastically significant difference of presence of digital whorl subtypes Englishhttp://ijcrr.com/abstract.php?article_id=410http://ijcrr.com/article_html.php?did=4101. ICMR Bulletin Estrogens and breast cancer. 2003 Feb; 3(2): 13-24.
2. Cotran, Kumar, Robins: Robins Pathologic Basis of Disease. 4th Edition, W.B. Sunders International edition. 1192-1193.
3. Hulka, B.S. and Stark, A.T. Breast cancer: cause and prevention. Lancet. 1995; 346: 833.
4. Kelsey, J.L. Gammon, M.D. and Jhon, E.M. Reproductive Factors and Breast Cancer. Epidemiol Rev. 1933; 15:36.
5. Kuller, L.H. Eating fat or being fat and risk of cardiovascular disease and cancer among women. Ann Epidemiol. 1994; 4:199.
6. Wu, A.H. Pike, M.C. and Starm, D.O. Meta analysis: dietary fat intake, serum estrogens levels, and the risk of breast cancer. J Natl Cancer Inst. 1999; 91:529.
7. Miller, W.R. Estrogen and breast cancer: Biological considerations. Br Med Bull. 1990; 47: 470. 8. Robert L. Nussbaum, Roderick R. McInnes, Hungtington F. Willard, Thompson and Thompson Genetics in Medicine. 6th Edition. Genetics and Cancer. pp. 311-333.
9. Fuller, I.CInherited. Predisposition to cancer. British J of ca. 1973; 28:186.
10. Ciovirnache. M, Dumitru. L, Mogos. I, Spandonide. T, Damian. A, Handoca. A, Stoenescu. D, Dermatoglyphics in thyroid cancer. Endocrinologie. 1986; 24(3): 171-83.
11. Edelstein, J. Amylon,M. Walsh, J.A. Dermsatoglyphics and acute lymphocytic lukemia in children. Pediar Oncol Nur. 1991; 8(1):30-8.
12. Murray H. Seltzer, Chris C. Plato, Peter E. Engler, and H. Stephen Fletcher. Digital dermatoglyphics and breast cancer.Berast cancer research and treatment.1982; 2,261-265.
13. Seltzer, M.H. Plato, C.C. Fox, K.M. Dermatoglyphics in the identification of women either with or at risk for breast cancer. Am J Med Genet. 1990; 37(4):482-8.
14. Abilasha S, Harisudha R, Janaki CS. Dermatoglyphics: a predictor tool to analyze the occurrence of breast cancer. Int J Med Res Health Sci. 2014;3(1): 28-13.
15. Bhanu B. V. (1991).Digital patterns: A new classification system in dermatoglyphics today. B Mohan Reddy, S.B. Reddy, S.B. Roy, and B.N. Sarkar. (eds) Calcutta: 1-16.
16. Sakineh Abbasi, Nahid Einollahi, Nasrin Dashti, F. Vaez-Zadeh. Study of dermatoglyphic patterns of hands in women with breast cancer. Pak J Med Sci 2006 ; (22) 1 : 19-22.
17. Chintamani , Rohan Khandelwal, Aliza Mittal, Sai Saijanani. Amita Tuteja, Anju Bansal, Dinesh Bhatnagar and Sunita Saxena. Qualitative and quantitative dermatoglyphic traits in patients with breast cancer: a prospective clinical study. BMC Cancer 2007; 7:44.
18. J Lavannya, P Saraswathi, J Vijayakumar, S Prathap. Analysis of dermatoglyphc traits in patients with breast cancer. Journal of Pharmaceutical and Biomedical Sciences. 2012; 23(24): 1-5.
19. Aprajita Raizada, Vishwas Johri, T Ramnath, D S Chowdhary, R P Garg. A Cross-Sectional Study on the Palmar Dermatoglyphics in Relation to Carcinoma Breast Patients. Journal of Clinical and Diagnostic Research. 2013 April, 7(4): 609-612.
20. S.B. Sukre, A.A. Mahajan, A.G. Shroff. (2003) Dermatoglyphics in the identification of women either with or at risk for breast cancer. Paper presented at National Conference Anatomical Society Of India Dec 2003; Smt N. H. L. M. Medical College Ahmedabad.
21. P.E. Natekar, F. M. DeSouza, D.D. Motghare and A.K. Pandey. Digital Dermal Patterns in Carcinoma of Breast. Anthropologist .2006; 8(4): 251-254.
22. Oladipo GS, Paul CW, Bob-Manuel IF, Fawehinmi HB, Edibamode EI. Study of digital and palmar dermatoglyphic patterns of Nigerian women with malignant mammary neoplasm. J. Appl. Biosci.2009; 15: 829-34.
23. Daljit Singh, B.R.Prabhakar, Shivmohan Singh Bhalla Dermatoglyphic study in breast carcinoma. Indian J. Pathol Microbiol. 1979; 21: 27-32.
24. Nandy A. Identification of an individual In: Principles of Forensic Medicine. New Central Book Agency (P) Ltd. Calcutta. 2nd ed. (Reprint); 2001: 48- 111.
