Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11ELECTROMIOGRAPHY AND ITS ORTHODONTIC APPLICATION
English0104Saqib HassanEnglish Megha TrehanEnglish Khaja Amjad HussainEnglish Bassel TarakjiEnglish Ibrahim AlzoghaibiEnglish Saleh Nasser AzzeghaibiEnglishElectromyography is one of the usefull techniques for evaluating muscle function and efficiency by detecting their electrical
potentials. It helps in determine the muscle activity. It helps in recording the electrical activity evoked in a muscle by electrical stimulation of its nerve. This article outlines some of the uses in orthodontics.
EnglishElectromyography, Muscle function, OrthodonticsINTRODUCTION
The Electromyographic technique consists of various types of electrodes. The two main types of electrodes are surface electrodes and needle electrodes. the introdation of electromyography in orthodontics determined the beginning of some studies about neuromuscolar system’s response to physiological and pathological oral alterations and the effect of masticatory muscles on facial morphology.1 Experimental studies demonstrated that a real change in muscolar function causes morphology alterations.1 Several studies in literature, from Watt e Williams, who studied in 1951 the effect of masticatory bolus on mouse maxillary and mandibular development, to Avis who in 1961 showed how muscolar function was important for gonial region development, connect morphology and function.2 Electromyographic analysis of the masticatory muscles constitutes an important complementary instrument in orthodontic diagnosis, as a careful evaluation of muscle activity before and during treatment guides the professional in selecting suitable therapy, as well as in the choice of more individualized retainers, minimizing relapses.3 In what it refers to diagnosis tools to evaluate the man? dibular kinesiology, the surface of electromyography that studies the kinesiology of the muscular groups, it rep? resents a useful diagnosis technique for dentists, physi? otherapists, phonoaudiologists therapeutic occupation, neurologists, otorhinolaryngologists, orthopedic special? ists and of professionals of other areas that need objec? tive parameters for clinical evaluation of the muscular activity, as well as to evaluate the therapeutic results. The electromyography also investigates general muscular alterations, it determines the beginning of muscular activation and it evaluates the coordination or unbalance of the different muscles involved in the kinesiology of the muscles.4
ELECTROMYOGRAPHY IN ORTHODONTICS
The first effort to apply electromyography to dentistry was made by Robert E. Moyers.4 He observed that the normal relations of teeth to each other in the same jaw and with those of the opposite jaw were influenced by muscular balance. With relevance to orthodontics, the muscles of importance are the mandibular elevators, namely: masseter muscle, temporalis muscle, and the medial pterygoid muscle; and the mandibular depressor, i.e. the lateral pterygoid muscle. The genioglossus muscle also plays an important role in determining facial morphology. This muscle is responsible for the protrac-tion of the tongue. Mentalis muscle and orbicularis oris muscle are also important. Allen Brodie said that, ‘If we could learn to control the musculature through the critical period of growth, we might be able to expect that, in at least a proportion of the patients, there would be spontaneous unfolding of development, that we thought previously must be man? aged with orthodontic force’.5 Graber points out that in contract to Class I malocclusion where the muscle func? tion is usually normal (except for open bite cases), most Class II division 1 malocclusions involve abnormal mus? cle activity. In Class II division 2 malocclusion, there is compensatory muscle activity, with dominance of poste? rior fibers of both the temporalis and masseter muscles. Graber also added that in Class III and Class II division 1 malocclusions, the problem is that of dominant bone dys? plasia with adaptive muscle function and tooth irregular? ity reflecting a severe basal dysplasia.6 Pancherz analysed the electromyographic activity in the masticatory muscles of patients with Class II division 1 malocclusion and normal occlusion. Recordings were made during maximal biting in centric occlusion and during chewing. The results revealed: During maximal biting in intercuspal position, the Class II exhibited less electromyographic activity in the masseter and temporal muscles than the controls. The reduction in electromyo? graphic activity in the study group was most apparent for the masseter muscle. During chewing the Class II subjects showed less electromyographic activity in the masseter muscle than in the normals. For the tempo? ral muscle, no differences were found between the two groups. High positive correlations were found between the electromyographic activity during maximal biting and chewing for both muscles of the two groups. The im? paired muscle activity found in the Class II cases may be attributed to a diverging dentofacial morphology and un? stable occlusal contact conditions.7 Moyers investigated electromyograms of children with Class II division 1 mal? occlusion and found dysfunction of the temporal muscle in habitual occlusion and at rest (increased activity in the posterior part of the temporal muscle). He asserted that this dysfunction might be an etiologic factor of postnormal occlusion.4 The study by Lacouture et. al. on the action of 3 types of functional appliances on the activity of the masticatory muscles. The appliances used were – Herbst, Frankel and simulated Twin block. The authors found that the use of these appliances in non-human primates was associated with a statistically significant decrease in functional ac? tivity of the jaw muscles. This study was used to test the ‘lateral pterygoid hypothesis’, which states that postural and functional activity of the superior, and inferior heads of the lateral pterygoid muscle increases after the inser? tion of a functional appliance.8 This increased activity, especially in the superior head of the lateral pterygoid muscle then acts to stimulate increased condylar growth. The electromyographic activity of the masseter, digastric, superior and inferior heads of the lateral pterygoid mus? cles were monitored and were found to decrease with functional appliance treatment. This study did not sup? port the lateral pterygoid muscle hypothesis.8,9 The study of temporal muscle activity during the first year of Class II division 1 malocclusion treatment with activator. They found no evidence of decrease in the pos? tural activity of the posterior temporal muscle, although such a decrease has been described as a sign of forward displacement of the mandible during treatment with a functional appliance.10 The study done on Class III subjectsshowed that the correction of the anterior crossbite in Class III patients in creases the electromyographic activities of the masseter and anterior temporal muscles, or improves coordination of the bilateral masseter and anterior temporal muscles. A study by Deguchi and Iwahara tested this hypothesis. They used chin cup therapy for Class III patients and found a decrease in masseter muscle activity on both the working (chewing) and balancing sides, with no improvement in the coordination of bilateral masseter and anterior temporal muscles. It has been reported that the integrated electromyographic activity of the masseter and temporal muscles in Class III cases is less than in normal occlusion subjects. Electromyographic activity during swallowing The electromyographic activity of the facial muscles shows characteristic differences during normal and abnormal swallowing. In the normal mature swal low, the mandible rises as the teeth are brought together during the swallow, and the lips touch lightly. The facial muscles do not show marked contractions. The temporal muscle contracts as the mandible is elevated. During the teeth-apart swallow, no contraction of the temporal muscle is seen. Here mentalis muscle and lip contractions are needed for mandibular stabilization.11 Winders studied the forces exerted on the dentition by perioral and lingual musculature during swallowing. He concluded that the buccal and labial musculatures do not contract during swallowing unless there is an anterior open bite with accompanying antero–posterior skeletal dysplasia. All the muscles of the body are continually being remodeled to match the functions that are required of them. Any muscle that is used more than optimal level hypertrophies, and thus its total mass increases. Atrophy occurs when the muscle is not used causing a decrease in muscle mass. In tongue thrust swallowing, the tongue activity is increased. The tongue has to come more forward than normal to produce an oral seal to help initiate the swallowing procedure. Therefore, the tongue muscle, especially the genioglossus muscle (which is responsible for protrusion of the tongue), hypertrophies. Virtually all muscle hypertrophy results from increase in the number of actin and myosin filaments in each muscle fiber, thus causing enlargement of the individual muscle fiber1. This is called fiber hypertrophy. This usually occurs in response to contraction of a muscle at maximal or almost maximal force. Another type of hypertrophy occurs when muscles are stretched to a greater-than-normal length. This causes new sarcomeres to be added at the ends of the muscle fibers where they attach to the tendons. Whenever a muscle hypertrophies, its electromyographic activity increases relative to the normal. This is because of increased motor units being activated during muscle contraction. This applies to the tongue muscle as well. When the tongue is retrained and the tongue habit is cor? rected, the muscle remains shortened continually to less than its normal length. Thus sarcomeres at the ends of the muscle fibers disappear, and the amount of actin and myosin decreases. Therefore, there is a relative atrophy of the muscle fibers. The electromyographic activity af? ter habit correction returns to normal levels. It is by this process that muscles are continually remodelled to have an appropriate length for proper muscle contraction. 12 Pain has been shown to have an effect on muscle activity even when it does not originate in the muscle itself or in the related joint. The effect of pain from archwire adjust? ment on jaw muscle activity is unclear. Goldreich et al. evaluated the effect of orthodontic archwire adjustment pain on masseter electromyographic activity. The elec? tromyographic levels during function decreased signifi? cantly after treatment started. The results suggest that orthodontic pain on teeth tend to reduce muscle activity during function.13 Ngan et al. assessed masticatory mus? cle pain and electromyographic activity before, during, and after treatment with orthopaedic protraction head? gear. In general, 800 g of orthopaedic force is used to protract the maxilla and 75% of this force is transmitted to the temporomandibular area via the mandible. The results of the study demonstrate no significant increase in masticatory muscle activity or muscle pain associated with orthopaedic treatment using maxillary protraction headgear. 14 The study of lips showed different electromyographic activity occurred between youngsters with Class II, Division 1 and those with normal occlusion, This activity was shown to be greater in youngsters with Class II, Division 1, thus, suggesting decreased lip competence in this group.15 A higher activation level of masseter and temporalis muscles in rest position. Lower potential function of masseter and temporalis muscles. Inharmonious activity of the masticatory muscles during mandibular border movements. Higher asymmetry index of masseter and temporalis muscles.16 Electromyographic study on occlusal stability in cleft lip and palate patients. The occlusal stability index and the masseter muscle activity in the child constricted arch group were lower than those of normal child group and child non-constricted arch group. Also, the child constricted arch group showed higher value of asymmetry index than other groups.17
CONCLUSION
The role of muscles is one of the factor in causing malocclusion. As electromyographic studies have shown, the muscle will be active in rest position also. Compensatory activity can also be seen in Class II and Class III malocclusions. After orthodontic therapy, adaptations to the new morphologic relationship are clearly seen. Electromyographic studies may help in giving a clue to solving many malocclusion problems.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the manuscript, the authors are also grateful to authors’ editors and publishers of all those articles journals and books from where the literature for these article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=763http://ijcrr.com/article_html.php?did=7631. Serrao G. Relation between vertical facial morphology and jaw muscle activity in healthy young man. Prog Orthod 2003;4:45-51.
2. Watt DG. The effects of the physical consistency of food on the growth and development of the mandible and the maxilla of the rat. Am J Orthod Dentofac Orthop 1951;37(12):895-928.
3. Störmer K, Pancherz H. Electromyography of the perioral and masticatory muscles in orthodontic patients with atypical swallowing. J Orofac Orthop. 1999;60(1):13-23.
4. Moyers, R. E. Temporomandibular muscle contraction patterns in Angle Class II, Division 1 malocclusions: An electromyographic analysis. Am J Orthod Dentofac Orthop 1949; 35: 837-857.
5. Brodie, A. G. Muscular factors in the diagnosis and treatment of malocclusions. Angle Orthod 1953; 23: 71–77.
6. Graber, T. M. The “three M’s”: Muscles, malformation, and malocclusion. Am J Orthod Dentofac Orthop 1963; 49: 418-450.
7. Pancherz, H. Activity of the temporal and masseter muscles in Class II, Division 1 malocclusions: An electromyographic investigation. Am J Orthod Dentofac.Orthop 1980; 77(6): 679–688.
8. Lacouture, C., Woodside, D. G., Sectakof, P. A. and Sessle, B. J. The action of three types of functional appliances on the activity of the masticatory muscles. Am J Orthod. Dentofac Orthop 1997; 112: 560–572.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11BIOSYNTHESIS AND CHARACTERIZATION OF SILVER NANO PARTICLES USING BLACK CARROT ROOT EXTRACT
English0508Aminu Shehu AbubakarEnglish Ibrahim Bala SalisuEnglish Shiwani ChahalEnglish Geetika SahniEnglish Ramesh Namdeo PudakeEnglishThe synthesis of nano particles using the bio system is referred to as Green Synthesis, as it a cost-effective, energy-efficient and easy method. Here we have used the green approach for the synthesis of silver nanoparticles (AgNPs) using Black carrots as the source phytochemicals for reducing and capping agent for the reduction of silver ions to silver atoms and stabilization of the particles. The black carrot extract was added into 1mM silver nitrate solution and the formation of AgNPs was primarily detected by the change of colour to reddish-brown. The nano particles were further characterized by using UV-Vis spectroscopy and Transmission Electron Microscopy (TEM) analysis. The maximum Plasmon absorbance peak of 413 nm was obtained, and nanoparticles sizes ranges from 4.32 nm to 17.65 nm with an average diameter of 9.46 nm. Around 88 % of the particles depicted by the TEM image fall within the range 4-12 nm. The method used here confirms the synthesis of AgNps by using the root extracts of black carrots and, it is simple, eco-friendly and economical for large-scale production of AgNps.
EnglishBlack carrot, Silver nitrate, Green synthesis, Silver nanoparticle, NanometerINTRODUCTION
These days there are lot of research activities on nano particles which are going on all over the world. These particles that are intermediate between bulk materials and isolated atom sized materials in the range of 1 to 100 nm. They are being used for various pharmaceutical and agricultural applications [1]. Nowadays the nano particles are being synthesized from metal and also from non-metallic materials. But when it comes to the biological application of nanoparticles, silver and gold are most preferred metals [2, 3]. Synthesis of nanoparticles is an area of interest for many researchers, and is synthesized through various physical and chemical methods. During the chemical production of nanoparticles the toxic and hazardous risks are involved and is a potential threat to environment, as well as it is expensive [4]. The science of the synthesis of nanoparticles using biological means is a new emerging area and gained significant attention from researchers. The green approach uses living organisms or the bi-products of them, which act as reducing agent as well as stabilizers. Due to the environmentally friendly nature of such nano-products, it is being vastly utilized for production of nano particle [5-7] especially for synthesis of silver and gold nano particles. The silver nano particles have a wide range of applications in the field of nanobiotechnology and other related fields because of its new or improved properties depending upon their size, morphology, and distribution [8]. It has antimicrobial property [8, 9] and is also believed to be potential anti cancer agent [10]. And the AgNps have been synthesized by using various plant extracts and many microorganisms [5], but there is only one study aimed at producing eco-friendly nanoparticles using the starch derived from carrot [11].
Black carrot, also called purple carrot is one among the different colored varieties of carrot (Daucus carrota L.). It is rich in anthocyanin, which makes it suitable for use in food, nutraceutical and pharmaceutical preparations [12] and can be a potential source of reducing agent in the green synthesis of nanoparticles. It contains more than 40 phenolic acids and 5 predominant anthocyanins, two of which are nonacylated cyaniding glycosides and three derivatives of cyanidins acylated with sinapic, ferulic and p-coumaric acid [13]. Antioxidant activity of the carrot anthocyanins has the potential to synthesize NPs, but to our best knowledge, this is the first report on the green synthesis of silver nanoparticles using black carrot extract.
MATERIALS AND METHODS
Preparation of plant extract
Fresh roots of black carrots were collected from main research station of the school of agriculture, Lovely professional university, Phagwara, India situated at 31.250 North latitude, 75.700 East longitude and altitude of 105.5 m above sea level. This was brought to laboratory where it was thoroughly washed and chopped into pieces. 10 g of the chopped carrot was taken into a flask of 100ml sterile double distilled water and the mixture boiled for 5 minute. The extract was filtered using Whatman filter paper and used as reducing agent for the synthesis of AgNPs.
Preparation of silver nanoparticles
1mM aqueous solution of silver nitrate (AgNO3 ) was prepared and used for the synthesis of silver nanoparticles. 10 ml of the black carrot extract was taken and added into 90 ml of aqueous solution of 1 mM Silver nitrate and incubated in the dark, overnight at room temperature.
Characterization of AgNPs
Equal amount of sample aliquot and distilled water (1ml each) were mixed in a 10 mm-optical-path-length quartz cuvettes, and the UV-vis spectrum of the reaction medium was carried out to detect the reduction of pure Ag+ ions. The concentration of AgNPs produced was measured as reported by [14] using a Systronics UV double beam spectrophotometer, at a resolution of 1 nm, between 200 and 800 nm. The morphological analysis of the synthesized AgNPs was conducted using high-resolution, Hitachi H 7500 transmission electron microscopy (TEM).
Statistical analysis
A simple statistical tool, histogram was used to represent the nanoparticles sizes and its number as obtained from the TEM images. Histogram was plotted for particle number against sizes.
RESULTS AND DISCUSSION
The chemical reduction of aqueous solution of silver nitrate is one of the most widely used methods for the synthesis of silver nanoparticles. In the present study, the plant-mediated synthesis of nano silver particles was observed upon addition of the carrot extract into the colorless 1mM aqeuos solution of AgNO3. This is visibly detected by characteristic colour change of the reaction mixtures (Fig. 1), which occurs due to the reduction of ionic silver to atomic silver owing to the activities of phytochemicals present in black carrot root. The phenolics and anthocyanins compounds of black carrot [13] are capable of reducing the ions. Reddish brown color was formed within few minutes of incubation. Silver nanoparticles show different color ranging from brown to dark brown, and some times reddish or yellowishbrown color in aqueous solution due to the phenomenon of surface Plasmon [15]. The successful biosynthesis of the nanoparticles was further confirmed by using UV-Vis spectroscopy analysis. The use of UV–Vis spectroscopy in metal nanoparticles characterization is crucial technique that gives information on formation and stability of the nanoparticles in aqueous solution [16]. There is a relationship between UV-visible absorbance characteristics and sizes and shapes of the particles formed [17]. Using UV-Vis spectroscopy, maximum surface Plasmon absorption band was obtained at the maximum peak of 413 nm. The absorbance peak was observed in the range of 425-460 in other studies, where the nanoparticles are synthesized by using different plants [4, 18-20] showing the presence of spherical Ag nanoparticles which was later confirmed by further analysis. The TEM analysis depicted silver nanoparticles of varying sizes ranging from 4.32 nm to 17.65 nm with an average diameter of 9.46 nm. The highest number of particles obtained (42%) fall within the range of 10-12 nm, followed by 4-6 nm range (29%). Out of the particles captured by the TEM machine 88 percent were between the ranges of 4-12 nm. The efficiency of nanoparticles function depends on their sizes. Their small size nature, shape and surface structure, charge, chemical nature and solubility make them interact more with biomolecules and cells [21, 22] and it is this size modification that make them of significant interest compared to their bulk counterpart. The size range (4-18 nm) of the AgNPs obtained in this study was comparably smaller than the earlier reported using other different plant material like 29-68 nm in Acanthephylum bracteatum [4], 5-55 nm size range in Dalbergia sissoo [20], and 55-80 nm using Cinnamomum camphora [23]. But there is study in which the leaf extracts of Emblica officinalis have been used to synthesize nanoparticles of silver having smaller sizes of 10-20 nm [24].
