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NATIONAL JOURNAL OF MEDICAL RESEARCH

Volume 7 │ Issue 1 │ Jan – March 2017 │ Page: 1 - 78

print ISSN: 2249 4995│eISSN: 2277 8810

NATIONAL JOURNAL OF MEDICAL RESEARCH Official Publication of National Association of Medical Research

Print ISSN: 2249 4995 Online ISSN: 2277 8810

EDITORIAL BOARD

Chief Editor Dr. Viren Patel MD (Pathology), USA

Associate Editor Dr. Sunil Nayak MD (Community Medicine), Patan, Gujarat

Executive Editor Associate Executive Editor Dr. Harsh Shah, MD (Skin & VD) Mr. Bhaumik M

Members

Dr. Chirag Mehta MS (ENT), Palanpur Dr. Mehul Gosai, MD (Pediatric), Bhavanagar Dr. Deepak Agrawal, MD (Pathology), Agra Dr. N K Gupta, MS, MCh (CTVS), PGDHHM, Lucknow Dr. Deepak Parchivani PhD (Biochem), Bhuj Dr. Praful J. Dudharecha MD (Medicine), Rajkot Dr. Deepak Shukla MD (Medicine), Surat Dr. Rajesh Solanki, MD (TB & Chest), Ahmedabad Dr. H. R. Jadhav, MS (Anatomy), Ahmedabad Dr. Gunvant Kadikar MD (Ob. & Gy.), Bhavnagar Dr. Hitendra Desai MS (Surgery), Ahmedabad Dr. Indira Parmar, MD (Pediatric), Vadodara Dr. Kaushik Kadia MS (Surgery), Patan Dr. Rudresh Jarecha, DMRE, DNB (Radio.), Hydrabad Dr. Uma Gupta, MD (Ob. & Gy.), Lucknow Dr. Suprakash Chaudhury, MD (Psychi.), PHD, Ranchi Dr. Shalini Srivastav MD (PSM), Greater Noida Dr. Vani Sharma, MD (Ob. & Gy.), Himachal Pradesh Dr. K. M. Maheriya MD (Pediatrics), Ahmedabad Dr. Gurudas Khilani, MD (Med & Pharmac), Patan

All the views expressed in the articles are personal views of the authors and not the official views of the National Journal of Medical Research or the Association. The Journal retains the copyrights of all material published in the issue. However, reproduction of the published material in part or total in any form is permissible with due acknowledgement of the source as per ethical norms.

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CORRESPONDENCE Mr. Bhaumik M., Associate Executive Editor, NJMR Email: [email protected], Mob: 8140975850

PUBLISHER MedSci Publications National Journal of Medical Research (Reg. No. 24-022-21-48410) C-43, Umiya Bunglows, www.njmr.in Bhadreshwar, Hansol, Ahmedabad – 382475. [email protected] NATIONAL JOURNAL OF MEDICAL RESEARCH │ Volume 7│Issue 1│ Jan – March 2017

Open Access Journal NATIONAL JOURNAL OF MEDICAL RESEARCH

NATIONAL JOURNAL OF MEDICAL RESEARCH Volume 7│Issue 1│Pages 1 – 78│Jan - March 2017

Table of Content Original Article

Walking a Mile in Patients’ Moccasins: Measuring Empathy Among Indian Medical Students Ashok K Srivastava, Kritika Tiwari, Shaili Vyas, Deep Shikha, Sunil D Kandpal, Jayanti Semwal ...... 1-4

A Study of Fetomaternal Outcome In Eclampsia - A Case Control Study Priyanka Chandrakant Patel, Krina Krunal Kathawadia, Hardevsingh Bachittarsingh Saini ...... 5-8

Comparison of Recovery Profile After the Use of Desflurane, Sevoflurane and Propofol in Day Care Laproscopic Surgeries Reshma R Korat, Vimal Karagathara, Bhavin Patel ...... 9-12

Plain Radiography & MRI Correlation in Soft Tissue Injuries of the Knee Joint – A Case Control Study Rahul H Sharma, Hinal Bhagat, Girish Ghodadara, Nirali Patel ...... 13 - 17

Study of Impact of Glycosylated Hemoglobin on Acute Cardiac States Pratik S Savaj, Trupti R, Praful Chhasatia ...... 18 - 21

Comparative Study of Intravenous Infusion of Clonidine and/or Magnesium Sulphate on Haemodynamic Stress Response to Tracheal Intubation and Pneumoperitoneum Palak P. Sheth, Bhavna Soni, Keyur Kapadia ...... 22 - 25

A Study of Diphtheria Cases among Hospital Admissions in Ahmedabad Hiral H Shah, Bijal H Shah, Deepa A Banker, Meet A Leuva, Meghavi Patel, Darshan S Patel ...... 26 - 28

Assessment of Quality of Life in Chronic Kidney Disease Patients in a Tertiary Care Hospital from South India Sasi Sekhar T.V.D, Appala Naidu R, Vara Lakshmi R, Ramya A, Uma Devi U ...... 29 - 32

The Influence of Central Corneal Thickness on Intraocular Pressure, Measured by Different Tonometers: Noncontact and Goldmann Applanation Tonometers Punit Singh, Raghunandan Kothari, Himadri Patel ...... 33 - 36