25. Uduak Umana, C.O. Ahunna, J.A. Timbuak, A.O. Ibegbu, S.A. Musa and W.O. Hamman. Dermatoglyphics and Cheiloscopic Patterns in Cancer Patients; A Study in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria. Current Research Journal of Biological Sciences. 2013; 5(5): 220-225.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareEVALUATION OF MYERS-BRIGGS PERSONALITY TRAITS IN OFFICES AND ITS EFFECTS ON PRODUCTIVITY OF EMPLOYEES: AN EMPIRICAL STUDY
English5358Zahra PoursafarEnglish Nandineni Rama DeviEnglish Lewlyn L. R. RodriguesEnglishBackground: Office design after physical requirement has a second concern which belongs to Psychology. The concept of Psychology and office spaces is a prominent issue for designers when planning stages of a redesign or a new workspace. Offices or workspaces today are an evolution of sorts affected by the truly diverse mixture of architectural and psychological elements which are working together in the same space.
Aim: The focus of first part of this research is to identify the employee’s Personality type in Architect’s offices in two Asian countries; Iran and India. The second part of the study investigates the existing productivity of employees to identify the influence of Personality types.
Methodology: The good-quality data has been collected from a well- designed questionnaire. The mode of the delivery was through the online questionnaire and hardy copy ones.
Result: The findings of this study explore the dominant Personality type in Architect’s offices and also reveal that productivity in an Architect’s office interior is affected by employee’s Personality types.
Conclusions: Designers benefit from knowing occupant’s Personality types. Since each Personality types have own characteristics, needs and desires, then outcome of the study could be used as a guideline for designer to have a more successful project. Differences between Personality types would have positive and negative effects on their Productivity. The results would help designers to improve the physical environment of office suits to occupant’s wishes.
EnglishPsychology, Personality types, Architect’s office, ProductivityINTRODUCTION
Architect’s office is an office which employs one or more architects and practices the profession of Architecture. The goal of these offices is to provide services (drawing, planning and consulting) in connection with the design and construction of buildings. The quality of the work environment in these offices requires the response to two issues:
• Managerial behavior and environmental condition
• User needs and their relationship to the environmental design
An important part of this environment is about “psychological implications of Architecture”. In Architectural Psychology can be described as a branch of environmental or ecological Psychology. This deals with the psychological processes of the interaction between man and his environment, as for example spatial perception, spatial thinking, orientation behavior, or spatial experience, territorial behavior, living requirements and satisfaction, local identity1 . It is not merely about the physical characteristics and features of buildings; it is about occupant’s perception and reaction to physical environment. This research, attempts to investigate and evaluate the distribution of Personality types in a comparison approach to enhance knowledge about work Psychology. The survey conducting to two populated country in Asia; Iran and India, to determine the dominant Personality type and find out the frequency of each type in Architect’s offices. According to different psychological characteristics of each type, environment can be designed to suit dominant user’s preferences, which will be more efficient in terms of cost and quality. The second part, studies the existing Productivity of employees in workplace to identify the influence or lack of influence of Personality types on employee’sProductivity in Architect’s office. ?
LITERATURE REVIEW
Workplace Psychology
Workplace design needs to be based on actual work practices and satisfy a range of human needs to inspire the most productive and innovative work outcomes2 . Davies (2005) argues that for a worker to be productive and committed, the reward structure and work itself, need to be aligned with their values. Workplace Psychology has a number of underpinning theories of motivation and commitment that to try to predict and influence worker behaviour and thus their Productivity3 .
Personality
Personality is one of the important concepts in Psychology. Sometimes Personality can be defined as noticeable psychological differences between individuals. Personality traits can be defined as dimensions of individual differences in tendencies to show consistent patterns of thoughts, feeling, and actions4 . Individual Personality traits such as extroversion and introversion can also influence a worker’s satisfaction with office layouts. Extroverts are more likely to be comfortable in open plan5 .Work situations with the likely increased number of interactions and their greater comfort with higher levels of arousal6 . This research is applying the MBTI theory to identify the employee’s Personality types. Myers-Briggs Type Indicator (MBTI) is a Personality theory that was developed by Isabel Briggs Myers and Katharine Briggs, and has been in use for over 60 years unlike many Personality theories, the MBTI is based on the assumption that people prefer a certain way of being7 . The history of the Myers-Briggs Type Indicator started with Carl Jung, the founder of analytical Psychology. Jung believed that people are either energized by the external world (Extraversion) or their own internal world (Introversion). He also observed that people took in information (Perceiving) or organized the information and came up with a conclusion (Judging). He noted that people generally engaged in one more than the other. Thus, in 1921, Jung published Psychological Types in which he presented the idea of Jungian archetypes7 . Isabel Myers believed in the beauty of human Personality. Myers wanted to develop an instrument that would reflect one’s preference not only for Introversion or Extraversion but for Perception and Judgment as well. With the onset of World War II, she developed the test to resolve conflicts and help people decide on appropriate careers. She believed that many problems involving human interaction and personal choices could be handled more successfully with Carl Jung’s theory of psychological types in mind. The Myers-Briggs Type Indicator, developed by Myers, and her mother Katharine C. Briggs, provides a structure for understanding both similarities and differences among human beings8 . The Myers- Briggs model of Personality is based on four preferences:
• E or I (Extraversion or Introversion)
• S or N (Sensing or intuition)
• T or F (Thinking or Feeling)
• J or P (Judgment or Perception)8
The 16 Personality types of the Myers-Briggs Type Indicator instrument are listed in
figure 1. Figure 1, Myers Briggs Personality types, source; http:// www.myersbriggs.org
Office Productivity
To achieve high levels of employee Productivity, organizations must ensure that the physical environment is conducive to organizational needs facilitating interaction and privacy, formality and informality, functionality and cross-disciplinarily. Consequently, the physical environment is a tool that can be leveraged both to improve business results9 . Employees are a company’s livelihood. How they feel about the work they are doing and the results received from that work directly impact an organization’s performance and, ultimately, its stability10. Employee’s morale and state of mind would have impacts on their performance in work area. Morale has a direct impact on the Productivity11.