CONCLUSION
Green synthesis of metal nanoparticles using both plants and microorganism is rapidly becoming area of interest due lack of environmental threat especially when plants are used. Black carrots, being an important crop (rich in phythochemicals that were to act as both reducing and capping agent) was used and silver nanoparticles of smaller sizes were successfully synthesized. In future the method can be standardized, and used for scaling up the production of sliver nano particles.
ACKNOWLEDGMENTS
The authors would like to show their appreciation to the Sophisticated Analytical Instrument Facility (SAIF), Panjab University, Chandigarh for the TEM analysis, as well as Dr. Madhu Sharma and Amit Panwar of Lovely Professional University, Phagwara for their kind help during the study. Authors also acknowledged Journals and Publishers whose articles were cited in this work.
Englishhttp://ijcrr.com/abstract.php?article_id=764http://ijcrr.com/article_html.php?did=7641. Salata OV (2004) Applications of nanoparticles in biology and medicine. J Nanobiotech 2:3
2. Kholoud MM, Abou El-Noura, Ala’a Eftaihab, Abdulrhman Al-Warthanb, Reda A.A. Ammar (2010) Synthesis and applications of silver nanoparticles. Arabian J Chem 3(3):135–140
3. Dykman LA, Khlebtsov NG (2011) Gold nanoparticles in biology and medicine: Recent advances and prospects. Acta Naturae 3(2): 34–55
4. Forough M, Farhadi K (2010) Biological and green synthesis of silver nanoparticle. Turkish J Eng Env Sci 34:281 – 287
5. Kalishwaralal K, Deepak V, Ramkumarpandian S, Nellaiah H, Sangiliyandi G (2008) Extracellular biosynthesis of silver nanoparticles by the culture supernatant of Bacillus licheniformis. Mater Lett 62:4411–3
6. Oxana V, Kharissova HV, Dias R, Boris I, Kharisov, Pérez OV and Victor MJP (2013) The greener synthesis of nanoparticles. Trends in Biotech 31:240–248
7. Shams S, Pourseyedi S, Raisi M (2013) Green synthesis of Ag nanoparticles in the present of Lens culinaris seed exudates. Inter J Agric and Crop Sci. Available online at www. ijagcs.com.
8. Awwad AM, Salem NM, Abdeen AO (2013) Green synthesis of silver nanoparticles using carob leaf extract and its antibacterial activity. Inter J Industrial Chem 4:29
9. Deepak V, Kalishwaralal K, Pandian SRK, Gurunathan S (2011) An insight into the bacterial biogenesis of silver nanoparticles, industrial production and scale-up. In Rai, M. Duran, N. (Eds), Metal nanoparticle in microbiology, pp 303. Springer. DOI: 10.1166/jnn.2005.184.
10. Sulaiman GM, Mohammed WH, Marzoog TR, Al-Amiery AA, Kadhum AH, Mohamad A (2013) Green synthesis, antimicrobial and cytotoxic effects of silvernanoparticles using Eucalyptus chapmaniana leaves extract. Asian Pac J Trop Biomed 3(1): 58-63
11. Engelbrekt C, Sorensen KH, Zhang JD, Welinder AC, Jensen PS, and Ulstrup J (2009) Green synthesis of gold nanoparticles with starch–glucose and application in bioelectrochemistry. J Mater Chem 19:7839
12. Ersus S, Yurdagel U (2006) Microencapsulation of anthocyanin pigments of black carrot (Daucuscarota L.) by spray drier. J Food Engin 80:805–812
13. Montilla EC, Arzaba MR, Hillebrand S, Winterhalter P (2011) Anthocyanin composition of Black Carrot (Daucus carota ssp. sativus var. atrorubens Alef.) cultivars antonina, beta sweet, deep purple, and purple haze. J Agric Food Chem 59:3385–3390
14. Abubakar AS, Salisu IB, Chahal S (2014). Green synthesis of nano silver particles using some selected plant species: comparative studies. Indian J App Res 4(7): 5-8
15. Jae YS, Beom SK (2009) Rapid biological synthesis of silver nanoparticles using plant leaf extracts. Bioprocess Biosyst Eng 32:79-84
16. Philip D, Unni C, Aromal SA, Vidhu VK (2011) Murraya koenigii leaf assisted rapid green synthesis of silver and gold nanoparticles. Spectrochim Acta A Mol Biomol Spectrosc 78:899-904
17. Mubayi A, Chatterji S, Rai PM, Watal G (2012) Evidence based green synthesis of nanoparticles. Adv Mat Lett 3(6): 519-525
18. Sriram T, Pandidurai V (2014) Synthesis of silver nanoparticles from leaf extract of Psidium guajava and its antibacterial activity against pathogens. Int J Curr Microbiol App Sci 3(3):146-152
19. Jacob SJP, Narayanan PRA, Finub JS (2013) Green synthesis of silver nanoparticles using Piper nigram leaf extracts and its cytotoxic activity against hep-2 cell line. World J Pharmaceutical Res 2(5): 1607-1616
20. Singh C, Baboota RK, Naik PK, Singh H (2012) Biocompatible synthesis of silver and gold nanoparticles using leaf extract of Dalbergia sissoo. Adv Mat Lett 3(4): 279-285
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24. Ankamwar B, Damle C, Ahmad A, Sastry M (2005) Biosynthesis of gold and silver using Emblica officinalis fruit extract, their phase transfer and transmetallation in an organic solution. J Nanosci Nanotechnol 5(10):1665-71
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11STRATEGIC ANALYSIS OF ELECTROCUTION FATALITIES IN RURAL SOUTH INDIA OBSERVED IN A YEAR
English0912Ananda ReddyEnglish Sengottuvel PEnglish Balaraman REnglishBackground: This study was performed to analyse the frequency, profile and pattern of injuries among electrocution fatalities. Materials and Methods: Cross sectional study of all electrocution deaths autopsied at Puducherry during the calendar year 2013. We gathered incident information from the relatives and investigating officers, autopsy findings are interpreted and data were analyzed for results. Results: Electrocution deaths have accounted for 1.29% of all medicolegal autopsies (n=1320) conducted at our study centre during the study period. The chief victims are males and adults in their third and fourth decade of life. The majority of the victims are Hindus, literates, agricultural workers and from rural background. The prime body part injured in electrocution are hands and fingers (65%), followed by soles and toes. Entry marks and exit marks alone were noticed in 47% and 18% respectively, but both marks were noticed in 30% of cases. Most electrocution incidents were occurred during summer season and during the day times. All the cases are accidental in nature. Conclusions: Electrocution deaths are only a small proportion of unnatural deaths and they are prevalent in domestic and occupational places. Health education and safety precautions are in need to reduce the electrocution mortalities.
EnglishElectrocution fatalities, Autopsy, Entry and Exit marks, DomesticINTRODUCTION
Electric current is of greatest importance at domestic and occupational places in today’s human life. The amount of body damage caused by the electric current depends upon the type, strength and duration of exposure. Electrical injuries are responsible for considerable morbidity and mortality in developed countries, even with significant improvement in product safety1 and implementation of rules and regulations. In low income countries electrocution deaths are emerging into an public health problem because of lack of awareness and poor safety issues.2 Indian national data on accidental deaths and suicides for calendar year 2010 and 2011 has reported 9059 and 8945 electrocution deaths respectively, with a share of 2.4% of total accidental deaths.3 Almost every electrocution death is an accidental one, but very rarely it is either suicidal or homicidal.4 Puducherry has reported the highest rate of accidental deaths as compared to the national average. This study was designed to know the frequency, victim’s profile, pattern of electrical injuries and manner of death among the study population.
MATERIALS and METHODS
This autopsy oriented, cross-sectional study was conducted at the department of Forensic Medicine, Indira Gandhi Government General Hospital and Postgraduate Institute (IGGGH and PGI), Puducherry during the calendar year 2013 (from 1st January to 31st December). All cases of electrocution deaths autopsied at the study centre were considered. We gathered detailed history of electrocution incident, demographic profile and thereof of each case by personal interview with family members / accompanying person, police officers and by referring hospital records. The medicolegal autopsy was conducted meticulously from head to toe. The deceased was examined thoroughly for electrical injuries and any other mechanical injuries over the body. Ethical principles were upheld by maintaining confidentiality and by obtaining consent from the relatives and medical record department. Finally the deceased profile, examination findings and ancillary investigation (histopathological, chemical analysis) data were collected, entered into Microsoft Excel (2007) sheet, and analyzed for frequencies and percentages. The results were interpreted by using tables and bar diagrams.
RESULTS
1320 medico-legal autopsies were conducted in the study center during the calendar year 2013, among that 17 (1.29%) were on electrocution fatalities. The chief victims were males (gender ratio of 3.2:1) and adults in the age group of 21-40 years (53%) (Table 1). Demographically most victims belonged to Hindu religion (82%), Rural background (53%), Married (53%), Literates (70%) and lower socioeconomic status (59%) (Table 2). The occupation of the victims was categorized as follows; agricultural workers (29%), laborer (18%), students (18%) and housewives (12%) (Figure 1). To a great extent these incidents were occurred in the summer seasons, (Figure 2) and during day times between 6 AM to 6 PM (76%) (Figure 3). It was remarkable that victims were electrocuted while handling domestic appliances in the house (47%), industrial machines (18%) and electric wires (12%). It was noticed that 65% cases were found dead at the scene of crime and the rest were declared dead at the hospital. The frequent location for entry and
exit wounds of electrical injuries are hands and fingers (65%) of upper extremities and soles and toes (17%) of lower extremities respectively (Table 3). The manner of death was accidental in nature in all cases and no suicidal or homicidal death was reported. DISCUSSIONS We noticed, the low frequency of electrocution deaths (1.29%) in this region compared to studies conducted in various parts of India and abroad (1.9 to 3.3%).5,6,7,8 The frequency of electrocution fatalities in each territory depends upon multiple factors like weather non-uniformity, education status and awareness of electrocution in general public, safety measures adopted by the public and also rules and regulations followed by the government. Males are predominantly victimized than females, having a resemblance to the conclusions of studies conducted in Coimbatore, South Delhi, Nagpur and Manipur on electrocution deaths. 4,5,6,9 The adults of second to fourth decade are in a vulnerable position to electrocution deaths, but these incidents were rare in extremes of ages. The age findings of the present study are in more congruous with Rautji work (21-40 years). 5 Age group in danger was narrowed to 21-30years in few studies 4,9 and quite wider in most other studies (20-50 years). 6,10 Adult males are more often actively engaged in electricity dependent occupations, either at their workplace or home during their second to fourth decades, hence they are prone to electrocution hazards. Demographically most deceased are Hindus (82%), Rural people (53%), Married (53%), Literates (70%) and low socioeconomic status (59%). The main occupation of the victims was reported to be agriculture (30%), laborer (18%), students (18%) and housewives (12%). These people are at greater risk of electrocution because of their poor level of education, lack of awareness of electrical hazards and wrong handling of electric appliances at work places. Higher incidents of electrocution deaths during summer may be due to increased humidity and high usage of electric appliances, and these findings are in consistent with Tirasci study.8 Nearly threefourth of electrocution accidents were occurred during day time, which is in harmony with highest usage of domestic appliances and industrial machines actively during day times. Approximately three-fourth of the victims were found dead at the scene of the crime and the rest were declared dead at the hospital. The maximal deaths are due to AC current used for domestic purposes (AC, 220-240 Volts) and due to it’s “catch on effect”. 61% of victims were found dead at the scene of crime in Tehran study11 and 80% died immediately after electrocution in Manipur study.9 The distinct injury marks produced at the site of contact with electric wire (entry mark) and joule burns in electrocution cases can be considered as a classical external sign of electrocution. Entry mark alone were seen in nearly half of the autopsied cases, comparatively the exit mark alone were less than one-fourth of cases, but both marks were noticed nearly in one-third of cases. Previous studies have reported much higher percentage of entry marks varying from 72% to 86.27%.5,8,9 The hands and fingers of the upper extremities are the most frequent sites for electrical injuries (entry marks), while exit wounds were commonly located on the soles and toes of lower extremities, because extremities are the most common sites of contact with the source of electric current. Similar findings were reported from other studies.5,8,9
The chemical investigations were carried out in nine cases and it was found positive for alcohol consumption in three cases. The histological examination of the skin from suspected electrical injury marks were useful for diagnosis in eleven cases. The chemical analysis of the viscera and histopathological examination of the skin from the injury site may be useful in deriving the cause and manner of death in suspected electrocution deaths. It was remarkable that the manner of death in all the studied cases was determined to be accidental in nature, no suicidal or homicidal cases were reported. Suicidal and homicidal electrocution deaths are very rare to occur. History, visit to the scene of crime, circumstantial evidences, autopsy findings and accessory investigations methods will be very useful to determine the cause of death. Limitations and suggestions of this study- small sample size, not able to arrive at the exact cause of death based on autopsy findings alone, hasn’t visited the scene of crime in most cases and thus manner of death was declared based on the history and autopsy findings. Ancillary investigations were not performed in all cases, but it was useful in deciding the cause and manner of death in investigated cases. Data of electrocution deaths among Puducherry may be useful for statistics, preventive steps and remedies.
CONCLUSIONS
Most of the electrocution deaths were overwhelmingly occurred in middle aged males and during the daytimes, when they are actively involved in the home or workplace activities. These incidents are preventable by endorsing simple safety precautions at work place and home, and also by imparting health education at community levels. Almost all incidents are accidental in nature, but it is difficult to distinguish the manner of death in certain circumstances.
ACKNOWLEDGEMENTS
Authors would like to express their gratitude to all the faculty members of the Departments of Forensic Medicine, Indira Gandhi Government General Hospital and PostGraduate Institute and Sri Manakula Vinayagar Medical College, Puducherry. The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=765http://ijcrr.com/article_html.php?did=7651. Koumbourlis AC. Electrical injuries. Critical care Medicine 2002;30:424-30.
2. Mashreky SR, Rahman A, Khan TF, Svanstrom L, Rahman F. Epidemiology of Childhood electrocution in Bangladesh: findings of national survey. Burns 2010;36:1092-5.
3. Accidental deaths and Suicides in India 2011. National Crime Records Bureau. Ministry of Home Affairs. Available at http://ncrb.nic.in/CD-ADSI2011/ADSI-2011%20 REPORT.pdf. accessed on 24 June 2014
4. Shaha KK, Joe AE. Electrocution-related mortality: A retrospective review of 118 deaths in Coimbatore, India, Between January 2002 and December 2006. Med Sci Law 2010 Apr;50(2):72-4.
5. Rautji R, Rudra A, Behara C, Dogra TD. Electrocution in South Delhi; A retrospective study. Med Sci Law 2003; 43(4):350-2.
6. Shrigiriwar M, Bardale R, Dixit PG. Electrocution: A six year study of Electrical Fatalities. JIAFM 2007;29:50-3.
7. Cekin N, Hilal A, Gulmen MK. Medicolegal childhood deaths in Adana, Turkey. Tohoku J Exp Med 2005; 206:73- 80.
8. Tirasci Y, Goren S, Subasi M, Grukan F. Electrocution related mortality: A review of 123 deaths in Diyarbakir, Turkey between 1996 and 2002. Tohoku J Exp Med 2006 Feb;208(2):141-5.
9. Ragui S, Meera T, Singh KP, Devi PM, Devi AS. A study of electrocution deaths in Manipur. J Med Soc 2013; 27:124-6.
10. Gupta BD, Mehta RA, trangadia MM. Profile of deaths due to Electrocution: A retrospective study. JIAFM Jan-March 2012;34(1):13-15 1
1. Sheikhazadi A, Kiani M, Ghadyani MH. Electrocution –related mortality; A survey of 295 deaths in Tehran, Iran between 2002 and 2006. Am J Forensic Med Pathol 2010;3:42- 5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11EXTRACTION OF LIPID FROM ALGAE GROWN IN DIFFERENT OPEN CAST MINING AREAS
OF JHARIA COALFIELD UNDER DISTRICT DHANBAD, JHARKHAND: AN EXPERIMENTAL
STUDY
English1316Deepanjali SinghEnglish Kumar NikhilEnglishIntroduction: Microalgae have been enjoying the focus of several renewable energy researchers for past few decades, due to their high photosynthetic activity and lipid content. These lipid acts as a precursor for the production of biodiesel, a green fuel. Aim: The present experimental study was done to estimate the lipid prospect of microalgae growing in the wastewater of abandoned coal mining and open cast areas of Jharia Coalfield of Dhanbad district, Jharkhand, India.
Methodology: The algae samples were collected from wastewater accumulated in different coal mining areas as well as from the municipality water bodies like pond and river. They were then morphologically analyzed under the microscope to identify the most prevailing algal species in the coal mining areas. Lipid was extracted from these species by the traditional Chloroform and Methanol method i.e., Bligh and Dyer method. Results: The species prevailing in the coal mine waste water were identified as Spirogyra and Oscillatoria. Estimation of the lipid content extracted showed the variation of lipid content from algae grown in mine water to the algae grown in river water and pond water. Algal biomass from coal mining areas contained 16.3% more lipid than the algal biomass from the pond water. Conclusion: The findings reveal the different algal species which are predominantly found in the coal mine waste water. It also gives an idea about the quantity of lipid that can be extracted from them. Thus, this experimental study gives an idea about the possible use of the barren wasteland of the coal mining areas for the algae cultivation, in order to generate the biofuel.
EnglishMicroalgae, Lipid extraction, Coal mining areas, Wastewater, Open cast mines, BiofuelINTRODUCTION
The vast difference between the demand and supply of fossil fuels such as coal, petroleum and the natural gas and the increasing concern about their harmful effect on the environment has resulted in turning the focus towards the sustainable renewable energy. Microalgae biomass is one such sustainable energy source which can be easily harnessed in barren lands and wastewater [1] like the open cast mines. Apart from various other uses, lipid extracted from the algae biomass can be used as the feedstock for biodiesel production [2]. Since long time, algae have been viewed as having a vast potential resource of energy because of their ability to harness solar energy via photosynthesis, which is almost 70% greater than other green plants. Algae are the fastest growing plants in the world and about 50% of their weight is lipid, a feedstock of bio fuel/biodiesel used for running cars, trucks, airplanes, etc. They can grow almost anywhere, even on sewage or salt water and do not require fertile land as food crops; the processing requires less energy than the algae provides. Algae can be a replacement for oil based fuels, one that this more effective and has no disadvantage. Coal is the dominant energy source in India, accounting for more than half of the country’s requirement. Jharia coalfield has a large amount of coal deposit and is one of the largest producers of coal in the world. In the coal mining operation, every year huge quantity of water is discharged from the coal mines to the rivers to facilitate safe mining. As per the estimates, the coal mines of Jharia region discharge about 3, 40, 120 gallons per minute of waste water, which amount to 2.22 million cubic meter of water discharged per day approximately. Besides, a huge quantity of unused mine water is already available in all abandoned open cast mines. These abandoned coal areas can be used for the cultivation of microalgae from which the feedstock of biofuel, i.e., lipid can be extracted. As microalgae have faster growing rates than most terrestrial crops, the per unit area yield of oil from algae is estimated to range from 20, 000 to 80, 000 lakhs per acre per year. This is 7-31 times better than the next best crop, palm oil. The lipid and fatty acid content of microalgae vary in accordance with the culture/growing conditions. Abandoned coal mine possesses ideal conditions for the growth of algae. These coal mines are vast barren land having unlimited sunlight and carbon dioxide, which are the ultimate requirement for algal growth. Cultivating algae in these areas may put these barren lands, in the form of open pit not back-filled, into use as well as reduce the level of green house gases by carbon-dioxide sequestration. Though there are several constraints when cultivating algae in open cast project, open cast projects are ideal for algae growth in the post monsoon duration, i.e., winter and during rainy season. However, during the summer, algae quantity is greatly reduced. Moreover, the quality and the quantity of the lipid extracted are greatly affected by the deposition of the coal dust as minute particles over the microalgae biomass. These accumulations make the lipid extraction process longer as the algae has to be thoroughly cleaned and exempted from these dust particles before undergoing the lipid extraction process. The objective of the present work is to explore the lipid prospect from microalgae found in abandoned open cast coal mines/pits, which involves; a. The analysis of conditions required for higher algal growth in the waste water pits found in the abandoned open cast coal mines. b. Determination of algal lipid potential in the open cast coal mines/ abandoned pits.
METHODOLOGY ADOPTED
Standard operating protocols were followed for the sample collection, microscopic identification of the algae species and lipid extraction from them. All the samples were collected with utmost care in the sterilized jars and brought to the laboratory under aseptic conditions. In the laboratory, the algae samples and the chemicals were used as defined under the standard protocol.
Collection of Algae Samples
The algae samples were collected in sterilized jars from the water accumulated in different abandoned open cast mines of Jharia Coalfield situated at Dhanbad, Jharkhand, India. The temperature details and the environmental data were carefully noted for each day of the sample collected. They were brought to the laboratory under aseptic conditions to carry out the further experiment.
Species Identification
The samples collected were first taken for the microscopic identification of the algal species present, under the standard operating protocols. The purity of the culture was maintained through microscopic observations and isolates were grown under 30°C with 300 lux light intensity for 12 days and night cycle in all 9 algae water samples collected. Further, the isolates were extracted for lipid production from all the samples collected.
Lipid Extraction
The method adopted for the extraction of lipids from the algae samples collected from different locations of the coalfield area of Jharia, Dhanbad was the traditional Chloroform and Methanol extraction method as proposed by Floch et al [3] and Bligh and Dyer [4]. This is a rapid method of extraction of lipids by means of phase partition of a ternary mixture of chloroform and methanol (methyl alcohol).
RESULT AND DISCUSSION
In the present study, the cyanobacteria and green algae were isolated from 9 different sites in district Dhanbad of Jharkhand, India of which 7 sites were from Jharia Coalfield and 2, which included 1 pond and 1 river, were from the Dhanbad Municipality. Totally 2 isolates, i.e., Cyanobacyeria e.g., Oscillatoria sp. (Figure 1) and green algae e.g., Spirogyra sp. (Figure 2) were morphologically identified from the algal samples (Table 1). The occurrence of green algae and cyanobacteria in wastewater has been supported earlier by the works of Ramachandra et al [5] and Sriram and Seenivasan [6]. In the present study, the lipid content from Oscillatoria sp. and Spirogyra sp. was extracted in combination and compared with all the 9 algae samples collected from different areas.
All the 9 algae samples containing algae species were dried and 100g dry weight were taken evenly for the extraction of lipid, which was found to be 0.627, 0.671, 0.785, 0.546, 0.582, 0.733, 0.669, 0.796 and 0.574 ml per 100 g of dry weight (Figure3). This result was similar to the work done by Sheriff Hossain and Shellah [2]. Therefore, the result proved that lipid can be produced from both cyanobacteria and green algae. But Spirogyra sp. contains higher lipid content than the Oscillatoria sp. Kamalbasha [7] reported and agreed with the experiment. The 3 types of water taken for the study were coal mine water, river water and pond water. As stated by many researchers, mine water contains various chemicals and micro particles which act as nutrients for the effective growth of microalgae. The air surrounding the coal mining area tends to be highly polluted having high level of carbon dioxide. These add to the growth of the microalgae and thus, also help in the effective algal biomass production from them. As agreed by Convertis et al [8], decrease in nitrogen concentration and increase in other micronutrients in the water lead to the increase in the lipid content of the microalgae. The same was agreed upon by this experiment. Figure 4 below shows the variation in the lipid content extracted from the algae samples which were collected from 3 different types of water-locations, viz., coal mine, river and pond. Figure 4 depicts that in the present study, there was 15.6% reduction in lipid production from river water than the coal mine waste-water. Moreover, there was reduction of 1.3% lipid concentration in pond water compared to the river water lipid production. However, there was a reduction of 16.3% lipid concentration in pond water when compared to the lipid production from coal mine wastewater, from the algal biomass growth.
CONCLUSION
The findings reveal predominance of microalgae species Spirogyra and Oscillatoria in the coal mine wastewater and the presence of high quantity of lipid content in them. The result from the above study gives an idea about the high potential of the abandoned coal mine areas for the cultivation of microalgae. It also states that the algae which are grown in the coal mining environment have the capacity of high lipid content in comparison to the algae grown in fresh water or the stagnant water. This study and the work done will help in finding out the economic and environmental prospect of using the vast abandoned open cast mines of the coalfields. This would not only help in the carbon dioxide sequestration by microalgae (thus, reducing the carbon dioxide pollution level of the atmosphere) but also lead to the effective and efficient utilization of those barren waste lands containing the waste water. This would also prove to be an alternative source of revenue generation for the organization as well as source of employment for the local population. Though, this experiment requires a lot of validation to quality and quantify the lipid produced, for net result biodiesel production for the compatibility of fuel vehicles, it would prove to be a step ahead in the biopurification of mine wastewater through algal biomass to generate profitable sources like lipid and electricity. However, this study is a partial experimental approach for the utilization of barren and infertile land as a source of sustainable and renewable energy generation, in the form of biofuels. More intensive and continuous study and experiments are required to be conducted to prove this hypothesis in future.
ACKNOWLEDGEMENT
The authors are highly grateful to Director, CSIR-CIMFR, Dhanbad and Head, Environment Management Group, CSIR-CIMFR, Dhanbad for providing the facility to complete this experimental work and the permission to publish it. The authors also acknowledge the immense help received by Md. Iqbal Ansari, Project Assistant, Level-II, EMG, CSIR-CIMFR, Dhanbad in carrying out the various experimental works. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to authors/ 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=766http://ijcrr.com/article_html.php?did=7661. Ghayal M.S and Pandya M.T. “Microalgae biomass: a renewable energy source.” Energy Procedia 32(2013) 242- 250.
2. Sharif Hossain A.B.M, Salleh Aishah, Boyce, Amru Nasrulhaq, Chowdhary Partha, Naqiuddin Mohd. “Biodiesel fuel production from algae as renewable energy.” American Journal of Biochemistry & Biotechnology. 2008, Vol 4 Issue 3, p250-254.
3. Floch J, Lees M and Stanley G H S. “A simple method for the isolation and purification of total lipids from animal tissues.” 1957. J. Biol. Chem., 226, 497-509.
4. Bligh E G and Dyer W J. “A rapid method of total lipid extraction and purification.” 1959. Can. J. Biochem. Physiol. 37,911-917.
5. Ramachandra TV, Mahapatra DM, Samantray S, Joshi NV. “Algal Biofuels from urban wastewater in India: Scope and Challenges.” Renewable and Sustainable Energy Reviews 21 (2013) 767-777
6. Sriram S and Seenivasan R. “Microalgae Cultivation in Wasteland for Nutrient Removal.” J. Algal Biomass Utln. 2012,3(2): 9-13.
7. Kamalbasha N. “Biodiesel production by Chorella sp. and Oscillatoria sp.” IJPI’s Journal of Biotechnology and Biotherapeutics. Vol 2:10 (2012) ISSN 2229-6824.
8. Convertis A, Casazza A A, Ortiz E Y, Perega P and Borghi M D, “Effect of temperature and nitrogen concentration on the growth and lipid content of Nannochloropsis oculata and Chlorella vulgaris for biodiesel production.” Chemical Engineering and Processing 48 (2009) 1146–1151.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11UNICYSTIC AMELOBLASTOMA ASSOCIATED WITH A COMPOUND ODONTOME: AN UNUSUAL PRESENTATION
English1720Hari Shanker AlampallyEnglish Ankur Kaur ShergillEnglish Sunitha CarnelioEnglish Chetana ChandrashekarEnglish Gurshinder Pal SinghEnglishAim: Association of odontomes with odontogenic neoplasms is reported but their manifestation in conjunction with unicystic ameloblastoma is very unusual. Case Report: Herein we report a very rare case of a 28 year old male patient who was diagnosed with unicystic ameloblastoma associated with a compound odontome. Discussion: Ameloblastoma is the most common true odontogenic neoplasm in the oral cavity subsequent to odontomes. Unicystic ameloblastoma is a lesser aggressive variant of ameloblastoma as compared to its solid, multicystic counterpart. Its association with odontomes has been seldom reported in English literature. Conclusion: Reporting of such rare entities achieved through a comprehensive clinico pathological correlation can assist in a definitive diagnosis of similar cases.
EnglishAmeloblastoma, Odontoma, Odontogenic cysts, ToothINTRODUCTION
Unicystic ameloblastoma is one of the four variants of ameloblastomas, the others being intraosseous, infiltrative and peripheral type. It accounts for 5%-22%1 of all the types of ameloblastomas but has a lower recurrence rate as compared to the other types (6.7%-35.7%)1 . Owing its low recurrence rate, a more conservative surgical approach like enucleation or curettage or cautery is employed. Radiographically, it mimics non-neoplastic cysts which can pose diagnostic difficulties to both the surgeon and pathologists. Odontomes are most common benign hamartomas consisting of dentin, cementum or pulp like tissue found in the oral cavity2 . Unicystic ameloblastoma occurring with an odontome is a very unusual presentation and has rarely been reported in English literature. We report a very rare case of a unicystic ameloblastoma associated with a compound odontome in a young patient.
CASE REPORT
A 28 year old male patient reported to our institution with a chief complaint of pain in the lower right back region since two months. The swelling was insidious in onset, associated with chronic dull pain and had grown slowly to the existing dimensions. The patient did not report with any history of trauma or altered taste sensation. His past medical and dental history were non-contributory. Following this, a thorough clinical examination was carried out to determine the nature of the lesion. Extraoral examination was normal with no visible facial asymmetry. Intraoral examination revealed a small swelling 3.5 x 2.5 x 2 cm in maximum dimensions in the parasymphseal region approaching the midline. The vestibular space in 31-35 region was obliterated. The overlying mucosa appeared normal with no ulceration and pus discharge. On palpation, the swelling was bony hard in consistency extending in the vestibular region from 35 to 41 region of mandible crossing the midline. The teeth associated with the swelling were non-tender, vital with no signs of mobility. The clinical examination was followed by a complete radiographic evaluation of the lesion. Orthopantamogram (OPG) of the lesion revealed a well-defined unilocular radiolucent lesion in the mandible in relation with 35 to 43 region crossing the midline with sclerotic borders in medial and inferior aspect (Fig. 1). A few tooth like radio opacities were seen within the radiolucency in the antero-inferior region of mandible. Based on the clinico – radiographic findings, dentigerous cyst and unicystic ameloblastoma were considered in the differential list of provisional diagnoses. Taking into consideration the clinical and radiographic findings which were suggestive of a benign cystic lesion, surgical enucleation under general anaesthesia was considered as the preferred surgical approach. The enucleated specimen was sent for histopathological evaluation. The post-operative healing was uneventful and the patient was kept under follow up. Gross examination of the surgical specimen revealed the presence of a cystic lesion attached to the neck of a tooth like structure 3 x 1.5 x 2 cm in maximum dimensions, soft to firm in consistency, reddish brown in colour and with a smooth surface (Fig. 2). The cross section of the soft tissue specimen revealed other bits of tooth like material attached to the main tooth like structure thus establishing it to be a compound odontome (Fig. 3). The soft tissue specimen was dissected from the hard tissues and sent for routine tissue processing. On microscopic examination the H & E stained, soft tissue section revealed a cystic lumen lined by 2-3 layers of tall columnar hyperchromatic cells with nuclei showing reverse polarity and basilar cytoplasmic vacuolisations resembling ameloblasts (Fig. 4). The superficial layer of cells were loosely cohesive and resembled stellate reticulum. Squamous metaplasia of the cystic epithelium was noted at a few places. Areas of hyalinisation in sub-epithelial region were evident in few places of the connective tissue stroma. The underlying cystic wall appeared delicate to dense fibrous with abundant areas of haemorrhage. Few odontogenic rests and dystrophic calcifications were also seen. Collections of eosinophilic material were also noted (Fig. 5). Correlating the chronic, benign nature of the cystic lesion with the unilocular radiographic appearance, a final diagnosis of unicystic ameloblastoma associated with a compound odontome was given.
DISCUSSION
Ameloblastoma is the most common odontogenic tumor arising from the epithelial component of an embryonic tooth bud affecting generally molar-ramus region of the mandible3 . Based on the clinical and prognostic aspects, ameloblastoma was characterised into4 conventional (classic / intraosseous / solid / multicystic), unicystic and peripheral type. Unicystic ameloblastoma was first described by Robinson and Martinez in 1977. The most common site of occurrence is posterior mandible followed by the parasymphseal region. Reports from earlier literature have revealed occurrence of bone, dentin and dentinoid like material in this tumor. Ackermann in 1988 reclassified unicystic ameloblastoma into three types based on its prognostic and therapeutic implications5, 6 which include:
1. Luminal unicystic ameloblastoma - Unilocular cyst lined by epithelium.
2. Intra luminal or plexiform type – epithelial nodules arising from cystic lining project into cystic epithelium.
3. Mural type – showed presence of invasive islands of ameloblastomatous epithelium into connective tissue wall.
Robinson and Martinez proposed unicystic ameloblastoma to be a lesser aggressive variant7 . This feature contributes to a conservative surgical modality like enucleation of the tumor. Unicystic type was earlier thought to be a variant of solid multicystic type 4 . Our case presented with the typical findings of a 2-3 layered cystic lining with tall columnar basal cells with hyper chromatic nuclei, reverse polarity and basal cytoplasmic vacuolisation. The superficial layer had loosely cohesive stellate reticulum like cells. There were areas of squamous metaplasia. Hyalinisation in sub epithelial region in connective tissue stroma was seen in few sites. Peripherally eosinophilic material was seen. All these features were consistent with Vickers and gorlins criteria4, 8 (1970) which led us to the diagnosis of unicystic ameloblastoma, but the presence of an associated compound odontomes was unique. Odontoma are considered to be the most common odontogenic hamartomas found in the oral cavity. These tumors are composed of variable amounts of enamel, dentin, cementum and pulp tissue. A compound odontoma consists of agglomerates of tooth resembling material while the complex type fails to organize into the latter and consists of disordered dental hard tissues. Association of odontomes with odontogenic tumors like adenomatoid odontogenic tumour, dentigerous cyst have been reported in literature but the association of unicystic type of ameloblastoma with odontomes is very rare. As per English literature, only 2 cases of unicystic ameloblastoma, one associated with calcified hard tissues (Shivpathasundaram et al.)9 and one associated with a single odontome by Ogunsalu et al10 is reported. Herein we reported a very rare case of a unicystic ameloblastoma with a compound odontome.
CONCLUSION
Unicystic ameloblastomas in association with odontomes is a very rare entity. A thorough clinical, radiographic and histopathogical examination is essential to arrive at the correct diagnosis. There is a requisite in the current scenario to report such rare cases to increase awareness among the clinicians and pathologists hence evading misperception and misdiagnosis.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the manuscript, the authors are also grateful to authors’ editors and publishers of all those articles journals and books from where the literature for these article has been reviewed and discussed. We would also like to thank the Departments of Oral medicine and Radiology and Oral and Maxillofacial Surgery for their constant help and support.
Englishhttp://ijcrr.com/abstract.php?article_id=767http://ijcrr.com/article_html.php?did=7671. Dunsche. A, Babendererde. O, Jutta. L, Springer I. N. G. Dentigerous cyst versus Unicystic ameloblastoma- differential diagnosis in routine histology: Journal of Oral pathology and Medicine 2003; 32:486-91.