METHODOLOGY
The primary data for the survey was collected from 302 employees. Initially 600 questionnaires were distributed randomly to the respondents in India and Iran. Table 1 explains the details of sampling techniques. Table 1, Sampling techniques, source; authors Totally out of many offices in town and cities in both countries, 80 offices in six cities were taken as sample (table 2). Table 2, Sample distribution details, source; authors The data which is collected through the survey is based on the workers’ self-awareness and honestly to answer the Personality test questions and opinions about the workplace. The objectives of the study include: • To determine the Personality types distribution in Architect’s offices, • To identify the dominant Personality type in Architect’s offices in two countries, • To investigate the effect of Personality types on employee’s Productivity. Survey results could bealtering if the survey would conduct to the other office’s employees, because of changing in dominant Personality types. Also, analysis could be extended by investigating the gender differences towards the effects of Personality on workplace environment. Thus, this research study explores the following research hypothesis; Ha ; Personality types in Architect’s offices has a significant influence on Productivity. In this connection, the relationship between Personality types and Productivity can be conceptualized and depicted in Figure 2. Figure 2, Conceptual Model
FINDINGS
Demographic Information
The first part of questionnaire dedicated to demographic data, collected from the 302 employees from both countries, as shown in table 3. Table 3, Demographic information, source; authors The questionnaires equally distributed in both the countries in case of numbers, but the return rate was different. Around 58% of Iranian and 42% of Indian respondents returned the questionnaire. The number of Iranian attendees in the survey is more, but overall result is coming in the form of the percentage to whole. According to the table3, most of the employees are Architect Offices are female in both the countries. Dominant age group for Iranian employees is 25-34 years old, but data indicates that Indian employees in Architect’s offices are younger (Englishhttp://ijcrr.com/abstract.php?article_id=411http://ijcrr.com/article_html.php?did=4111. Oberascher, L. 2015. Available from: http://leoncolor.com.
2. Davies, H. The psychological and physical needs of workers impacting office design, in COBRA 2010: Proceedings of the RICS Foundation Construction and Building Research Conference, COBRA, London, England. 2010.
3. Davies, H. Productivity and the knowledge worker, QUT Research Week International Conference, Queensland University of Technology, Brisbane, Australia. 2005.
4. McCrae, RR, Costa, PT. Personality in adulthood: a five-factor theory perspective, New York, Guilford Press. 2003.
5. Vischer, J. The concept of workplace performance and its value to managers California Management Review. 2006; 49(2): 1-18.
6. Oseland, N. The impact of psychological needs on office design, Journal of Corporate Real Estate, 2009; 11(4): 244-254.
7. Myers, I B, Mc Caulley, M H, Quenk M H, Hammer A L. Manual: a guide to the development and use of the Myers-Briggs type indicator instrument. 3rd ed. Mountain View, USA: CCP, Inc, 2009.
8. Myers-Briggs type indicator manual, WC Personality, Inc., 2012. Available from: http://calpoly.edu/~cwang24/mbtimanual. pdf.
9. Mohr, R. Office space is a revenue enhancer, not an expense, 1996, Available from: http://nreionline.com/mag/office-spacerevenue-enhancer-not-expense.
10. Mc Forson, J E. Impact of Motivation on the Productivity of Employees at Gtbank Ghana, 2012, Available from: http://ir.knust. edu.gh/bitstream/123456789 /4297/1/JOYCE%20ESSEL%20 MC%20FORSON.pdf.
11. Neely, G H. The Relationship between Employee Morale and Employee Productivity, 1999. Available from: http://www.usfa. fema.gov/pdf/efop/efo29954.pdf.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareASSESSMENT OF BONY TRABECULAR PATTERNCHANGES SEEN IN GROWING SKELEAL CLASS-II MALOCCUSION TREATED WITH TWIN BLOCK THERAPY
English5965Shaharyar AhmadEnglish Ranjit H. KambleEnglish Sunita ShrivastavEnglish Narendra SharmaEnglish Ranjit PatilEnglish Abhilasha GoyalEnglishPurpose: The purpose of this study was to assess the bony trabecular pattern changes seen in growing skeletal class-II malocclusion treated with twin block therapy and comparison with non-treated group.
Material and Methods: Full mouth Periapical radiographs of patients were taken pre and post twin block therapy. Regions of interest (100×100 pixels) were located between apices of the teeth of the maxillary and mandibular anterior, premolar, and molar area. The fractal dimension (FD) was calculated by using the box counting method. The particle count (PC) and area fraction (AF) analyses were also performed.