2. Nelson. B. L compound odontome. Head and Neck Pathol 2010; 4:290-291.
3. Gardner Dg, Heikinheimo K, Shear m, Philipsen, Coleman H: Ameloblastomas. In world Health Organisation Classification of Tumours. Edited by Barnes L, Eweson JW, Reichart P, Sidransky D. IARC Press, Lyon, France; 2005:296- 300.
4. H. P. Philipsen and P. A. Reichart. Unicystic ameloblastoma. A review of 193 cases from the literature. Oral Oncology: 1998; 34 (5):317-325.
5. Lee PK, Samman, Ng IO, Unicystic ameloblastoma—use of Carnoy’s solution after enucleation. Int. Journal of Oral Maxillo facial. Surg. 2004; 33:263-267.
6. Seintou A, Martinelli-Kay CP, Lombardi T. Unicystic ameloblastoma in children: systematic review of clinicopathological features and treatment outcomes International Journal of Oral Maxillofacial Surgery. 2014; 43:405-412.
7. Olaitan AA, Adekeye EO, Unicystic Ameloblastoma of the Mandible: A Long-Term Follow-up Journal of Oral Maxillofacial Surg 1997; 55:345-348.
8. Vicker RA, Gorlin RJ. Ameloblastoma: Delineation of Early Histopathologic Features of Neoplasia. Cancer 1970; 26:699-710.
9. Sivapathasundharam B, Einstein A. Unicystic ameloblastoma with the presence of dentin. Indian Journal of Dent Res 2007; 18:128-30.
10. Ogunsalu C, West W, Lewis A, Williams N. Ameloblastoma in Jamaica – Predominantly Unicystic: Analysis of 47 Patients over a 16-Year Period and A Case Report on Reentry Cryosurgery as a New Modality of Treatment for the Prevention of Recurrence. West Indian Med J 2011; 60 (2):240.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11STRATEGIC EVALUATION OF SUICIDE NOTES
English2124Mallikarjun S. BallurEnglish Viveka S.English Sudha M.J.English Priyanka MurgodEnglish G. SujathanEnglishBackground and objectives: Suicide note is message left behind by a person who intends to commit suicide. Study of such suicide notes show the psyche of the patient and play important role in understanding reasons for suicide. Very few studies have concentrated on such suicide notes from Indian subcontinent. Aim of study was to evaluate such suicide notes with respect to mode of writing, to whom it is addressed and victim’s last wish. Methods: This prospective study was conducted among victims of hanging brought to Dr. B. R. Ambedkar Medical College morgue, Bangalore during the period November 2010 to October 2012. Detailed information regarding the deceased and the circumstances of death was collected from the police and relatives. In some cases, this information was supplemented by either, visit to scene of occurrence or from the photographs of scene of occurrence Results: Out of 232 cases studied, suicide notes were found in 22 cases. Last wish was mentioned in fifteen cases. In thirteen cases suicide notes were addressed to the parents. One suicide note in the form of mail was reported. Conclusions: Suicide note is an important piece of evidence showing psyche of the patient. Due importance should be given at the site of crime for recovery of suicide note. Studies involving larger number of victims are required to have psychological insight and eventually such data may lead to prevention of suicides
EnglishSuicide note, Hanging, suicide, Suicidal thoughtsINTRODUCTION
“To end is to start; to surrender is to know. Despair and depression, together they grow. Hope shall meet hopeless when there’s nowhere to go”. Misao Fujimura, a Japanese philosophy student and poet has written this famous poetry in his suicide note.1 A message left behind by a person who intends to commit suicide constitutes a suicide note. It can be a written note, typed message sent through mail, an audio message, or a video. The reasons for writing suicide note may be diverse. The most common among them is to dissipate guilt in the survivors. A person may write that terminal note to increase the pain of survivors.2 Suicide note may give out valuable information about the reasons for suicide. Person by writing a note may try to express his/ her feelings which otherwise not expressed in life. Study of suicide notes show light on the psyche of the person.3 It will show light on the possible events which would have led to fatality.4 It may reveal the possible loneliness, alienation, isolation, rejection, exclusion of victim. Writing suicide notes are rare because most victims feel highly disturbed and think that communication through a note seems meaningless.5 Leaving a suicidal note was thought to be a result of victim’s desire to share his or her dilemma with the acquaintances. Suicide notes, though may give direct lead to the suicide, reasonable average rates would be 25%.6 Unfortunately, there are very few studies have been conducted in this regard. In this study an attempt was made to analyse and evaluate such suicide notes. We analysed suicidal notes of hanging victims not only from death scene investigation but also from other sources. Ours is the first study to report suicidal notes from south Indian scenario in hanging.
METHODS
This prospective study was conducted among victims of hanging brought to Dr. B. R. Ambedkar Medical College morgue, Bangalore during the period from November 2010 to October 2012. Detailed information regarding the deceased and the circumstances of death was collected from the police and relatives. Apart from this, we have visited the scene of crime wherever possible. Photographs of scene of suicide were also evaluated. In every case we enquired police and relatives and also searched for the possible suicide notes or any other written or typed documents communicating the message left by the deceased person. Wherever such documents are noted they are photographed using digital camera under proper day lighting. They are analysed for the following: written or typed; to whom it was addressed; last wish of the deceased; motive for the suicide. All suicide notes were handed to investigating officer for further legal action.
RESULTS
We studied 232 cases of hanging. Among them suicide note was noted in 22 cases (9.48%) (Table1). Remaining 210 cases (90.52%) had not written any suicide note. Twenty one suicide notes were handwritten and one suicide note was typed and sent through mail. Last wish was mentioned in fifteen cases. In thirteen cases suicide notes were addressed to the parents. In one case it was written without any reference to any person, place or time. Reasons mentioned in the suicide note are tabulated in table 1.
Suicide note written through mail indicating extramarital affair and dowry harassment (fig 1) and a hand note which is totally neutral not indicating any person or event (fig 2) are given below.
DISCUSSION
Suicide notes may serve some explanatory purpose and may have a therapeutic role in helping the surviving relatives to understand the suicide. Knowledge of the messages contained within suicide notes could be useful for suicide prevention programmes. The significance of suicide notes is best understood within the context of the occurrence of suicides. To decipher the contents of suicide note one needs special training. Forensic linguistics is the branch of linguistic studies which investigates legal text in crime. One can use the linguistic aspects to investigate the suicide text to have an insight to victims’ psy che.6-8 John Pestian et al have devised computational algorithms for understanding a suicidal patient’s thoughts, as represented by suicide notes.9 Study of suicide note gives inside information about psychopathology of suicide victims. Suicide notes are used as an important piece of evidence for abetment under section 306 Indian Penal Code.4, 10 Suicide notes analysis may show us different themes of writing. Tom Foster has studied 42 suicide notes and noted prominent themes like “apology/shame”, “love for those left behind”, “life too much to bear”, “instructions regarding practical affairs post-mortem”, “hopelessness/ nothing to live for”. He concludes that most of the victims with major unipolar depression are more likely to pen down their feelings than those without.11 Writing suicide notes may be influenced by age. Allen Darbonne has found out that there will be certain degree of consistency and meaning of suicide notes with relation to age groups; which may permit accurate interpretation of intent for suicide. This may help in prevention and therapeutic approach for suicide.2 We noted themes of apology and life too much to bear. Suicide notes are recovered from the sight of crime in about 25% of the cases with a range of 8 to 40% (table 2). In our study we have found notes in 10% of the cases studied. Similar incidences of suicide notes are reported by Demirci S; Bhatia MS; Mohanty S. 3,4, 12-16 Contrasting to the reported percentages, Demicri et al noted a very high incidence of suicide notes.17
Ho TP, the pioneer in suicide research has studied suicide notes from Australia, New Zealand and Hong Kong. He has classified note- leavers as young females, of non-widowed marital status, with no history of previous suicide attempts, no previous psychiatric illness, and with religious beliefs. He has concluded that suicide notes written by young people were longer, rich in emotions, and often begging for forgiveness. Suicide notes written by the elderly were shorter, contained specific instructions, and were less emotional. He notes that a significant proportion of note-leavers did mention their difficulties.3,5,18,19 Manjeet Bhatia has studied 40 suicide notes from Delhi region and concluded that all suicide notes were handwritten and a last wish was mentioned in 30%. Suicide note was most commonly addressed to a sibling. They also noted disturbed love affair and financial problems were the common reasons mentioned in suicide notes. Hopelessness and depression were commonly noted.20 Our study goes according to this except that we found most notes were addressed to parents. This could be due to difference in age groups of suicide victims considered under the study. Recently there is increase in number of suicide cases. One would expect a similar raise in suicide note writing trends. But according to a study conducted in Kobe City, incidence of suicide note did not increase despite the increase in suicide rates during the economic recession.21 In other words, the incidences of note-leaving remained constant throughout the recent two decades although many socioeconomic factors such as economic recession and natural/artificial disasters, and/or cultural, ethnic and racial variations indirectly affect the suicide rate. In the notes from youth suicide victims, they present themselves they are fully responsible.22 We too noted similar self responsibility in notes from young individuals.
CONCLUSIONS
Suicide note is an important piece of evidence showing psyche of the patient. Due importance should be given at the site of crime for recovery of suicide note. Studies involving larger number of victims are required to have psychological insight and eventually such data may lead to prevention of suicides.
ACKNOWLEDGEMENT
We acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. We are also grateful to 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=768http://ijcrr.com/article_html.php?did=7681. O’Connor, Peter, and Aaron M. Cohen. Thoughts on the precipice: Japanese postcards, c. 1903–39. Japan Forum. 2001;13(1): 55-62.
2. Darbonne, Allen R. Study of psychological content in the communications of suicidal individuals. Journal of Consulting and Clinical Psychology. 1969;33(5):590-596.
3. Ho TP, Tay MS. Suicides in general hospitals in Hong Kong: retrospective study. Hong Kong Med J. 2004 Oct;10(5):319- 24.
4. Mohanty S, Sahu G,Mohanty MK, Patnaik M. Suicide in India- a four year retrospective study. Journal of Forensic and legal medicine. 2007;14(4):185-189.
5. TP Ho, SF Hung. The prevention of youth suicide: research and service. Hong Kong Med J. 1998;4:195-202.
6. Atal DK, Das S, Gautam P. Importance of Suicide Note: In Indian Context. Medico-Legal Update. 2014;14(1):1-5.
7. Eva T S Sudjana, Nurul Fitri. Kurt Cobain’s Suicide Note case: Foresic liguistic profiling analysis. International Journal of Criminology and Sociological Theory. 2013;6(4):217- 227.
8. Tijckman J, Kleiner RJ, Lavell M. Credibility od suicide notes. Am J Psychiatry. 1960;116:1104-1106.
9. John Pestian, Henry Nasrallah, Pawel Matykiewicz, Aurora Bennett and Antoon Leenaars. Suicide Note Classification Using Natural Language Processing: A Content Analysis. Biomed Inform Insights. 2010; 2010(3): 19–28.
10. Shneidman ES, Farberow NL. Clues to suicide. New York : McGraw-Hill, 1957.
11. Tom Foster. Suicide note themes and suicide prevention. International Journal of Psychiatry in Medicine, 2003;33(3):323-331.
12. TP Ho, P SF Yip, CWF Chiu, P Halliday. Suicide notes: what do they tell us? Acta Psychiatrica Scandinavica. 1998; 98(6):467-473.
13. Brian Ho Kong Wai, Clarice Hong, Kua Ee Heok. Suicidal behavior among young people in Singapore. General hospital psychiatry. 1999;21(2):128-133.
14. Bowers Len, Banda, Tumi, Nijman Henk. Suicide Inside: A Systematic Review of Inpatient Suicides. Journal of Nervous and Mental Disease. 2010;198(5):315-328.
15. McClure GMC. Recent trends in suicide amongst the young. Br J Psychiatry, 1984;144:134–138.
16. Shaffer D and Fisher P. The epidemiology of suicide in children and young adolescents. J Am Acad Child Psychiatry. 1981;20:545–565.
17. Demirci S, Dogan KH, Erkol Z , Deniz I. Precautions Taken to Avoid Abandoning the Act of Hanging and Reducing Pain in Suicidal Hanging Cases. Am J Forensic Med Pathol. 2009 Mar; 30(1):32-35.
18. Ho TP, Hung SF, Lee CC, Chung KF, Chung SY. Characteristics of youth suicide in Hong Kong. Soc Psychiatry Psychiatr Epidemiol. 1995;30(3):107-12.
19. Dong JY, Ho TP, Kan CK. A case-control study of 92 cases of in-patient suicides. J Affect Disord. 2005;87(1):91-9.
20. Bhatia MS, Verma SK and Murty OP. Suicide notes: psychological and clinical profile. Int J Psychiatry Med. 2006 ;36(2):163-170.
21. Shioiri T, Nishimura A, Akazawa K, Abe R, Nushida H, Ueno Y, Kojika-Maruyama M. And Someya T. Incidence of noteleaving remains constant despite increasing suicide rates. Psychiatry and Clinical Neurosciences, 2005 ;59: 226–228.
22. Anne Freuchen and Berit Grøholt. Characteristics of suicide notes of children and young adolescents:An examination of the notes from suicide victims 15 years and younger. Clinical Child Psychology and Psychiatry. 2013;1(1):1-13.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11STUDY OF ABERRANT LEFT HEPATIC ARTERY FROM LEFT GASTRIC ARTERY AND ITS CLINICAL IMPORTANCE
English2528Suman TiwariEnglish Roopashree R.English Padmavathi G.English Varalakshmi K. L.English Sangeeta MEnglishObjectives: Variations of the hepatobiliary region are frequent and are of concern to the radiologists and gastroenterological surgeons. The variations reported in the literature are of several kinds such as accessory hepatic arteries, replaced hepatic arteries and additional branches. The present study describes the incidence of origin of aberrant left hepatic artery from left gastric artery and its clinical importance. Methods: 50 adult embalmed human cadavers of both the sexes were studied by dissection method at the Department of Anatomy, MVJ Medical College and other medical colleges in and around Bangalore. Results: In 4(8%) specimens, the aberrant left hepatic artery had its origin from left gastric artery. Out of the 4 specimens, the aberrant left hepatic branch was accessory in 3(6%) specimens and replaced in 1(2%) specimens. Conclusion: The knowledge about variations in the anatomy of subhepatic region is of immense significance to hepatobiliary surgeons since bleeding from aberrant vessels may increase the risk of intra-operative complications.
EnglishAccessory left hepatic artery, Hepatobiliary surgery, Left gastric artery, Replaced left hepatic arteryINTRODUCTION
The common hepatic artery, a branch from coeliac trunk divides into right and left branches to the hepatic lobes. Variations of hepatic arteries are common and surgically important. 1 Aberrant hepatic artery is of two types, replacing and accessory. An aberrant replacing hepatic artery is a substitute for the normal (usual) hepatic artery which is absent. An aberrant (a variable) accessory hepatic appears in addition to one that is normally (usually) present. 2 The most common aberrant hepatic arterial variations are right hepatic artery originating from the superior mesenteric artery (10–12% of individuals) and left hepatic artery or accessory left hepatic artery originating from the left gastric artery (25% of individuals). 3 Michaels 4 in his dissection of 200 cadavers has reported the incidence of accessory left hepatic artery from left gastric artery in 8% and replaced left hepatic artery from left gastric artery in 10% specimens. An aberrant left hepatic artery arising from left gastric artery either as an accessory or replacing the left hepatic artery is occasionally seen in patients with gastric cancer. Resection of this aberrant vessel which feeds a wide area of the liver, as a part of gastrectomy procedure may cause postoperative liver dysfunction.5 Present study is undertaken to know the incidence of origin of aberrant left hepatic artery from left gastric artery and its clinical importance.
MATERIALS AND METHODS
Fifty adult embalmed human cadavers from south Indian population were studied irrespective of their sex. The specimens were obtained from the Department of Anatomy, MVJ Medical College and other medical colleges in and around Bangalore. The gross dissection was done following the guidelines of Cunningham’s manual. The peritoneal cavity was opened and the anterior layer of peritoneum from the lesser omentum close to the lesser curvature of stomach was removed. The Coeliac trunk and its branches namely, left gastric, common hepatic and splenic arteries were identified and cleaned. The dense autonomic plexus from its branches was removed. The left gastric artery was traced till it curves posteriorly around the superior surface of omental bursa. The common and proper hepatic artery and its branches to the porta hepatis were exposed and cleaned. The aberrant left hepatic artery from left gastric artery if present was identified and cleaned. The data obtained was analyzed and compared with that of previous studies.
RESULTS
Out of the 50 specimens studied, the aberrant left hepatic artery arising from left gastric artery was seen in 4 (8%) specimens. The remaining 46 (92%) specimens did not show the presence of aberrant left hepatic artery. It was observed that out of the 4 specimens, the aberrant left hepatic artery was accessory in 3(6%) and replacing in 1(2%) specimen. The aberrant left hepatic artery was originating from the proximal one third of left gastric artery in 3(6%) specimens and from the middle one third in 1(2%) specimen. In all the specimens, an aberrant branch arose from the left gastric artery and entered the visceral surface of the left lobe of the liver at a site independent from the porta hepatis. In specimen no.9 (Fig 1), the Coeliac trunk branched into four arteries; Gastroduodenal, Left gastric, Right hepatic and Splenic arteries. The replaced left hepatic artery was arising from left gastric artery and entered the left lobe of the liver. In specimen no. 26 (Fig 2), the coeliac trunk divided into Common Hepatic, Splenic, Left gastric, Dorsal pancreatic and Left inferior phrenic arteries. An accessory left hepatic artery was seen arising from the left gastric artery. This artery passed from below upwards in the cranial part of the lesser omentum and entered the left lobe of liver through the fissure for ligamentum venosum. The rest of the course of left gastric artery was normal in all the specimens.