Results: There was significant difference in the FD values among the different groups of age, gender, upper, and lower jaws. The p-value of FD-0.011, PC-0.001 and AF-0.002 showed significant results after post twin block therapy.
Conclusion: In this study pre-treatment radiographs showed irregular vertical arrangement of the spongy trabeculae running from the walls of the socket of one tooth or root to the next and also parallel to the long axis of tooth. Post-treatment radiograph showed a regular horizontal arrangement of spongiosa and dense trabeculation and perpendicular to long axis of tooth.
EnglishTwin block therapy, Bony trabeculae, Skeletal class II, Fractal dimensions(FD)INTRODUCTION
The alveolar bone is the thickened ridge of bone that contains a region of compact bone, adjacent to periodontal ligament(PDL), which is called the lamina dura when viewed on radiographs. The alveolar bone is divided into the alveolar bone proper(compact bone) and supporting alveolar bone (cortical and trabecular bone). The trabecular bone(cancellous bone) is located between alveolar bone proper and plates of cortical bone. It is stated that in the posterior maxilla; the trabeculae are typically thin, and numerous, forming a fine, granular, dense pattern, and the marrow spaces are consequently slightly larger than the anterior region of the maxilla and relatively numerous. In the posterior mandible, the peri-radicular trabeculae are somewhat thicker than in the maxilla resulting in a coarser pattern and they are relatively larger than the trabeculae in the anterior region of the mandible. The trabecular plates in the mandible are also fewer than in the maxilla and marrow spaces are correspondingly larger.(1)Because of its high surface-volume ratio the trabecular bone is believed to have an 8-fold higher turnover rate than cortical bone and to be highly responsive to metabolic stimuli.(2) This is an important phenomenon since the maxilla and mandible are rich in trabecular bone, particularly in the anterior regions.In 1892 Wolf’s Law stated that – “every change in the form and function of bone or of their function alone is followed by certain definite changes in their internal architecture and equally definite alteration in their external conformation, in accordance with mathematical laws”.(3)Wolf’s law states that there is a nature’s attempt to organize and orient the bony trabeculae in the direction of force vector. The most common skeletal problem in orthodontics is the Class II malocclusion characterized by mandibular retrognathia.(4) Functional appliances contribute to Class II correction in growing patients through a combination of dentoalveolar and skeletal effects. Skeletal changes has been shown to account for approximately one-third of the decrease in overjet that is seen in successful cases, with the remainder predominantly maxillary incisor retroclination.(5) A wide range of functional appliances aimed to stimulate mandibular growth by forward posturing of the mandible are available to correct this type of skeletal and occlusal discrepancy. (6)Among all the functional appliances, the Twin-block has gained increasing popularity during the last decade,(7)Hence twin block appliance was chosen to assess the changes in bony trabeculae. Twin block appliance was introduced by Scottish orthodontist William Clark, in 1977. It is like a two-piece or split activator using separate maxillary and mandibular appliances with occlusal acrylic portions that serve as inclined guide plane and bite blocks. This bite blocks induce favourably occlusal forces by causing a mandibular displacement in downward and forward direction. (8) Twin block appliance has to be worn full time and it is tooth borne and tissue borne. This appliance tends to bring out new pattern of mandibular closure. It favours or stimulates potential mandibular growth in sagittal plane thereby correcting skeletal class-II malocclusion and changing the orientation of trabeculae due to the change in the position of mandible. To visualize these changes in trabeculae, IOPA and Panoramic radiographs are the most preferable diagnostic aid. An understanding of normal anatomical structures on the radiographic image is fundamental for using the images as a diagnostic aid or in designing research. Therefore, an effort has been made to identify and understand most structures that appear on intra- and extra-oral radiographs. Dental researchers and clinicians have historically assumed the lattice-like pattern observed on intra-oral radiographs as an accurate image of the internal bony medullary cavity. The radiographic appearance of normal (healthy) trabecular bone was described almost 80 years ago and that traditional description has not been changed since then.(9) Bone trabecular pattern can be characterized by a number of measures including area of the bony plates, circumference of the trabeculae, number of bony and marrow regions, thickness of the trabeculae, trabecular spacing, and osseous fractal dimension.(10) It must be recognized, however, that it is unclear which structures give rise to the trabecular pattern seen on dental radiographs. Hence the purpose of this study was to visualize the changes seen in bony trabeculae due to change in the position of mandible by twin block appliance in skeletal class II patients with retrognathic mandible.
MATERIAL AND METHODS:
The present study was carried out in the Department of Orthodontics and Dentofacial Orthopaedics, Sharad Pawar Dental College, Datta Meghe Instiute of Medical Sciences, Wardha, and Maharashtra. The study was approved from the ethical committee of Datta Meghe Institute of Medical Sciences. Study sample comprised of 10 skeletal class-II cases with mandibular deficiency in mixed or early permanent dentition attended the OPD of Sharad Pawar Dental College and Hospital, Sawangi. Written consent form from all the participating samples was taken. Routine orthodontic records along with full mouth IOPA were taken. Data was analysed using software: - INTRA ORAL GRID for analysis of bony trabeculae’s. The sample consisted of 10patients (5Males and 5Females) with the average age of 10 to 13years with no specific medical history. The patients were clinically and cephalometrically diagnosed as skeletal class II with retrognathic mandible. IOPA of all 10 patients were taken at 2 intervals: pre-treatment and post twin block therapy (duration was 6-8months).
METHOD
The alveolar bone surrounding the maxillary and mandibular permanent or mixed dentition on the periapical radiographs was evaluated. The periapical radiographs were digitized with windows 8.1 interfaced with Adobe Photoshop 7.0 software. A 256-gray-scale image was captured from a single periapical film at a resolution of 600 pixels per inch. Region of interest (ROI) measuring 64 X 64 pixels was selected near the root apices of the incisors, canines, premolar and molar teeth. Teeth structure, periodontal ligament (PDL), and lamina dura excluded upon selection of each ROI. Then the image was cropped and saved in BMP format. The ROI was selected in six regions (anterior, premolar, and molar areas in the upper and lower jaws) from each case using Image J (ver. 1.46r, National Institute of Health, USA, Java 1.6.0_20: 64-bit). The ROI was selected and processed further using the method designed by White and Rudolph.(11) In brief, the original cropped ROI was filtered using Gaussian blur in Adobe Photoshop 7.0 software to remove the fine and medium scale variations in image brightness, and then saved again. Using Scion image, the original ROI and the blurred one were subtracted from each other and multiplied by 1 and added 128. Then the resultant image was converted to binary with threshold at grey level of 128. The binary image was eroded three times and dilated three times to reduce the noise shown in fig. 1 and 2. Final image was obtained and used for fractal analysis and particles count and area fraction. All digital manipulations and measurements were made within ROIs. Image J software was used for calculating the fractal dimensions (FDs) of the image by the Box Counting function. Initially, the binary or threshold image was converted by square grid and the widths of the square boxes were 2, 3, 4, 6, 8, 12, 16, 32, and 64 pixels.(12) Subsequently, the numbers of the counted tiles were plotted against the total number of tiles in a double logarithmic scale. Finally, FD was calculated from the slope of the line fitted on data points. Image J software was used to measure the particles counts (PCs) and the area fraction (AF) of the region of interest (ROI). The particles counts (PCs) command counted and measured the objects in the region of interest (ROI) in binary images. Here, AF means the percentage of pixels in the image.(12)
STATISTICAL METHODS
Statistical Analysis was done by using descriptive and inferential statistics using student’s paired t test and software used in the analysis was SPSS 17.0 version and pEnglishhttp://ijcrr.com/abstract.php?article_id=412http://ijcrr.com/article_html.php?did=4121. Van Rietbergen B, Muller R, Ulrich D, Ruegsegger P, Huiskes R. Tissue stresses and strain in trabeculae of a canine proximal femur can be quantified from computer reconstructions. Journal of Biomechanics 1992 February; 32(2) : 165-173.
2. Lang P, Steiger P, Faulkner K, Gluer C, Genant HK. Osteoporosis. Current techniques and recent developments in quantitative bone densitometry.RadiolClin North Am 1991; 29:49-76.
3. Wolf J, Das Gesetz der Transformation der Knochen. Hirschwald A, Berlin ( Springer-Verlag published an excellent English translation of this monograph in 1986),1982.
4. Proffit WR, Fields HW. Contemporary Orthodontics. 3rd edition. St Louis, Mo: Mosby; 2000; 13: 96–98, 260–269, 481.
5. O’Brien K, Wright J, Conboy F. Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1: Dental and skeletal effects. Am J Orthod Dentofacial Orthop. 2003;124: 234–243
6. McNamara JA Jr, Brudon WL. Orthodontics and dentofacial orthopaedics. Ann Arbor: Needham Press; 2001. p. 67-80.
7. Baccetti T, McNamara JA. Treatment Timing for Twin block Therapy; (Am J Orthod Dentofacial Orthop 2000; 118:159-70)
8. Clark WJ. The twin-block traction technique.Eur J Orthod 1982; 4:129-38.
9. Jett S, Shrout MK, Mailhot JM, Potter BJ, Borke JL. An evaluation of the origin of trabecular bone patterns using visual and digital image analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98: 598-604.
10. Parfitt AM. Trabecular bone architecture in the pathogenesis and prevention of fracture. Am J Med 1987; 82: 68-72.
11. White SC, Rudolph DJ. Alterations of the trabecular pattern of the jaws in patients with osteoporosis. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999; 88: 628-35.
12. Amer ME, Min-Suk Heo, Brooks SL, Benavides E. Anatomical variations of trabecular bone structure in intraoral radiographsusing fractal and particles count analyses. Imaging Sci Dent 2012; 42 : 5-12.
13. Diane P, Grethe J, Stavros K. Assessment of trabecular pattern on periapical and panoramic radiographs: A pilot study. Acta Odontol Scand, 2010; 68: 91-97.
14. Yasar F, Akgünlü F. Fractal dimension and lacunarity analysis of dental radiographs. Dentomaxillofac Radiol 2005; 34 : 261-7.
15. Haire TJ, Hodgskinson R, Ganney PS, Langton CM. A comparison of porosity, fabric and fractal dimension as predictors of the Young’s modulus of equine cancellous bone. Med Eng Phys 1998; 20: 588-93.