DISCUSSION
The incidence of aberrant left hepatic artery from left gastric artery varies from 6.1-21% in various studies 6-13 and is summarized in Table 1. The highest incidence of aberrant left hepatic artery from left gastric artery was reported by Urugel11 (21%) and the lowest by Iezzi 10(6.1%). In the present study, its incidence is 8% which is within the range. The embryological basis for the origin of aberrant left hepatic artery from left gastric artery is as follows: The primitive liver is supplied by 3 embryonic hepatic arteries namely, Left hepatic, Right hepatic and Common hepatic arteries. The Left and Right hepatic arteries undergo regression. If they persist, they lead to the development of aberrant hepatic arteries. Kulesza 14 has explained that there should be presence of sufficient quantities of signalling molecules and growth factors produced by the developing and migrating mammalian cells for the normal development of any viscera. In the event of an improper signalling and incorrect gradient, there may occur visceral anomalies. When an artery does not originate from an orthodox position, being the only supply to a particular lobe, it is called a replaced artery. The left hepatic artery arising from left gastric artery may be injured as it lies in the upper portion of the lesser omentum during mobilization of stomach in gastrectomy and hiatal hernia repair. So these aberrant vessels must be recognized, since even in gastrectomy because of gastric cancer it was shown that leaving the aberrant hepatic artery and the proximal left gastric artery has the same oncologic effect as complete ligation of the left gastric artery. Accessory left hepatic artery provides a source of collateral arterial circulation in cases of occlusion of the vessels in the porta hepatis. 1, 5 It is important that interventional radiologists who perform hepatic arterial embolisation be familiar with both common and rare hepatic arterial variants, because failure to recognize the presence of an aberrant vessel can result in incomplete embolisation of liver tumours. Familiarity with these variants can also help one avoid various surgical complications. The replaced left hepatic artery originating from left gastric artery must be identified and ligated before left hepatectomy is performed, because the major arterial branch to the left liver does not need to be found in the porta hepatis. The accessory hepatic artery provides an additional source of arterial blood to the left hepatic lobe and may be sacrificed without compromising the arterial supply to the left hepatic lobe. An accessory left hepatic artery needs to be occluded separately when controlling the inflow to the left hepatic lobe because this artery will not be occluded when the blood supply in the porta hepatis is occluded. Distinction between an accessory and a replaced artery is therefore important. Recognition of a replaced or an accessory artery is important so that the vessel can be ligated at the time of catheter placement to allow uniform perfusion of the hepatic parenchyma. 6, 8, 10 Accidental ligation of aberrant hepatic arteries may lead to liver necrosis and death. The role of the accessory arteries and the segments of the liver supplied should be considered during planning for liver surgery since these vessels are end arteries in most cases and injury would compromise liver supply, resulting in necrosis of the entire left hemiliver or some segments, commonly two and three. An aberrant hepatic artery may cause a potential error in the angiographic diagnosis of traumatic liver haematoma. So the aberrant hepatic vascularisation should be assessed preoperatively by invasive and non-invasive techniques to avoid fatal complications. 13, 15, 16
CONCLUSION
Aberrant left hepatic artery arising from left gastric artery is a common anomaly found in 8% of specimens. The knowledge of existence of aberrant hepatic arteries, either accessory or replacing, is important during hepatobiliary surgeries as they present potential bleeding risks and complicates the procedure. They also have importance in partial hepatectomy, gastric resection, operations performed near the gastro hepatic ligament, including esophagogastrectomy, gastric bypass, and antireflux procedures. Knowledge of variant hepatic arteries is of greatest importance in liver transplantation.
ACKNOWLEDGEMENT
The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed. Authors are grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=769http://ijcrr.com/article_html.php?did=7691. Williams PL., Bannister L.H., Berry M.M., Collins P., Dyson M., Dussek. J.E. et. al. Gray’s anatomy 38th ed. Churchill Livingstone, 2000, 1548-1552.
2. Bergman RA, Afifi AK, Miyauchi R., Hepatic Artery. Illustrated encyclopedia of human anatomic variation: opus II: Cardiovascular System: Arteries: Abdomen: Variations in Branches of Coeliac Trunk.
3. Hazirolan T, Metin Y, Karaosmanoglu AD, Canyigit M, Turkbey B, Oguz BS et al. Mesenteric arterial variations detected at MDCT angiography of abdominal aorta. American Journal of Roentgenology. 2009; 192:1097-1102.
4. Michels NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. Philadelphia and Montreal, B. Lippincott Company. 1955; 139-143.
5. Okano S, Sawai K, Taniguchi H, Takahashi T. Aberrant Left Hepatic Artery arising from the Left Gastric Artery and liver function after radical gastrectomy for Gastric cancer. World Journal of Surgery. 1993; 17: 70-74.
6. Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Brown KT. Variant hepatic artery anatomy revisited: digital subtraction angiography performed in 600 patients. Radiology. 2002; 224:542-547.
7. Rawat KS. CTA in evaluation of vascular anatomy and prevalence of vascular variants in upper abdomen in cancer patients. Ind J Radiol Imag. 2006; 16:4:457-461.
8. Winston CB, Lee NA, Jarnagin WR, Teitcher J, Dematteo RP, Fong Y et al. CT Angiography for Delineation of Coeliac and Superior Mesenteric Artery Variants in Patients Undergoing Hepatobiliary and Pancreatic Surgery. American Journal of Roentgenology. 2007; 189: W13-W19.
9. Chitra R. Clinically relevant variations of the coeliac trunk. Singapore Med J. 2010; 51(3): 216-219.
10. Iezzi R, Cotroneo AR, Giancristofaro D, Santoro M, Storto ML. “Multidetector-row Computed Tomography angiographic imaging of the Coeliac trunk :anatomy and normal variants. Surg Radiol Anatomy. 2008; 30(4):303-310.
11. Urugel MS, Battal B, Bozlar U, Nural MS, Tasar M,ORS F et al. Anatomical variations of hepatic arterial system, coeliac trunk and renal arteries: an analysis with Multidetector CT Angiography. The British Journal of radiology. 2010; 83: 661-667.
12. Andujar RL, Moya A, Montalva E, Berenguer M et al. Lessons Learned From Anatomic Variants of the Hepatic Artery in 1,081 Transplanted Livers. Liver Transplantation: 2007; 13:1401-1404.
13. Sehgal G, Srivastava AK, Sharma PK, Kumar N, Singh R. Variations of extrahepatic segments of hepatic arteries: A Multislice Computed Angiography Study. International Journal of Scientific and Research Publications: 2013; 3( 2): 1-8
14. Kulesza RJ Jr, Kalmey JK, Dudas B, Buck WR. Vascular anomalies in a case of situs inversus. Folia Morphol. 2007;60:69-73
15. Saeed M, Rufal AA. Duplication of hepatic artery. Saudi J Gastroenterology: 2001; 7(3):103-108
16. Hollinshed WH. Anatomy for surgeons. The thorax, abdomen and pelvis. 1st edition. New York: Hoeber-Haper, 1956, 344-358.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11EFFECT OF MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY ON HAND FUNCTION OF HEMIPLEGIC CEREBRAL PALSY
English2936Pranali ThakkarEnglishIntroduction: From the last few years constraint induced movement therapy (CIMT), as an intervention, has received a great deal of attention for children with Hemiplegic cerebral palsy (CP). To date, evidence on this treatment has been very poor and limited so additional research required. For various reasons, traditional form of therapy was neither considered feasible nor do child and family friendly for that we had use a modified form of CIMT Objective: To determine the effectiveness of modified CIMT on hand function of hemiplegic CP children characterized by restraining the unaffected hand with short glove up to wrist. Methodology: 10 children (age: 2 to 8 years) from pediatric physiotherapy clinics from Vadodara and Ahmedabad with hemiplegic CP were included in the study. Modified constraint was applied to unaffected hand. The intervention was given for 3 hrs/ day including 30 minutes of therapy time and home program which could split into different sessions of no less than 30 minutes duration for consecutive 4 weeks. Pre and Post outcome measure by using QUEST (Quality of upper extremity skill test) and PMAL (pediatric motor activity log) were taken. Result: Significant difference between Pre and Post values of all components of PMAL and QUEST (P < 0.05) showing the effectiveness of mCIMT in improving hand function and in ADL activities. Conclusion: mCIMT yields statistically as well as clinically significant improvements in both motor function and functional use of the affected upper extremity in children between the ages of 2 and 8 years with hemiplegic CP.
EnglishHemiplegic CP, Modified CIMT, Hand functionINTRODUCTION
Hemiplegia accounts for 35% (1 in 1300) of the children with CP and upper limb (UL) involvement is usually more pronounced than the lower limb.1 if hemiplegic stroke occurs in-utero, or any time between birth and two years of age, it is considered hemiplegic CP. The most common cause of hemiplegic CP is a CVA (Cerebro vascular accidents) commonly known as a stroke. Children with hemiplegia have unilateral involvement of upper and lower extremities opposite to the side of cerebral injury, often characterized as muscle weakness and spasticity.2 These factors may decrease movement efficiency3 , especially in the use of the upper extremity, which can also limit performance in functional activities at home and school.2, 4, 5They often learn to perform many tasks exclusively with their non-involve dextremity. This results in failure to use the involved extremity (i.e. developmental disuse). The impairment of the hand is often the result of damage to the motor cortex and cortico spinal pathways responsible for the fine motor control of the fingers and hand.4 Constraint induced movement therapy (CIMT) is a relatively new intervention derived from the basic sciences.6 In 1995, however, it was suggested that a promising new therapy for adults with hemiparesis consequent to stroke, known as Constraint-Induced Movement therapy,6-9 The CIMT protocol stems directly from basic research with monkeys.6, 10CIMT has been adopted as a method of teaching a child to use his/ her affected upper limb through use of a restraint on the non-affected limb and massed practice of movements of the affected limb.11
The elements of CIMT are: 1) Constraint of the unaffected arm to encourage the use of the affected hand, 2) Practice of the affected arm and 3) Use of intensive techniques to train the affected arm.12 A Cochrane review concluded that there was emerging evidence supporting CIMT for children with hemiplegia.13 Therapy accompanied in CIMT is constraint given for 6 hours per day. For various reasons, traditional form of therapy was neither considered feasible nor do child and family friendly for that we had use a modified form of CIMT A number of variations are used in mCIMT. Modified CIMT (mCIMT) involve the application of a restraint with less than three hours per day11 and Type of constraint use can be different Modification of this approach for children with CP has followed, but until recently efficacy was limited to case reports and small prospective studies.4,13-15 Need for this study was to overcome these methodological problems and design a trial that can give evidence on modified CIMT (Modified constraint) effect. This study presents the methodological choice (with less duration and short comfortable glove to the unaffected side for 3hrs per day) and to see the effectiveness of Modified CIMT (as a restraint glove combined with an intensive rehabilitation and home program) on hand function of hemiplegic CP children. MATERIAL AND METHODS Ethical approval: Study was approved by Ethical committee of Sumandeep Vidyapeeth University and From pediatric physiotherapy centers of Vadodara and ahemdabad, from where Participants met with inclusion criteria for the study was found and approval letters were taken from that physiotherapy centers. Permission for outcome measure scale (QUEST and PMAL) was taken by e-mail from author. Research Design: Single group pretest posttest design. Source of data: Pediatric Physiotherapy clinics of Vadodara and Ahmedabad Sampling method: Convenient sampling Sample size: 10Patients Inclusion Criteria • Participants with diagnosis of spastic hemiplegic cerebral palsy as diagnosed and reported in the medical history by a Physician • Age between 2 to 8 years • Active movement of the shoulder, elbow, wrist, digits and thumb of the affected upper limb, such that the: child is able to reach forward to an elevated position In front with mid-range shoulder flexion16,17 • Ability to extend wrist >20° and fingers at the meta carpophalangeal joints >10° from full flexion16,17 • Able to attend the tasks and follow simple commands • Muscle tone (i.e. 1-2, modified Ashworth scale) • Parents who are willing to commit for an intensive therapy program and agree to cease all other upper limb therapeutic interventions for the 4 weeks period of the trial. Exclusion Criteria • Known case of seizure and on anti–epileptic drugs • Visual problems interfering with treatment • Any surgery on the paretic hand within past 1 year • Botulinum toxin therapy in the upper extremity within the past 6 month
Procedure
Parents and Children (who were understandable) were explained about the study. Informed consent were obtained from parents prior to study. Modified Constraint Induced Movement Therapy (mCIMT):
Subjects participated in the study were provided to wear a fairly comfortable glove by Principal Investigator, as a modified restraint up to wrist is used which covers fingers, thumb and hand to avoid hand function of unaffected side. The subjects can however use the hand for support or for breaking a fall. (Figure: 1) The intervention was given for 3 hours/day including therapy time and home program which they can split into different sessions of no less than 30 minutes duration for consecutive 4 weeks (week days). 3 hours was decided according to children play time when maximum use of hand was needed. According to assessment, treatment plan based on unimanual activities were given. Treatment protocol • Reach out activities (forward, Lateral and backward reach-figure:3-5) • Grasping and releasing activities (using different size of cubes and different shape things e.g. Pencil, eraser, toys, glass etc.) • Fine motor movements (figure:7-10) • Protective function exercise • Resisted exe. For improving strength • Hand weight bearing exercise ( forward , lateral , backward ) • Functional ADL and play activities ( figure : 6) • Goal oriented activities Activities were facilitated by using simple verbal commands, encouragement, toys, demonstration and assistance was given when needed. Family members and / care givers were explained to undertake an intensive home program for 3 hours per day. Families were provided with specific goals after each session. Logbook (Work diary) - was given to primary care giver for collecting details of child activity during that 3 hour time period. Outcome measure The motor outcome was measured by using, PMAL (Pediatric motor activity scale) 18, 19(How often and how well) and QUEST (Quality of Upper Extremity Skill Test) 20(dissociated movement, grasp, protective extension, and weightbearing) Prior to treatment and after 4 week of treatment Materialsused in the study • Restraint (a glove) (Figure: 1) • Different Toys ( figure : 2)
• Work Diary • QUEST and PMAL Score sheet • Chair and Table • Mat Statistical Analysis: Data analysis was done by using SPSS 17 for windows, for both outcome measures PMAL and QUEST by statisti cian. Mean difference scores and Standard deviation for each variable were done. Wilcoxon signed rank test(as qualitative data) was used for data analysis. A significance level of 0.05 was set for all data analysis. RESULT Children in the study were aged between 2 to 8 years (the mean age was 5.25 years). There were of (60%) boys and (40%) girls, and equal numbers with the left or right arm affected. (Table 1, 2&3)(Graph 1&2) Result of PMAL in which p value (pEnglishhttp://ijcrr.com/abstract.php?article_id=770http://ijcrr.com/article_html.php?did=7701. Wiklund LM, Uvebrant P: Hemiplegic cerebral palsy. Correlation between CT morphology and clinical findings.Dev Med Child Neurol 1991, 33(6):512-523.
2. World Health Organization. International classification of functioning, disability and health (ICF). Geneva: World Health Organization; 2001.
3. Charles J, Gordon AM. A critical review of constraint-induced movement therapy and forced use in children with hemiplegia. Neural Plast. 2005;12(2-3):245-61.
4. Gordon AM, Charles J, Wolf SL. Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function. Arch Phys Med Rehabil. 2005;86(4):837-44.
5. Eliasson AC, Bonnier B, Krumlinde-Sundholm L. Clinical experience of constraint induced movement therapy in adolescents with hemiplegic cerebral palsy - a day camp model. Dev Med Child Neurol. 2003; 45(5):357-9.
6. Taub E, Uswatte G: Constraint-induced movement therapy: Bridging from the primate laboratory to the stroke rehabilitation laboratory. J Rehabil Med 2003, 35:34-40.
7. Taub E, Uswatte G, Pidikiti R: Constraint-induced movement therapy: A new family of techniques with broad application to physicalrehabilitation - A clinical review. Journal of Rehabilitation Research andDevelopment1999, 36(3):237-251.
8. Taub E, Pidikiti RD, De Luca SC, Crago JE. Effects of motor restriction of an unimpaired upper extremity and training on improving functional tasks and altering brain/behaviors. In: Toole J, Ed. Imaging and Neurologic Rehabilitation. New York, NY: Demos; 1996:133–154
9. Morris DM, Crago JE, DeLuca SC, Pidikiti RD, Taub E. Constraint-Induced (CI) Movement therapy for motor recovery after stroke. Neuro rehabilitation. 1997;9:29–43
10. Taub E. Movement in nonhuman primates deprived of somatosensory feedback. Exercise and Sports Sciences Reviews. Vol. 4. Santa Barbara, CA: Journal Publishing Affiliates; 1977:335–374
11. Hoare B, Imms C, Carey L, Wasiak J. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy: a Cochrane systematic review. ClinRehabil. 2007; 21:675-685.
12. Eliasson AC, Krumlinde-Sundholm L, Shaw K, Wang C: Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Developmental Medicine and Child Neurology 2005, 47(4):266-275.
13. Taub E, Ramey SL, DeLuca S, Echols K: Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics 2004, 113(2):305-312
14. Naylor CE, Bower E: Modified constraint-induced movement therapy for young children with hemiplegic cerebral palsy: a pilot study. Dev Med Child Neurol 2005, 47(6):365- 369.
15. Pierce SR, Daly K, Gallagher KG, Gershkoff AM, Schaumburg SW: Constraint-induced therapy for a child with hemiplegic cerebral palsy: A case report. ArchPhys Med Rehabil 2002, 83(10):1462-1463.
16. DeLuca S: Intensive movement therapy with casting for children with hemiparetic cerebral palsy: A randomised controlled trial. Dissertation. University of Alabama at Birmingham; 2002.
17. DeMatteo C, Law M, Russell D, Pollock N, Rosenbaum P, Walter S: Quality ofUpper Extremity Skills Test Hamilton: Neurodevelopmental ClinicalResearch Unit, Chedoke-McMaster Hospitals; 1991.
18. Taub E, Griffin A, Nick J, Gammons K, Uswatte G, Law CR. Pediatric CI therapy for strokeinducedhemiparesis in young children. DevelNeurorehabil2007;10:1-16
19. Taub E, Griffin A, Uswatte G, Gammons K, Nick J, Law CR. Treatment of congenitalhemiparesis with pediatric Constraint-Induced Movement therapy. JChild Neurol2011; 26:1163-1173.
20. DeMatteo C, Law M., Russell D, Pollock N, Rosenbaum P. “The quality of upper extremity skills test”, PhysOccupTherPediatr1993;13 (2), 833-845.
21. Willis JK, Morello A, Davie A, Rice JC, Bennett JT: Forced use treatment of childhood hemiparesis.Pediatrics 2002, 110(1):94-96.