16. Jolley L, Majumdar S, Kapila S. Technical factors in fractal analysis of periapical radiographs. Dentomaxillofac Radiol 2006; 35: 393-7.
17. Updegrave, William J. Normal Radiographic Anatomy. Dental Radiorraphy and Photography, December 1958: 57-65.
18. Nicholas Joseph Brescia. A Roengenographic Study of the Trabecular Pattern of the Alveolar Processes of the Human Maxilla and Mandible.Loyolauniversity, Chicago 1959.
19. Graber, Rakosi and Petrovic, Dentofacial Orthopaedics with Functional Appliances, 2nd Edition.
20. Laura E, Bollen AM, Robert ML, Susan WH, Jeremy BC, Curtis SK Chen, Lars GH et al. Trabecular and cortical bone as risk factors for orthodontic relapse. Am J Orthod Dentofacial Orthop 2006; 130:476-84
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241721EnglishN2015November11HealthcareEVALUATION OF PERINATAL OUTCOME IN PRETERM LABOUR
English6671Gulshan AkhterEnglish Syed Masooma RizviEnglish Syed Imtiyaz HussainEnglish Farhat AliEnglish Asifa AliEnglishBackground: Preterm labour is a common complication that contributes significantly to high perinatal morbidity and mortality. Premature babies are physiologically and metabolically immature. As a consequence, preterm infants are at higher risk than are term infants of developing many immediate and long term complications.
Objectives: To compare morbidity and mortality of preterm infants to those born at term. Appropriate intervention, institutional deliveries and good neonatal care back up facilities.
Methodology: The present prospective, randomized, comparative study was conducted over a period of 18 months and a total of 200 patients were selected and allocated in two groups. Study group who were in preterm labour and control group who were in full term labour. Perinatal outcome was measured by birth weight, gestational age, Apgar score at 1 and 5 minutes, admission in intensive care unit, respiratory morbidity, neonatal sepsis, need for emergency section and neonatal deaths. All babies were followed up for a period of 7 days after delivery.
Results: Preterm infants were at significantly higher risk for over all morbidity and mortality than term infants. Out of 100 preterm infants 43 had low birth weight, 70 had respiratory morbidity, 68 had sepsis, 83 required ICU admission and 35 had early neonatal death while the corresponding figures for term infants were 10, 0, 4, 6 and 5 respectively. The mean Apgar score at 1 and 5 minutes of cases was 5.54 and 6.47 respectively. The mean Apgar score at 1 and 5 minutes of controls was 7.16 and 7.64 respectively. Emergency caesarean section was required in 39 cases and 27 controls which was statistically non-significant.
Conclusion: Compared with term infants, preterm infants are at high risk of overall morbidity and mortality. Clinical suspicion, early detection and correction of risk factors, institutional delivery and good neonatal care back up facilities can improve the outcome of preterm labour.
EnglishPerinatal, Preterm labour, Apgar score, Caesarean, Clinical suspicionINTRODUCTION
Preterm labor is defined as occurrence of regular uterine contractions (three or more in ten minutes) with cervical changes (effacement more or equal to 80% and dilatation more or equal to 1 centimeter) in women with intact fetal membranes and gestational age less than 37 weeks1 . In India its incidence is 10 to 15% and accounts for about 75 % of perinatal deaths2 . Preterm labor is the leading cause of neonatal morbidity in developed countries.50 to 60% of preterm births occur following spontaneous labor 30 % due to PROM and rest are iatrogenic termination for maternal or fetal benefit.1,3 Preterm labor is one of the syndromes characterized by premature activation of final path way of parturition. Preterm labor may either be a physiological process that has occurred too soon or pathological process following an abnormal stimulus. The etiology of preterm labor may be multi-factorial. The earlier the onset of labor the more likely is that a pathological process is implicated.4
RISK FACTORS
PAST HISTORY
• Previous preterm birth
Second trimester losses
• Habitual abortions
• Uterine anomalies
• Conization of cervix
ANTEPARTUM
• Threatened abortion.
• Young or advanced maternal age.
• Poverty.
• Short stature.
• Vitamin C deficiency.
• Occupational factors such as prolonged walking or standing, strenuous working conditions and long weekly work hours.
• Inter pregnancy interval 59 months.
• Bacterial Vaginosis6 .
• Twins, triplets (51% and 91% chance of preterm delivery respectively)7
• Preterm rupture of membranes
• Polyhydramnios
• Antepartum haemorrhage
• Intra-abdominal surgery
• Urinary tract infection
• Tobacco or cocaine use
• Serious maternal infection
• Physical/emotional trauma.
DIAGNOSIS7
SUGGESTIVE EARLY SYMPTOMS
• Low abdominal pain and/or cramps and/or pelvic pressure
• Low backache
• Increased vaginal discharge
• Bleeding/spotting/show
DEFINITIVE SIGNS8
Regular uterine activity (contractions of 3 in 10 minutes or 8 in 60 minutes) accompanied by cervical effacement (80% or more) and dilatation (>1 cm)
Preterm infant can be
• Late preterm -->33-36 weeks
• Moderate preterm --> 28-32 weeks
• Extreme preterm -->20-27 weeks
Preterm infants are physiologically and metabolically immature.9 As a consequence, preterm infants are at higher risk than are term infants of developing medical complications that result in higher rates of mortality and morbidity during the birth hospitalization.10.
Premature babies are at risk of many immediate and long term complications. Immediate (short term) neonatal mobidity includes respiratory distress syndrome, hypothermia, hypoglycemia, jaundice, intraventricular haemorrhage, necrotizing enterocolitis, broncho-pulmonary dysplasia, sepsis and patent ductus arteriosus. Long term morbidity includes cerebral palsy, mental retardation and retinopathy of prematurity.11 Residual mental and motor handicaps are the major deterrents to the optimal development of preterm infant12.
AIM OF STUDY
1. To compare morbidity and mortality of preterm infants to those born at term.
2. Appropriate intervention, institutional deliveries and good neonatal care back up facilities.
MATERIALS AND METHODS:
Study Design: Prospective, comparative study.
Source and Data Collection: The patients fulfilling the inclusion criteria were selected for the study. The study was conducted in the Postgraduate Department of Gynaecology and Obstetrics, Lalla Ded Hospital, which is the sole tertiary care hospital in the valley and an associated hospital of Government Medical College, Srinagar, for a period of 18 months from March 2013- September 2014.
Inclusion Criteria
• Primigravida and multigravida.
• Gestational age 28 weeks.
• Spontaneous onset painful regular uterine contraction occurring at least 3 per 10 minutes each lasting 40 seconds.
• Progression in cervical score in the form of effacement > 80% and dilatation > 3cm.
• Presence of show or bag of membranes.
• Singleton pregnancy
• Vertex presentation
Exclusion Criteria
• Congenital fetal abnormalities.
• Multiple pregnancy.
• Gestation age >40 weeks and < 28 weeks.
• Patients with false labor pains.
• Presentation other than vertex.
• Pregnancy complicated by preterm premature rupture of memranes and maternal complication
METHOD
About 200 patients were selected for the study. The study group was comprised of 100 women admitted in Preterm Labor and the comparative group was comprised of 100 women in full term Labor.
Following considerations were given to patients in preterm labor.
1. Close observation with monitoring of uterine contractions and serial examinations (after every 4 hrs under all asceptic precautions) were done to assess cervical changes and labor progression.
2. Close monitoring of fetal heart rate and timely intervention at early signs of fetal distress.
3. For pregnancies less than 34 weeks corticosteroids were given for enhancement of fetal lung maturity (2 doses of betamethasone 12mg each 24 hour apart).13
4. A broad spectrum antibiotic (ceftriaxone 1g i/v bid) was given for prevention of neonatal infections.
5. Pediatrician was available at the time of delivery.
6. Babies were transferred to premature baby care unit for neonatal care and perinatal outcome was analyzed.
Gestational age was assessed by maternal last menstrual period or by first trimester ultrasound scan. Perinatal outcome was measured by birth weight, gestational age, APGAR score at 1 and 5 minutes, admission in special care baby unit (SCBU), assessment of indication of admission in SCBU, Respiratory morbidity, neonatal infection, need for emergency caesarean section and neonatal deaths. All babies were followed up for a period of maximum 7 days after delivery.
RESULTS AND OBSERVATIONS
The present study included 100 patients (Group A) in preterm labor and 100 patients (Group B) in full term labor.
DISCUSSION
Gestational Age of Group A and Group B
In the present study, the minimum gestational age of Group A was 28 weeks and maximum gestational age was 36 weeks with mean of 33.19 weeks and SD 2.53. While in Group B, the minimum gestational age was 37 weeks and maximum gestational age was 40 weeks with mean 38.2 weeks and S.D. 1.12.
Respiratory Morbidity
Twenty four studies published between 2000-2009 consistently revealed that infants born at 32-36 weeks experience Respiratory Distress Syndrome, Transient Tachypnea of Newborn, pneumonia and pulmonary hypertension of the newborn at higher rates than term infants75. Subsequent studies delivered similar conclusion. The rate of respiratory compromise in US hospitals was 10.5% of late preterm and 1.13% of term infants14. Broadly et al15 concluded that clinically significant respiratory morbidities are least common at 39-40 weeks. In the present study all forms of respiratory morbidity and overall respiratory failure decreased significantly with gestational age until 40 weeks. One study of all California singleton live births who survived to 1 year of age found that infants born at 34-36 weeks gestation were 3-9 times more likely to require mechanical ventilation than infants born at 38 weeks gestation.
Sepsis
Preterm infants are more likely to develop severe infections such as sepsis, meningitis and pneumonia than term infants. In a large retrospective population report, McIntire and Leveno16 found an increased risk of sepsis in late preterm versus term infants. The rate of sepsis in moderate preterm infants has also been shown to be almost double than in late preterm infants. In a twin population, Refuerzoet al17 found 5% of sepsis in moderate versus 2.2% in the late preterm infants.
Need for Neonatal Intensive Care Unit
Admission Preterm infants are more likely than term infants to have longer initial hospital stays and to be admitted to the Neonatal Intensive Care Unit18 One large cohort study found that 88% of infants born at 34 weeks gestation, 54% of infants born at 35 weeks gestation, 25% of infants born at 36 weeks gestation, 12% of infants born at 37 weeks gestation and 2.6% of infants born at 38-40 weeks gestation were admitted to a Neonatal Intensive Care Unit. In the present study Neonatal Intensive Care Unit admission was required in 83% of preterm infants (< 36 weeks) 6% of term infants (> 37 weeks – 40 weeks).