22. Levy CE, Nichols DS, Schmalbrock PM, Keller P, Chakeres DW: Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraintinduced movement therapy. American Journal of Physical Medicine and Rehabilitation 2001, 80(1):4-12.
23. Liepert J: Motor cortex excitability in stroke before and after constraint induced movement therapy. Cognitive and Behavioral Neurology 2006, 19(1):41-47.
24. Carr LJ, Harrison LM, Evans AL, Stephens JA: Patterns of central motor reorganization in hemiplegic cerebral palsy. Brain 1993, 116(5):1223-1247.
25. Carr LJ: Development and reorganisation of descending motor pathways in children with hemiplegic cerebral palsy. ActaPediatrica1996, 85(416):53-57.
26. Farmer SF, Harrison LM, Ingram DA, Stephens JA: Plasticity of central motor pathways in children with hemiplegic cerebral palsy. Neurology 1991, 41(9):1505.
27. Sutcliffe TL, Gaetz WC, Logan WJ, Cheyne DO, Fehlings DL: Cortical reorganization after modified constraint-induced movement therapy in pediatric hemiplegic cerebral palsy. Journal of Child Neurology 2007, 22(11):1281-1287.
28. Schmidt RA, Lee TD. Motor Control and Motor Learning: A Behavioral Emphasis, 2nd edition. Human Kinetics Publishers Inc.; 1988.
29. Charles J, Lavinder G, and Gordon A: Effects of constraintinduced therapy on hand function in children with hemiplegic cerebral palsy. PediatrPhysTher 2001, 13(2):68-76.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11PREVALENCE AND ANTIBIOGRAM OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS ISOLATES AT A TERTIARY CARE HOSPITAL IN BANGALORE, SOUTH INDIA
English3740Kala Yadhav M. L.English Gayathri J. PanickerEnglishBackground: The emergence of Methicillin-resistant Staphylococcus aureus (MRSA) has posed a serious therapeutic challenge. MRSA is an important cause of nosocomial infections worldwide. Objectives: The aim of this study was to determine the prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) from clinical samples in a tertiary care hospital and to analyse the antibiotic susceptibility patterns of MRSA isolates. Materials and Methods: Various clinical specimens were cultured and staphylococcus aureus was identified using standard tests like catalase test, slide and tube coagulase and growth on Mannitol salt Agar. All staph isolates were then tested for routine antibiotic sensitivity by Kirby - Bauer disc – diffusion method following CLSI guidelines. MRSA were then identified from amongst the Staph isolates by using cefoxitin (10 mcg) discs by the disc-diffusion method. The D-test was performed on all isolates of Staphylococcus aureus to identify erythromycin induced clindamycin resistance. Results: The prevalence of MRSA in our study was found to be 66.84%. Linezolid and Vancomycin proved to be effective against 93.89% and 89.31% of MRSA isolates. There was statistically significant resistance to Penicillin,Cefoxitin and Oxacillin (pEnglishStaphylococcus aureus, MRSA, Cefoxitin, Clindamycin, Linezolid, Vancomycin.INTRODUCTION
In the early 1960s, Methicillin-Resistant Staphylococcus aureus (MRSA) emerged as a nosocomial pathogen. Since then, it has been increasingly reported from hospitals in countries around the world. Today, infection with MRSA is a common hospital-acquired as well as community-acquired infection encountered especially in developing nations. MRSA causes UTI, wound infection and even sepsis, endocarditis, osteomyelitis and other lifethreatening conditions which are difficult to treat owing to the multi-drug resistance developed by the organism [1]. Prolonged hospital stay and indiscriminate use of antibiotics has been implicated in the rapid emergence and spread of MRSA. Asymptomatic health-care workers are the major sources and carriers of this pathogen in a hospital. Fearing MRSA, physicians prescribe Vancomycin and other glycopeptide antibiotics in order to treat their patients, without undertaking appropriate antibiotic sensitivity tests. This has deleterious effects in the long-term as more resistance builds up. Currently, there are Vancomycin resistant staphylococcus aureus (VRSA) strains being isolated from some cases and these are highly difficult to treat. In this study, clinical samples from patients in a tertiary care hospital in South India were processed for the growth of Staphylococcus aureus and their antibiotic sensitivity patterns were obtained by Kirby- Bauer’s disc diffusion method. MRSA strains were identified using a 30 mcg Cefoxitin disc according to Clinical and Laboratory Standards Institute (CLSI) standards (2). The study also looks for erythromycin induced clindamycin resistance among staphylococcus isolates. This study was undertaken with the main aim of estimating the prevalence of MRSA and studying the antibiotic-sensitivity pattern of MRSA isolates among clinical samples from patients attending a Tertiary care centre, Bangalore. As a result, appropriate antibiotic schedules, control measures and prophylactic steps can be introduced in order to reduce infection rates and spread of MRSA.
MATERIALS AND METHODS
The present study was conducted for a period of 6 months on patients attending the OPDs and inpatient admissions to Tertiary care hospital attached to a medical college in Bangalore, South India. During this period 2821 various clinical samples like urine, blood, sputum, stool, body fluids and exudates (mainly pus from wounds, middleear infections and pyogenic abscesses) were received and processed in the microbiology laboratory. Institutional ethical clearance and informed consent of the patients was obtained for the study. The specimens were cultured on blood agar and MacConkey agar plates and incubated aerobically at 37°C for 48 hours. Staphylococcus aureus isolates were identified using standard tests like catalase, slide and tube coagulase, and growth on Mannitol salt agar [3]. Following identification of staphylococcus aureus, antibiotic sensitivity testing was performed by Kirby–Bauer disc diffusion method for the following antibiotics: Amoxicillin + clavulinic acid (50/10µg), cefotaxime(3oµg), oxacillin(5µg), linezolid(30µg), tetracycline(30µg), cotrimoxazole(25µg), ciprofloxacin (5 µg), chloramphenicol (30 µg), clindamycin (2 µg), gentamicin (10 µg), erythromycin (15 µg), netilmicin (30 µg), penicillin (10 units), and vancomycin (30 µg). Carbenicillin, nitrofurantoin and nalidixic acid were added if the isolate of Staphylococcus aureus was from a urine sample. D test: The test was done on a Mueller–Hinton agar plate inoculated with a lawn culture of 0.5 McFarland bacterial suspension. The erythromycin (15 µgm) disc and clindamycin (2 µgm) disc was then placed at a distance of 15 mm (edge-to-edge). After an overnight incubation at 370 C , flattening of the zone in the area between the two discs giving a (D-shaped zone) around clindamycin disc indicated inducible clindamycin resistance. Test for methicillin resistance was performed by Kirby– Bauer disc diffusion method using cefoxitin (30µgm) disc according to the Clinical and Laboratory Standards Institute (CLSI) guidelines, the test includes incubating a lawn culture of the test isolate on Mueller Hinton agar with 2% sodium chloride and cefoxitin disc (30 mcg) at 37o C for 24 hours, a zone size Englishhttp://ijcrr.com/abstract.php?article_id=771http://ijcrr.com/article_html.php?did=7711. Vidya Pai, Venkatakrishna I Rao, and Sunil P Rao. Prevalence and Antimicrobial Susceptibility Pattern of Methicillin-resistant Staphylococcus Aureus [MRSA] Isolates at a Tertiary Care Hospital in Mangalore, South India. J Lab Physicians. 2010 Jul-Dec;2(2):82-84. Cookson B. Staphylococcus aureus. In: Emmerson M, Kibbler C, Hawkey P eds. Principles of Clinical Bacteriology. Oxford: John Wiley, 1997; 109–30.
2. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-Second Informational Supplement. Clinical and Laboratory Standards Institute, Wayne, PA 2012.
3. Cookson B. Staphylococcus aureus. In: Emmerson M, Kibbler C, Hawkey P eds. Principles of Clinical Bacteriology. Oxford: John Wiley, 1997; 109–30.
4. Chandrashekar D K et al. Prevalence of Methicillin Resistant Staphylococcus aureus in a tertiary care hospital in Gulbarga, Karnataka, J. of Pharmaceutical and Biomedical Sciences. June 2012,19(19)1-3.
5. Shilpa Arora, Pushpa Devi, Usha Arora, Bimla Devi. Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in a tertiary care hospital in Northern India. J Lab Physicians. 2010 Jul-Dec;2(2):78-81.
6. Tiwari HK, Sapkota D, Sen MR. High prevalence of multidrug-resistant MRSA in a tertiary care hospital of northern India. Infection and Drug Resistance. 2008;1:57–61
7. Bal AM1 , Gould IM. Antibiotic resistance in Staphylococcus aureus and its relevance in therapy. Expert Opin Pharmacother. October 2005;6(13):2257-69.
8. Kandle SK, Ghatole MP, Takpere AY, Hittinhalli VB, Yemul VL. Bacteriophage typing and antibiotic sensitivity pattern of Staphylococcus aureus from clinical specimen in and around Solapur (South Maharashtra) J Commun Dis. 2003;35:17–23
9. Yilmaz G, Aydin K, Iskender S, Caylan R, Koksal I. Detection and prevalence of inducible clindamycin resistance in staphylococci. J Med Microbiol. 2007;56:342–5.
10. Kavitha Prabhu, Sunil Rao, and Venkatakrishna Rao. Inducible Clindamycin Resistance in Staphylococcus aureus Isolated from Clinical Samples. J Lab Physicians. 2011 JanJun; 3(1): 25–27.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September4SERUM TOTAL ALKALINE PHOSPHATASE ENZYME LEVEL AND SEVERITY OF CHRONIC PERIODONTITIS
English4144Gopu Chandran Lenin PerumalEnglish Mythili R.English Senthil KumarEnglish Subashini SuyambukesanEnglishPurpose: Conventional diagnosis of chronic periodontitis relaying on the clinical probing methods and radiographic evaluation doesn’t predict the progression or severity of the disease state. The recent methods to identify the status of disease relies on the biochemical mediators and / or enzyme level measurements. One such commonly used enzyme assay is alkaline phosphatase. Estimation of this enzyme has shown proven results in diseases involving bone. Chronic periodontitis is one such disease where there is an appreciable amount of bone destruction. The purpose of this study was to estimate and compare the levels of alkaline phosphatase enzyme in serum of healthy individual and in chronic periodontitis patients with varying severity. Materials and Methods: Serum samples were obtained from 67 individuals. 31 are from healthy individuals and 36 from chronic periodontitis patients categorized as mild, moderate and severe based on clinical attachment loss values. The samples were used to determine the total alkaline activity (ALP) level using a fully automated analyzer. Results: Comparison of the total alkaline phosphatase activity between the control and experimental groups namely mild, moderate and severe chronic periodontitis patients showed an increase in total alkaline phosphatase activity from healthy to mild and moderate. There was a decrease in total ALP level in severe periodontitis patients as compared to moderate chronic periodontitis group. Conclusion: The measurement of alkaline phosphatase level in serum cannot be considered as a standalone enzymatic assay for evaluating the severity of chronic periodontitis. This may provide useful information towards the disease severity and progression if evaluated repeatedly over a period of time.
EnglishAlkaline phosphatase, Chronic periodontitis, Severity of chronic periodontitis, Serum enzymatic assayChronic periodontitis is a longstanding inflammatory disease affecting the supporting structures of the dentition namely the gingiva, periodontal ligament, cementum and adjacent surrounding alveolar bone. Most routine methods to diagnose chronic periodontitis is by clinical evaluation of affected site and measuring the attachment loss followed by radiographic confirmation by identifying bone loss. These methods do not shed light on the status of progression or regression occurring in the diseased sites and also fail to identify newly developing disease sites.[1,2] For better evaluation of prognosis and effective treatment, it is important to identify the current status of the disease. Changes at both cellular levels and sub – cellular levels show us the current status of the disease and are evaluated or identified using biochemical assay. The most common and widely relied enzyme assay for bone disease is alkaline phosphatase (ALP) measurement. Alkaline phosphatase has been found in various periodontal tissues [3,4] with increased activity noticed during progression of periodontitis.[5,6] Serum level of ALP enzyme can be used as an indicator for bone formation. [7] The purpose of this present study was to evaluate and compare the alkaline phosphatase enzyme level in serum of healthy individuals with the severity of chronic periodontitis.
MATERIALS AND METHODS
This study was done in division of Periodontics, RMDC and H, Annamalai University after ethical clearance. Informed consent were obtained from 67 participants who were selected randomly among the patients who visited the division of Periodontics. 31 individuals in control group and 36 patients in test groups of age 30 -55 years were selected with the criteria’s listed below and are grouped as Group A: Control group – healthy individuals [Clinical attachment loss of 0 mm] and Group B: Test groups – Chronic periodontitis patients sub categorized as B1 : Mild (Clinical attachment loss 1 – 2 mm); B2 : Moderate (Clinical attachment loss 3- 4mm) and B3 : Severe (Clinical attachment loss ≥ 5mm)[8] Exclusion criteria: Smokers, malnourished, anemic, subjects taking medicines known to affect periodontal conditions or gingival secretion, having cardiac disease, hepatobiliary disease, diabetes, thyroid and parathyroid abnormalities, Viral, fungal or bacterial infection, history of recent trauma or tooth extractions, pregnant or lactating women, women on oral contraceptives, history of systemic antibiotic therapy within 6 months were excluded from the study. The clinical examination was done following a brief and precise medical and dental history using mouth mirror, dental explorer and William’s periodontal probe. The following parameters were recorded: OHI – S (Green and vermillion 1967); Probing pocket depth in mm and Clinical attachment loss in mm. 5ml of blood samples was collected from all participating individuals after overnight fasting and was allowed to clot in a test tube placed slantingly. After an hour the supernatant serum was extracted and sent to biochemical laboratory for assay. Total alkaline phosphatase was evaluated using a fully automated analyzer and the results were expressed in U/L. The values obtained were tabulated and subjected for statistical analysis of data. Results were tabulated; Sample’s mean and standard deviation for the results were determined. Between each study groups, the results were compared using Analysis of Variance (ANOVA) test for the determination of statistical significance. All statistical analysis was performed using standard statistical software. P Englishhttp://ijcrr.com/abstract.php?article_id=772http://ijcrr.com/article_html.php?did=7721. Page RC. Host response tests for diagnosing periodontal diseases. J Periodontol 1992;19:43-8.
2. Fine DH and Mandel ID. Indicators of periodontal disease activity: An evaluation. J Clin Periodontol 1986;13:533-46.
3. Cimasoni G. Crevicular fluid updated. In: Myers HM, editor. Basel: Karger; 1983. P.77-9, 108-16.
4. Nakashima K, Roehrich N, Cimasoni G. Osteocalcin, prostaglandin E2 and alkaline phosphatase in gingival crevicular fluid:their relations to periodontal status. J Clin Periodontol 1994;21: 327-33.
5. Binder TA, Goodson JM. Gingival fluid levels of acid and alkaline phosphatase. J Periodontal Res 1987;22: 14–19.
6. Chapple HC, Matthews JB, Thorpe GH, Glenwright HD, Smith JM, Saxby MS. A new ultrasensitive chemiluminescent assay for the site specific quantification of alkaline phosphatase in gingival crevicular fluid. J Periodontal Res 1993;28:266–273.
7. Delmas PD. What do we know about biochemical bone markers? Baillieres Clin Obstet Gynaecol 1991;5:817-30.
8. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999: 4; 1 - 6.
9. Gopu chandran lenin perumal et al. Serum total alkaline phosphatase enzyme levels in chronic periodontitis patients among Tamilnadu population. Paripex – Indian journal of research 2014:3(7):57
10. Jaiswal et al. Serum alkaline phosphatase: A potential marker in the progression of periodontal disease in cirrhosis patients. Quintessence Int 2011;42:345–348.
11. Shaheen A, Khattak S, Khattak AM, Kamal A, Jaffari SA, Sher A. Serum alkaline phosphatase level in patients with type 2 diabetes mellitus and its relation with periodontitis. KUST Med J 2009; 1(2): 51-54.
12. Gibert P, Tramini P, Sieso V, Piva MT. Alkaline phosphatase isozyme activity in serum from patients with chronic periodontitis. J Periodontal Res 2003;38:362-5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11STUDY OF VISUAL ONLINE REACTION TIME IN DIFFERENT PHASES OF MENSTRUAL CYCLE IN HEALTHY FEMALES
English4547Rinku GargEnglish Varun MalhotraEnglish Usha DharEnglish Yogesh TripathiEnglishAims and objectives: The present study was designed to study the influence of various phases of menstrual cycle on visual online reaction time. Material and Methods: Fifty females in the age group of 18-25 years were recruited for the study. Visual reaction time test was taken online. Statistical Analysis: Results were analysed by ANOVA with SPSS version 17.0 using paired ‘t’ test. Results: showed that there was significant prolongation of reaction time (pEnglishFollicular phase, Luteal phase, Online reaction timeINTRODUCTION
The biological activity of the menstrual cycle is created by the coordination among hypothalamic, hypophyseal and ovarian hormones.[1]. The established hypothalamic, hypophyseal and ovarian axis and its cyclical hormonal changes during the three phases of normal menstrual cycle are as follows.[2]. Follicular phase: is mainly a phase of oestrogen, influenced by follicular stimulating hormone. Luteal phase: primarily a phase of progesterone influenced both by follicular stimulating hormone and luteinizing hormone. Menstrual cycle: the cervical bleeding phase, due to the withdrawal of hormonal effect on endometrium. The fluctuations in hormonal levels affect not only the female reproductive tract but also many other tissues of the body. Various studies have shown that female sex hormones modulate auditory, visual and taste threshold, latency and amplitude.[3] Behavioural and neurological symptoms like decreased concentration, nervous, irritability, emotional instability, poor judgement, tension and depression are seen in women during premenstrual phase.[4] This may be due to due to effect of gonadal hormones on neural functions.[5] Reaction time is the measure of how fast a person responds to a particular type of stimuli. It can be defined as the time interval between the application of a stimulus and an appropriate voluntary response from the subject. It measures the ability to process information and judges the ability to concentrate and coordinate.[6] Flow of information in an organism can be depicted in this way: [7,8,9]
Various studies have shown that ovarian steroids influence dopamine release in the nigrostriatal pathway.[10,11] Estradiol has widespread effects throughout the brain regions involved in affective state as well as cognition.[12,13]
Online visual reaction times during various phases of menstrual cycle studies have not been studied in other researchers. As menstrual cycle is associated with fluctuating levels of ovarian hormones, this study was designed to study the visual online reaction time across different phases of menstrual cycle. MATERIAL & METHODS The present study was a cross-sectional study, conducted in Department of Physiology, Santosh Medical College, Ghaziabad. Ethical approval was taken from the research committee of the Institution before starting the study. One hundred apparently healthy female volunteers in the age group of 18-25 years with history of regular menstrual cycle were studied in follicular, luteal and menstrual phases of menstrual cycle. Mensrual history including age of menarche, regularity of cycles, history of dysmenorrohea, history of premenstrual symptoms like irritability, headache were collected. Female subjects with age >above 25years, history of irregular menstrual cycles, use of contraceptive pills, use of psychotropic drugs (sedatives, hypnotics and tranquilizers), antihistaminics, antiepleptics, and smokers or consuming alcohol were excluded from the study. Females with history of psychiatric illness or recent psychological trauma or sleep disorders were also excluded from the study. Informed consent was taken from all the subjects. Height was measured using a standard stadiometer with the subject standing in erect posture. The readings were taken to the nearest 0.1cm. Weight was recorded in kgs using a calibrated weighing machine (Avery) scale with a capacity of 120 kg and a sensitivity of 0.05 kg. BMI (body mass index) was calculated as the weight in kilograms divided by the square of the height in meters [weight(kg)/height(m2 )] .[14] Online Reaction Time Test: Visual reaction time test was taken online.[15].It consists of a traffic light signal of red, yellow and green. The subject is instructed to click on a button to begin when ready, to wait for the stoplight to turn green, and click the button when it turns green quickly! The average of five responses in seconds is taken as a reading. Statistical Analysis: Results were analysed by ANOVA with SPSS version 17.0 using paired ‘t’ test and expressed as Mean ± SD. P value < 0.05 was considered as significant.
DISCUSSION
Our study results have shown that there is prolongation of online visual reaction time in luteal phase [mainly progesterone] as compared to the follicular phase [mainly oestrogen]. Delayed reaction time in the luteal phase may be due to female sex hormones [mainly progesterone] that cause salt and water retention thus affecting the axonal conduction. Altered axonal conduction influences the availability of neurotransmitter at synapses in signal processing pathway that causes slow conduction of the impulse and hence prolonged reaction time[16]. . Kaneda et. al. have also showed that increased latency of visual evoked potentials may be due to high progesterone levels during the luteal phase[17]. Various studies have showed that effects of estrogen on brain are antagonistic to that of progesterone therefore explaining less reaction time in follicular phase as compared to luteal phase[18,19,20,21]. Progestrone may also decrease the sensitivity of neurons and blunts the estrogen potentiated GABA (Gamma-Amino Butyric Acid) release[22,23].Moreover, estrogen has been shown to be neuroprotective[24].
It has been shown by many authors that female sex hormones act at the receptor level on the hippocampus and hypothalamus that alters the excitability of the neurons across different phases of the menstrual cycle[25,26]. Limitation of our study is that we have not measured hormonal levels of estrogen and progesterone in the serum during various phases of menstrual phases. These also have not been statistically correlated with reaction times.
CONCLUSIONS
Variation in visual reaction time could be due to the fluctuating levels the female sex hormones across the menstrual cycle. The prolongation of reaction time in menstrual phase correlates well with the mood swings associated with premenstrual syndrome. Tasks requiring short reaction times like emergencies situations in speeding while driving, air force postings on the war front may be avoided in this phase, as these are prolonged during the phase.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors are also thankful to subjects and all the technical staff for their contribution in the completion of the project.
Englishhttp://ijcrr.com/abstract.php?article_id=773http://ijcrr.com/article_html.php?did=7731. Cooke WH, Ludwig DA, Hogg PS, Eckburg DL, Convertino VA. Does the menstrual cycle influence the sensitivity of vagally mediated baroreflexes. Clin Sci 2002;102: 639-644
2. Williams. Pregnancy planning and antepartum management, Text Book of Obstetrics. 2006,22nd edition,226.
3. Vogel W, Broverman DM, Klaiber EL. EEG responses in regularly menstruating women and in amennorrheic women treated with ovarian hormones. Science. 1971;172:388.
4. Pawar BL, Kulkarni MA, Syeda A, Somwanshi ND, Chaudhari SP. Effect of premenstrual stress on cardiovascular system and central nervous system. J Obstet Gynecol India. 2006;56(2):156–58.
5. Walpurger V, Pietrowsky R, Kirschbaum C, Wolf OT. Effect of the menstrual cycle on auditory event related potentials. Hormones and Behavior. 2004;46:600
6. Nene AS, Pazare PA. A study of auditory reaction time in different phases of the normal menstrual cycle. Indian J Physiol Pharmacol. 2010;54(4):386–90.
7. Formulate and test hypotheses regarding reaction times. Biology 104. A online PDF literature form Radford University.www.radford.edu/jkel/reaction. 8. Robert JK. A Literature Review of Reaction Time, 2005. Available from: http://www.biae.clemson.edu/bpc/bp/ Lab/110/reaction.htm#Arousal. [Accessed 2005 Mar 17].
9. Marieb Elaine N. Exercise 22 Human reflex physiology. Activity 9: testing reaction time for basic and acquired reflexes. Human Anatomy and Physiology Laboratory Manual (Cat Version). 7 th ed. San Francisco, California: Benjamin Cummings; 2003. p. 232-3.
10. Mc Ewen B. Estrogen action throughout brain. Recent Prog Hormon Res 2002; 57: 357-384.
11. Mc Dermott JL. Effects of estrogen on dopamine release from corpus straitum of young and aged female rats. Brain Res 1993; 606:118-125.
12. Asso D. The relationship between menstrual cycle changes in nervous system activity and psychological behaviour and physical variables.Biol Psychol 1986;23: 53-64.
13. Asso D, Braier JR. Changes with menstrual cycle in psychophysiological and self report measures of activation. Biol Psychol 1982; 15: 95-107.
14. Everett RB, Worley RJ, MacDonald PC and Gant NF. Modification of vascular responsiveness to Angiotensinogen II in pregnant women by intravenously infused 5 alpha dihydroprogestrone. Am J Obstet Gynaecol 1978;131:352-357.
15. The Online Reaction Time Test (http://getourwebsitehere. com/jswb/rttest01.html.)
16. Das S, Gandhi A, Mondal S. Effect of premenstrual stress on audiovisual reaction time and audiogram. Indian J Physiol Pharmacol 1997;41:67-70.
17. Kaneda Y, Ikuta T, Nakayama H, Kagawa K, Furuta N. Visual evoked potential and electroencephalogram of healthy females during the menstrual cycle. J Med Invest. 1997;44:41–46.
18. Kawakami M, Sawyer CH. Effects of sex hormones and antifertility steroids in brain thresholds in the rabbit. Endocrinology. 1967;80:857–871.
19. Kluck N, O’Connor S, Hesselbrock V, Tasman A, Maier D, Bauer L. Variation in evoked potential measures over the menstrual cycle: a pilot study. Prog Neuropsychopharmacol Biol Psychiatry. 1992;16:901–911.
20. Vingerling JR, Dielemans I, Witteman JC, Hofman A, Grobbee DE, de Jong PT. Macular degeneration and early menopause: a case-control study. BMJ. 1995;310:1570–1571.
21. Párducz A, Perez J, Garcia-Segura LM. Estradiol induces plasticity of gabaergic synapses in the hypothalamus. Neuroscience. 1993;53:395–401.
22. Yadav A, Tandon OP, Vaney N. Auditory evoked responses during different phases of menstrual cycle. Ind J Physiol Pharmacol 2002; 46: 449-456.
23. Yadav A, Tandon OP, Vaney N. Long Latency auditory evoked responses in ovulatory and anovulatory menstrual cycle. Ind J Physiol Pharmacol 2003; 47: 179-184.
24. Behl C, Widmann M, Trapp T, Holsboer F. 17-beta estradiol protects neurons from oxidative stress-induced cell death in vitro. Biochem Biophys Res Commun. 1995;216:473– 482.
25. McEwen BS, Davis PG, Parsons B, Pfaff DW. The brain as target for steroid hormone action. Ann Rev Neurosci. 1979; 2: 65-73.
26. Curtis DR, Game CJA, Johnston GAR, McCulloch RM. Central effects of β-(p chlorophenyl)-γ-aminobutyric.Brain RES. 1974; 70: 493-99.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11EARLY SUBPERIOSTEAL AND INTRA-ORBITAL HAEMATOMA EVACUATION IN TRAUMATIC SKULL AND PAN ORBITAL FRACTURE - VISION SAVING AND LIFE SAVING
English4851N. EzhilvathaniEnglish V. S. HariEnglishFractures of the skull and the orbit can lead on to devastating morbidity and mortality to a patient if not identified and treated early. Skull and facial fractures are often complicated by ocular injuries. A case of early surgical drainage of an infected intra orbital and subperiosteal haematoma in a traumatic craniofacial fracture involving all the four walls of the right orbit and frontoparietal bone causing severe proptosis and exposure keratopathy resulting in improving the visual status and general condition of the patient is reported. The resolution of proptosis, exposure keratopathy and the restricted ocular motility resulted in clearing the corneal opacity leaving only a small residual macular corneal opacity away from the visual and pupillary axis following the surgical evacuation. The purulent collection from the intra orbital space would have spread to the brain due to the orbital roof and
the co-existant fronto-parietal fracture culminating in a severe meningeal and cerebral infection deteriorating the condition of a young patient, had a delayed decision been taken. Moreover, the value of comprehensive management of craniofacial fractures is evident from the aesthetic and the functional outcome.
EnglishIntra orbital haematoma, Subperiosteal haematoma, Pan orbital fracture, Proptosis, Ophthalmoplegia, Exposure keratopathy, Traumatic optic neuropathyINTRODUCTION
A comprehensive understanding of orbital fractures is necessary for the treating physician due to the functional and aesthetic deformities that often result. Studies have estimated that orbital fractures account for roughly 10 to 25% of all cases of facial fractures, and similar to all facial traumas, they are most commonly seen in conjunction with assaults and motor vehicle accidents [1]. Motor vehicle accidents related orbital fractures, in particular, tend to be more destructive and are associated with more concomitant organ injuries, zygoma fractures and multiple orbital wall fractures than the other common causes of assault, sports-related and falls etc [1]. Additional damage to the globe, optic nerve, extra ocular muscles is almost always an accompaniment to these fractures. About 11 to 15% of orbital fractures are associated with ophthalmological emergencies [2]. A retrospective chart review undertaken by Ansari in 2005 revealed 30 cases of blindness following facial trauma and the other subsequent facial fractures required operative intervention in 2503 patients. [3] Their analysis revealed the vast majority of cases were secondary to zygoma or zygomaxillary complex fractures with retrobulbar hemorrhage or severe damage to the eye. Therefore, in this case, an early evacuation of an infected subperiosteal and intra-orbital hematoma had prevented blindness and also death due to intra cranial infection.
REPORT
A 29 year old male had met with a road traffic accident while riding in a two wheeler in an inebriated condition. He had sustained head injuries and right facial injuries. He had a history of loss of consciousness for about twenty minutes and bleeding through nose. There was no history of seizures or vomiting. On receiving in the casualty, the patient was found to be drowsy and disoriented. However he obeyed to oral commands and moved all four limbs to painful stimuli. His Glasgow coma scale score was 12/15, E4V4M4. His pulse rate was 98/minute, Respiratory rate was 20/minute, and Blood pressure was 140/80mmhg. He was found to have partial ptosis, severe proptosis of right eye with sub-conjunctival hemorrhage and restricted ocular movements. Right eye bed side visual acuity was 6/12 and left eye was 6/6. Right eye pupil was 4mm in size sluggishly reacting to direct light reflex. Left eye pupillary size and reflex was normal.
Patient was admitted in the emergency ward with room air ventilation. He was started on anti-cerebral edema measures, antibiotics, anti-convulsants, IV fluids and general supportive measures. Patient was advised topical lubricating eye drops and topical non-steroidal eye drops for the right eye. Patient regained consciousness and became oriented from the day of admission. His Glasgow coma scale score improved to 15/15 E4V5M6. Patient developed dryness of right eye cornea four days following the head injury and was advised tapping of lids along with lubricating eye ointments. Patient had developed severe exposure keratopathy and his vision dropped to 6/36 in right eye with corneal opacification in the inferior interpalpabral part of cornea. Patient was also complaining of restricted ocular movements and double vision. On diplopia charting, it was found to be a crossed diplopia with right hypotropia. Colour vision was defective in right eye and normal in left eye indicating right optic neuropathy.
Surgical evacuation of the retro-bulbar and sub-periosteal haematoma was decided as the right eye proptosis was not resolving with medical management even after 10 days. With a curved right sub brow incision, periosteum of the superior orbital wall was incised and about 20 ml of altered blood and pus was aspirated from the retrobulbar and superior sub-periosteal space.
DISCUSSION Orbital hematomas can be caused by trauma and can be classified as intraorbital or subperiosteal by Landa[4]. Intraorbital hematomas are more common and show findings of subconjunctival hemorrhage, lid edema and bruising and diminished ocular movement. Subperiosteal hematomas, which occur secondary to rupture of subperiosteal blood vessels, are not as common and will present with proptosis, lid ecchymosis, exposure keratopathy, defective pupillary reflex and impairment of eye movement. The management of the hematoma depends on how impaired the vision is. Without visual disturbance, the hemorrhage can be observed without specific treatment. When vision is affected, the hematoma should be evacuated. Small retrobulbar hematomas generally get resorbed spontaneously within 3 weeks to 4 months. [5] However, hematoma may also organize to form an orbital blood cyst with no endothelial lining. Mortada [6] recommended an exploration of the orbital apex that is indicated through a lateral transconjunctival orbitotomy to evacuate the blood if medical treatment is unsuccessful in approximately 4 months. However, in this case, not only did the hematoma did not resolve with antibiotics and anti-inflammatories for 10 days, but also the collection behind the eye have turned to be purulent causing proptosis and severe exposure keratopathy compromising the vision. Therefore early evacuation of the subperiosteal haematoma is imperitive in this case for prevention of the vision loss from exposure keratopathy and secondary corneal infection. Also the spread of infection to the brain causing meningitis and encephalitis had been prevented. In this case the pupillary reflex had been sluggish from the time of injury indicating optic neuropathy due to nerve compression from extrinsic
(hematoma) or intrinsic (haematoma or edema) sources. Traumatic optic neuropathy is seen in about 0.5-5% of patients with orbital fractures [7]. This is confirmed by the fact that the patient had defective colour vision both during the pre operative and post operative period even though the vision improved to 6/9.There is a high association of orbital roof fractures with neurologic injury (57 to 90%),[8] ocular damage (14 to 38%), and additional orbital (76%) and facial fractures (33%) .Certain orbital injuries require emergent surgical intervention [9]. The timing of surgery for non emergent injuries is often in a semi-delayed fashion around 7 to 14 days, before soft tissue scarring develops, but after resolution of posttraumatic edema. After 2 weeks, soft tissue fibrosis can become significant, especially in young males, and require sharp dissection for reduction of orbital tissues [10]. In this case, patient had been operated 10 days following injury, thus avoiding the complications of delayed intervention.
CONCLUSION
• Early surgical evacuation of a subperiosteal and an intra orbital haematoma reduced the proptosis favouring the patient to close the eyes completely resolving the exposure keropathy and the consequent vision threatening infectious keratitis
• Subperiosteal hematoma had turned purulent and if left undrained, would have spread to the brain through the roof fracture
• Antibiotics do not penetrate through pus, therefore conservative management with antibiotics would have proved ineffective
• A team approach to surgical management of craniofacial and zygomatico orbital fracture along with orbital, faciomaxillary and neurosurgeons can save the life of an individual apart from achieving good functional and cosmetic effects.
ACKNOWLEDGEMENTS
Authors would like to acknowledge Mrs. Revathi, Entire surgical team, ophthalmic technician Mrs. Gomathi, Computer technician Mr. Baranidharan, Staff members of Department of Ophthalmology and Neurosurgery. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=774http://ijcrr.com/article_html.php?did=7741. Erdmann D, Follmar K E, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008; 60:398-403. [Pub Med]
2. Lee H J, Jilani M, Frohman L, Baker S.CT of orbital trauma. Emerg Radiol.2004; 10:168-172. [PubMed]
3. Ansari MH. Blindness after facial fractures: a 19-year retrospective study. J Oral Maxillofac Surg 2005; 63:229–237
4. Landa MS, Landa EH, Levine MR. Subperiosteal Haematoma of the orbit:case presentation. Ophthal plastic Reconst surg 1988; 3:189-192.
5. Pogrel MA. The superior orbital fissure syndrome: report of case. J Oral Surg 1980; 38:215–217 6.
6. Mortada A. Unilateral proptosis of unexplained origin and Superior orbital fissure syndrome of uncertain aetiology. Bull Ophthalmol Soc Egypt 1969; 62:191–204
7. Steinsapir K D, Goldberg RA. Traumatic optic neuropathy. Surv Ophthalmol.1994:38:487-518. [PubMed]
8. Hang RH, Sickels JE Van, Jenkins WS. Demographics and treatment options for orbital roof fractures. Oral Surg Oral Pathol Oral Radiol Endod.2002:93:238-246.[PubMed]
9. Fulcher TP, Sullivan TJ. Orbital roof fractures: Management of Ophthalmic Complications. Ophthal Plast Reconstr Surg.2003:19:359-363. [PubMed]
10. Fearson JA, Munro IR, Bruce DA. Observation on the use of rigid fixation for craniofacial deformities in infants and young children. Plast Reconstr Surg.1995:95:634-637. Discussion 638. [PubMed]
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11LATE PATELLAR TENDON RECONSTRUCTION - NOVEL TECHNIQUE
English5254Ravichandran S.English Surendher Kumar R.English Krishna BhargavaEnglish Krishnagopal R.EnglishTraumatic rupture of the patellar tendon occurs in the young and is caused by sudden contraction of the quadriceps against resistance.