Mortality
Preterm infants have high neonatal mortality rate than term infants. Larroque et al19 reported the results of EPIPAGE study on the survival of preterm infants born between 27-32 weeks in a geographically defined population of France in 1997, stratified by gestational age. The survival rate between 22 and 32 weeks was 67% of all births (including still births). 85% of live births and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age. 31% of all infants born alive at 23 weeks survived to discharge 78% at 28 weeks and 97% at 32 weeks. Survival among live births was lower for Small for gestation age infants. Vidyadhar B. Bangal et al20 conducted a study of perinatal outcome in preterm labor at tertiary hospital. He observed that perinatal mortality in the study group was 42.4%. Roberta De Luca et al21 similarly found that mortality and morbidities had strong gestational age related trend with the lowest incidence consistently found between 38 and 40 weeks of gestation. Need for Emergency Caesarean Section and Mode of Delivery The main finding in this study is that caesarean delivery did not enhance the neonatal survival of preterm infants nor did it decrease the morbidity in these infants. This is further supported by the work of Malloy et al and others22.
APGAR Score at 1 minute and 5 minutes
In the present study, it was found that there is a direct relationship between low APGAR score, gestational age and neonatal mortality in preterm infants. APGAR score in preterm infants at 1 minute was found to range from 4-8 with mean being 5.548 SD 1.27 while in term infants it ranged from 4.8 with mean being 7.16 and APGAR score at 5 minutes in preterm infants ranged from 4-8 with mean of 6.47 and SD 1.28 while in term infants it ranged from 4-8 with mean of 7.64 and SD 0.628. Henry Chong Lee, Mohammad Subeh and Jeffrey B. Gould23 conducted study on low APGAR score and mortality in preterm neonates born in the United States where they found that distribution of APGAR score depended on gestational age, the youngest gestational age having higher proportions of low APGAR score. Median APGAR score ranged from 6 at 24 weeks to 9 at (30-36 weeks) gestation. The RR of death was significantly higher at APGAR score 0-3 versus 7-10.
Low Birth Weight
The present study showed that preterm infants are at high risk of low birth weight than term infants and the low birth weight adversely affects the mortality of these preterm infants. Laurie S. Pulver, et al24 conducted a study on weight for gestational age affects the mortality of preterm infants being small for gestation age substantially increases the already higher mortality of preterm infants. This increased risk cannot be fully explained by an increased prevalence of lethal congenital conditions among small for gestation age preterm new borns.
CONCLUSION
Preterm onset of labor is a heterogeneous condition with multifactorial etiology. Clinical suspicion, from the past obstetric history, early detection and correction of risk factors like Group B of blood pressure in preeclampsia, correction of anaemia, treatment of cervicovaginal infections and asymptomatic bacteriuria, abstinence, use of tocolytics in over distended uterus, cervical circlage in proven cases of cervical incompetence can prevent preterm onset of labor and hence decrease the mortality and morbidity burden due to preterm births. Use of injectable progesterone in idiopathic threatened Preterm Labor can reduce the incidence of Preterm Labor. Maternal Betamethasone in Preterm Labor helps in enhancing the fatal lung maturity and reduces the incidence of Respiratory Distress Syndrome in newborn babies. Deliveries in the institution having facilities for neonatal care will improve the perinatal outcome in Preterm Labor. The rate of morbidity and mortality declines continuously when gestational age increases upto 39 weeks. There is a particular need to educate health care providers and parents about the vulnerability of infants born between 28-36 weeks gestation. From the present study and the literature, it is clear that preterm group is significantly more vulnerable when compared with the term group. This study will lead to review of care for preterm group and help optimize care for this cohort of infants. Reorganization of services and increased resource allocation to provide better clinical support to this group may be needed in most settings. The findings of this study may also affect antenatal counseling regarding delivery in preterm gestation. Based on the findings of the present study, it is concluded that caesarean delivery does not improve the outcome in preterm babies. Mode of Delivery does not influence mortality and morbidity in preterm infants, if there are no obstetric indications favoring a particular mode. Caesarean section cannot be recommended as the routine Mode of Delivery for preterm babies unless there are other recognized maternal / fetal indications. Preterm infants are physiologically less mature and have limited compensatory responses to the extra-uterine environment compared with term infants. An immature baby should be conveyed to an intensive care nursery as soon as possible in a portable incubator, if it is not immediately possible baby should be kept warm. It loses heat very easily and it should be supported by hot water bags, care should be taken to prevent burns which happen very easily and quickly. The ambient temperature may have to be about 320 C to maintain rectal temperature of 35.50 C. Understanding morbidity risk among preterm infants is not only important helping newborn care providers to anticipate and to manage potential morbidity during birth hospitalization and earlier follow up after hospital discharge, but also may possibly assist in guiding non-emergency obstetric intervention decisions. The present study is an attempt to obtain data in pattern of early neonatal morbidity and mortality to compare it with term neonates.
Conflict of interests The author(s) have not declared any conflict of interests.
Source of funding There is no source of funding.
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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