The lesion usually occurs at the point where the patellar tendon is attached to the lower pole of the patella. We present a 26-year-old male patient who presented to our hospital 4 months after history of bike accident. Following which the patient was unable to walk immediately. Patient was treated with native bandage for a month after which patient was able to weight bear. On
walking patient had pain, instability, locking and inability to extend the knee. Clinically, patient had a swelling over infra patellar region with extensor lag of 25-30 degrees. X-ray of the knee showed no bony injury and MRI showed complete tear of the patellar tendon. Patellar tendon rupture repaired with modified Ecker technique using hamstring graft. Post-op operatively, he was
immobilized with above knee slab for 2 weeks after which patient was made to weight bear partially. At 10 weeks, full weight bearing with knee brace was started and at the end of 3 months patient had near normal range of movements.
EnglishPatellar tendon rupture, Patellar tendon repair, Modified ecker technique, HamstringINTRODUCTION
Surgical management of neglected patellar tendon rupture is more challenging than that of acute ruptures, and the results are less promising because of proximal patellar migration and retraction, atrophy of the quadriceps (1-3). Several methods to relocate the patella anatomically have been proposed including preoperative traction, quadricepsplasty and external fixation (1-8). We present a case with a neglected patellar tendon rupture which was treated successfully with a modified Ecker technique (7) and adjustable knee brace postoperatively. Good functional result was achieved with intensive rehabilitation.
CASE REPORT
A 26-year-old male was admitted to our hospital with a complaint of inability to extend his left knee. His history revealed a road-traffic accident 4 months earlier, after which the patient was unable to walk immediately, he went in for native treatment where 2 bandages around knee each for 15 days has been applied. After which the patient was able to walk with pain, instability, locking and inability to extend knee. On examination, swelling seen over infra-patellar region and patella was migrated proximally. Passive range of motion was full with an extension lag of 25-30 degree. Radiographs showed no evidence of any bony injury. MRI of the knee joint revealed complete tear of the patellar tendon. With all the clinical and radiographic findings we diagnosed as patellar tendon rupture. Pre-anesthetic workup was done and planned for surgical reconstruction of patellar tendon using modified ECKER technique. An anterior midline incision was given to expose patella and tibial tuberosity. Then two transverse tunnel was drilled in patella with a thick K wire and another one in tibial tuberosity with 4 mm drill bit. Holding the knee in extension a circular wire was passed from the tunnels and tightened until obtaining an adequate distance between patella and tibial tuberosity, considering Insall-salvati ratio (normal patellar tendon is approximately equal to the length of the patella) (9). Semitendinosus and Gracils tendon grafts were harvested by open end tendon stripper. The semi-tendinous tendon was prepared and passed through the tunnel drilled in the tibial tuberosity and the inferior tunnel drilled in the patella, then sutured. Then, the gracilis tendon was passed through the same tunnel in tibial tuberosity and superior tunnel of patella and sutured to the semitendinosus tendon graft. Circlage wire removed after the repair was completed. With Hip in 45 degree of flexion, the knee could be flexed to 20% with gravity of the leg and the repair was found to be stable. The knee was immobilized by plaster slab in extension post-operatively.
DISCUSSION Fresh patellar tendon ruptures require immediate repair of the extensor mechanism for optimum results. End to end repair with circulage wiring or with non-absorbable suture material and cast immobilization for 6-8 week is recommended (3). Better outcome has been reported in early repair of patellar tendon with no extension lag and quadriceps strength (3). Neglected rupture of the patellar tendon is a rare condition [5–8,10]. Patellar tendon rupture is often missed in patients with multiple injuries, especially in obese population. End to end approximation is difficult in neglected rupture cases. Late the presentation greater the chances of quadriceps retraction and proximal patellar migration. It is difficult to locate the ruptured ends in neglected cases due to fibrosis, in such conditions it is recommended to reconstruct patellar tendon with fascia lata, hamstring tendons (commonest) or Achilles tendon (11-12). Several techniques have been reported for relocation of patella to its anatomical position in cases with severe quadriceps contracture and migrated patella with external fixation using pins and Ilizarov technique(5). Mandelbaum et al. [2] proposed ‘Z’ lengthening for the quadriceps tendon and ‘Z’ shortening for the patellar tendon with augmentation using semitendinosus and gracilis tendon grafts. Postoperatively immobilized in plaster with knee in full extension for 4 weeks followed by 10 degree per week of knee flexion in a hinged knee brace reporting 130 degree flexion at end of 1 year follow up. Even though being a neglected rupture, interoperatively we did not have any difficulty in moving the patella in spite of no preoperative traction. Semitendinosus-gracils graft were used to reconstruct the patellar tendon without any circulage wiring. Postoperatively immobilied in above knee plaster with full extension for 4 weeks followed by 10 degree per week of flexion in a hinged brace. At the end of 12 weeks patient had 120 degree of knee flexion with no extension lag and good strength of quardriceps was acheived.
CONCLUSION
Modified Eckar technique is a good and promising procedure in reconstruction of neglected patellar tendon rupture. Outcome will be better if treated earlier. Still a good result can be obtained in reconstruction of the patellar tendon using an autologus tendon graft along with intensive rehabilitation.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=775http://ijcrr.com/article_html.php?did=7751. Takebe K, Hirohata K (1985) Old rupture of the patellar tendon. Clin Orthop Relat Res 196:253–255.
2. Mandelbaum BR, Bartolozzi A, Carney B (1988) A systematic approach to reconstruction of neglected tears of the patellar tendon. Clin Orthop Relat Res 235:268–271.
3. Siwek CW, Rao JP (1981) Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 63:932–937.
4. Nsouli AZ, Nsouli TA, Haidar R (1991) Late reconstruction of the patellar tendon: case report with a new method of repair. J Orthop Trauma 31:1319–1321.
5. Isiklar ZU, Varner KE, Lindsey RW et al (1996) Late reconstruction of patellar ligament ruptures using Ilizarov external fixation. Clin Orthop Relat Res 322:174–178.
6. Kelikian H, Riashi E, Gleason J (1957) Restoration of quadriceps function in neglected tear of the patellar tendon. Surg Gynecol Obstet 104:200–204.
7. Ecker ML, Lotke PA, Glazer RM (1979) Late reconstruction of the patellar tendon. J Bone Joint Surg Am 61:884–886.
8. Shephard GJ, Christodoulou L, Hegap AIA (1999) Neglected rupture of the patellar tendon. Arch Orthop Trauma Surg 119:241–242.
9. Insall J, Salvati EA (1971) Patella position in the normal knee joint. Radiology 101:101–104.
10. Casey MT, Tietjens BR (2001) Neglected ruptures of the patellar tendon, a case series of four patients. Am J Sports Med 29:457–460.
11. Matava MJ (1996) Patellar tendon ruptures. J Am Acad Orthop Surg 4:287–296.
12. Burks RT, Edelson RH (1994) Allograft reconstruction of the patellar ligament: a case report. J Bone Joint Surg Am 76:1077–1079.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241617EnglishN2014September11MULTIPLE TRICHOBEZOAR (GASTRIC and ILEAL) PRESENTING AS INTESTINAL OBSTRUCTION: CASE STUDY OF TWO PATIENTS
English5558Vineet ChoudharyEnglish Ravi Kumar MathurEnglish Sadhna MathurEnglish Brijesh SinghEnglishAim: We are presenting two rare cases of simultaneous occurrence of Gastric and Ileal trichobezoar presenting with intestinal obstruction.
Case Report: First case is 22 year old female with 6 months pregnancy complicated by intestinal obstruction due to multiple trichobezoars, Gastric and Ileal, which were removed successfully by exploratory laparotomy. Pregnancy and simultaneous occurrence of gastric and Ileal trichobezoar presenting as Intestinal obstruction makes this case rare and interesting. The second case is a 10 year old girl presenting with intestinal obstruction due to trichobezoars in both Gastric and Ileum. In this patient in iew of the clinical history of trichophagia, trichotillomania, radiological imaging studies suggestive of intestinal obstruction due to trichobezoar; Exploratory laparotomy done which revealed simultaneous Gastric and Ileal trichobezoar which were successfully removed.
Discussion: Isolated Gastric trichobezoar, those with extension into the duodenum and small intestinal trichobezoars have been described in the literature however the presence of discrete gastric and intestinal trichobezoars are rarely presented. Conclusion: These cases emphasize the importance of careful clinical history, role of radiological studies including USG, Barium contrast study, complete intraoperative evaluation of intestine at the time of dealing with a Gastric trichobezoar in diagnosis of trichobezoar.
EnglishTrichophagia, Trichotillomania, Bezoar, Trichobezoar, Intestinal obstruction, SimultaneuosINTRODUCTION
The Term Bezoar refers to a tightly packed mass of fruit, vegetable matter, hair or other material that formed in gastro intestinal tract. The term Bezoar derives from the Arabic word Badzehr which mean antidote.(1) Trichobezoar is a Greek word Trich which mean hair. (2) Trichobezoar consist of hair with other fiber and usually occur in young women (90%), including those with Psychiatric difficulty. The incidence of small bowel obstruction due to bezoars including food boluses is 0.3-6%. (3) Trichobezoars are often associated with Trichophagia(hair swallowing). Trichotillomania may be unintentionally done and is part of the DSM IV psychiatric classification of impulse control disorders.(4,5) Trichobezoars most commonly occurs in adolescent females.(6) Acute intestinal obstruction during pregnancy has reported incidence of 1 in 1500.(7)
CASE 1:
A 22yr old female with 6mths pregnancy was referred by Dept of Gynaecology with complaints of abdominal pain, vomiting off and on and constipation for last ten days. Abdominal pain was severe in nature, vomiting was bilious. On examination Patient was depressed and dehydrated. Vital signs were normal. Abdominal examination revealed distention, tender upper abdomen with sluggish bowel sounds. No organomegaly except uterus, which was palpable upto umbilicus. Fetal movements were felt by patient. Haematological investigations were normal. USG abdomen revealed 26 weeks live pregnancy, dilated fluid filled bowel loops with minimal interloop fluid. A trial of conservative management was given initially which failed. Patient developed absolute constipation with distention, visible loops of intestine after 72 hrs of admission. Exploratory laparotomy done which revealed distended loops of the small intestine and a palpable mass in terminal Ileum, 20 cms away from ileocaecal junction causing intestinal obstruction. Ileal mass was found to be Trichobezoar measuring 10x4x3 cm which was removed by enterotomy. On further exploration an intragastric mass was palpable, gastrotomy was performed and a huge trichobezoar measuring 20x11x6cm was removed. It was occupied whole stomach. Postoperative period was uneventful. Patient was discharged on the 10th postoperative day. CASE 2: A 10 yr old girl presented to the emergency surgery department with complaints of colicky abdominal pain and bilious vomiting. Patient’s medical history was positive for trichophagia and trichotillomania. On physical examination patient’s hairs were normal. Her abdomen showed epigasric fullness, slight guarding , abdominal distention. Bowel sounds were absent. Blood picture showed hypochromic microcytic anaemia (Hb 9gm%). Her Xray abdomen (erect) showed dilated bowel loops. Ultrasound abdomen showed dilated bowel loops with minimal free fluid and a mass adjacent to the left lobe of liver. No definite diagnosis was made regarding mass on ultrasound. Barium contrast study showed mottled intraluminal space occupying lesion with a honeycomb appearance in fundus of stomach suggestive of trichobezoar. In view of clinical features of intestinal obstruction and a provisional diagnosis of trichobezoar, decision made for exploratory laparotomy. On exploration stomach was found to be dilated, containing a large mass within gastric lumen. Mass was adherent with the thickened gastric wall all around. A gastrotomy was made over body of stomach and 14x7x6 cm trichobezoar was removed. One separate mass was palpable in the terminal ileum. It was measuring 6x4x3 cm.which was also removed by enterotomy. Postoperative period was uneventful. CASE DISCUSSION Clinical manifestations of Trichobezoar are nonspecific abdominal pain, nausea, constipation but Trichobezoars can lead to serious complications like bowel obstruction, haemorrhage or perforation.(8,9) Although 1 in 2000 children suffer from Trichotillomania, only half of the patients give history of Trichophagia and just 1% of these individuals eat enough hair to accumulate Trichobezoar that require surgical intervention.(10) Case 1: Small Bowel Bezoars are managed surgically if intestinal obstruction supervenes. At laparotomy attempts can be made to advance the bezoars into colon manually if these efforts are unsuccessful enterotomy and extraction are necessary. One must guard against not infrequent occurrence(4-17%) of multiple bezoars by examining the stomach and the entire small bowel at laparotomy. Preoperative endoscopy have important in cases of small bowel obstruction as a result of bezoars in order to recognize unsuspected gastric or duodenal bezoar and extract or fragment these if possible ,as they may be readily missed upon attempted palpation specially when there has been previous Gastric surgery.(11) In this Case preoperative endoscopy was not done as the patient was initially seen by Gynaecologist and excessive vomiting was confused and treated as Hyperemesis gravidarum. Abdominal Ultrasound revealed 26 weeks live pregnancy, dilated bowel loops. X Ray Abdomen and Barium contrast study were not done due to pregnancy. Exploratory laparotomy revealed Trichobezoar in the terminal ileum and on further exploration huge gastric trichobezoar was also detected. This emphasizes strongly that when dealing with intestinal Trichobezoar one should never forget to look for unsuspected Trichobezoar in the stomach, duodenum and the rest of Intestine. Bezoars as a cause of acute small intestinal obstruction were studied in another series of 12 patients. In 9 of them Bezoars were localized in ileum,3 in jejunum.Necessity of surgical intervention in these patients is noted. Bezoars were removed with enterotomy in 10 patients,in 2 patients with fragmentation and transposition in caecum. No complications reported in this series.
(12) The approach to intestinal obstruction is the same in pregnancy as in the general population except that decisions are more urgently required because both the fetus and intestine are at risk. Fetal exposure to radiation is a concern. Morbidity and Mortality from intestinal obstruction are related to the diagnostic delays. Mortality is Englishhttp://ijcrr.com/abstract.php?article_id=776http://ijcrr.com/article_html.php?did=7761. A Samad, M. Ahmed,and Z latif, “Bezoars” a review of Two cases ,”Journal of the college of Physicians and Surgeons, Pakistan, vol 7, no 6pp263-265,1997.
2. M.E. Rabie, A.R. Arishi, A Khan, H. Ageely, GA.S. El- Nasr, and M Faghl,” Rapunzel Syndrome: the unsuspected culprit” World Journal of Gastroenterology,vol 14, no7, pp1141-1143, 2008.
3. Safford S. Goldstein, James H. Lewis, Robin Rothstein, Intestinal obstruction due to bezoars, The American Journal of Gastroentrology, vol 79, No4, 1984:313-318.
4. American Psychiatric Association, Diagnostic and statistical manual of mental Disorders,American Psychiatric Association, Washington, DC,USA, 4th Edition, 2000.
5. G.A.Christenson and SJGow,”The characterization and treatment of Trichotillomania”Journal of clinical Psychiatry, vol 57, no8, pp42-49,1996.
6. C. Bouwer and D.J. Stein,” Trichobezoars in Trichotillomania: case report and literature review “Psychosomatic Medicine, vol 60,no5, pp658-660,1998.
7. Andrus CH, Ponsky JL. Bezoars: Classification, Pathophysiology, and treatment. American J. Gastroenterol.1988;83:476-478.
8. Krausz MM, Moriel EZ, Ayalon A, Pode D, Durst AL. Surgical aspects of gastrointestinal persiminon phytobezoar treatment Am J Surg. 1986 Nov;152(5):526-30.
9. Escamilla C, Robles-Campos R, Parrilla-ParcioP,LujanMompean J, Liron-RuizR, Torralba-Martnez JA. Intestinal obstruction and bezoars JA. Intestinal obstruction and bezoars J.Am. Coll Surg 1994;179:285-288.
10. Yao cc, Wong HH. Chen CC. Wang cc,Yang cc. Lincs. Laparoscopic removal of large Gastric Phytobezoar Surg. Laparosc Endosc percutan technique 2000;10:243-45.
11. Michael N. Margolies,Foreign Bodies and Bezoars,Oxford Text Book of Surgery 2000 vol 2:1339-1341.
12. Kurguzoup, Bezoars as a cause of Acute Small Intestinal Obstruction. Khirurgiia (Mosk)2004(12)18-21 ISSN:0023- 1207.
13. Mitchell S Cappel, David, Friedel Abdominal pain during Pregnancy. Gastroenterology Clinics of North America. March 2003:22-23.
14. Narindr K Kaushik, Yash P Sharma, Asha Neg, A Jaswal, Indian Journal of Radoilogy and Imaging 1999/vol 9/issue3/ pno137-139.
15. Robert S Sander, Andresa Todisco, Gastric Bezoars, Text Book of Gastroenterology, 1999,vol1:1551-1552.
16. Vaughan ED, Sawyers JL, Scott HW. The Rapunzel Syndrome. An unusual complication of intestinal bezoar.SURGERY.1968;63:339-343.
17. Malhotra A, Jones L,Drugas G. Simultaneous gastric and small intestinal Trichobezoar. Pediatric Emergency care 12/ 2008, 24(11)774-776.
18. Hoover R, Piotrowski J, St Pierre K, Katz A, Goistein AM. Simultaneous gastric and small intestinal Trichobezoars-a hairy problem.J Pediatric Surgery.2006,41(8)1495-1497.
19. Kovacs V. Bruncak P. Cseri J. Malatnec J Simultaneous bezoars in the stomach, ileum and caecum causing illleus in a 30 year old imbecile.case report Rozhi Chir 2002;81:248- 251.
20. Palanivelu C, Rangrajan M, Senthil Kumar R, Madan Kumar MV. Trichobezoars in the stomach and ileum and their laparoscopy assisted removal.a bizarre case. Singapor Med J 2007Feb;48(2):e37-9.
21. M.R. Phillips, S. Zaheer and G.T. Druges, “Gastric Trichobezoar: ”Case report and literature review” Mayo clinic proceedings, vol 73, no7, pp653-656,1998 GASTRIC and ILEAL TRICHOBEZOAR.