A Study of Direct and Concentrated Smear Microscopy by Zeihl Neelsen and Fluorescent Staining for Diagnosis of Suspected Tuberculosis in Tertiary Care Hospital Rachana Patel, Pragnesh Bhuva, Mannu Jain, Shashwati Bhuva, Pinal Mangukiya ...... 37 - 41

Etiological Spectrum of Cirrhosis In Anand District, Gujarat, India Sulabhsinh G Solanki, Nikhil D Patel, Payal J Patel ...... 42 - 46

Morphometric Dimensions of Human Ear Ossicles of Males Shubhpreet Sodhi, Zora Singh, Jai Lal ...... 47 - 51

Vaccum Assisted Plastination Using Melamyne Aarushi Jain, Sandhya Mehra, Kalpana Makhija, Shweta Asthana ...... 52 - 56

Women Under Duress: A Cross-Sectional Study on Violence against Women in District Dehradun Vidisha Vallabh, Ashok K Srivastava, Ruchi Juyal, Jayanti Semwal ...... 57 - 61

Extrapancreatic Infections in Acute Pancreatitis and its Influence on Disease Outcome Majid Abbas Khawaja, Reyaz Ahmed Para, Mushtaq Ahmad Khan, Adnan Firdous Raina, Sumera Saba ... 62 - 65

Volume 6│Issue 4│ Oct – Dec 2016 print ISSN: 2249 4995│eISSN: 2277 8810

Open Access Journal NATIONAL JOURNAL OF MEDICAL RESEARCH

Propofol or Sevoflurane – Which is Better with respect to Nausea, Vomiting and Pain Postoperatively? Purvi Mehta, Shishir Mehta, Deepak Mistry ...... 66 - 68

Differential Diagnosis of HIV Positive Patients with Neurological Manifestations Ankur S Patel, HemantKumar M Shah, Ashok K Gagia, Dipika A Patel, Vinod A Dandge, Komal V Gamit, Nirmal K Patel ...... 69 - 71

A Study on Comparison of Dermoscopic Patterns Associated with Plaque Psoriasis and Pityriasis Rosea in a Tertiary Care Hospital of Pune City Riddhi C Chauhan, Kedar N Dash ...... 72 - 75

A Study on Prevalence of Different types of Dermatosis in Pediatric Age Group in Semiurban Population of Pune City Bhuvnesh G Shah, Sweta P Patel, Rachna V Patel, Jigar J Patel, Keya Shah ...... 76 - 78

Volume 6│Issue 4│ Oct – Dec 2016 print ISSN: 2249 4995│eISSN: 2277 8810

NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

WALKING A MILE IN PATIENTS’ MOCCASINS: MEASURING EMPATHY AMONG INDIAN MEDICAL STUDENTS

Ashok K Srivastava1, Kritika Tiwari2, Shaili Vyas3, Deep Shikha4, Sunil D Kandpal1, Jayanti Semwal5

Author’s Affiliations: 1Professor; 2Resident; 3Associate Professor; 4Assistant Professor; 5Professor and Head, Dept. of Community Medicine, HIMS, Dehradun, Uttarakhand Correspondence: Dr Jayanti Semwal Email: [email protected]

ABSTRACT

Introduction: Empathy is the ability to understand others’ experiences and emotional states from their perspective. It is considered as a part and parcel of healthy doctor-patient relationship. The assessment of empathy among undergraduate medical students is an important step towards yielding a better fruitage from medical education in the form of empathetic doctors. Objectives of the study were to assess the empathy level and its determinants among undergraduate medical students. Methodology: This study was conducted among 351 undergraduate medical students studying at Dehradun by using the “Jefferson Scale of Physician Empathy-Student Version (JSPE-S)” and analyzed by SPSS-22. Results: The arithmetic mean (±SD) of empathy scores was 98.89±12.9. Compared with male students, empathy scores were significantly higher in female students (p<0.05 by Independent sample t test). One way ANOVA followed by Post Hoc test revealed a peculiar finding that empathy is more on initial clinical exposure but decreases as the clinical experience increases. The variation in empathy scores according to the future specialty plans was inconclusive. Conclusion: This study showed a slightly low mean empathy score as compared to similar studies. Gender and clinical experience were found to be associated with empathy. Further studies are recommended to explore other determinants of empathy.

Keywords: Empathy, undergraduate, Jefferson Scale of Physician Empathy-Student Version (JSPE-S), clinical experience, future specialty plans

INTRODUCTION derstanding with an intention to help by preventing and alleviating pain and suffering.3 “I do not ask the wounded person how he feels; I myself become the wounded person.” ̶ Walt Whit- Empathy is considered as an essential component of man healthy doctor-patient relationship. This understanding can be conveyed verbally as well as non-verbally “Empatheia” is a Greek word, meaning affection or through words of comfort, body gestures and posi- passion with a quality of suffering, from which the tive non-verbal feedback. It, being a desirable quality word “empathy” has been derived.1 Empathy con- for clinicians, should be developed during medical notes to the ability of understanding others’ experi- education. Hozat had found in his study that medical ences and emotional states from their perspective or graduates with higher empathy did better in clinical frame of reference, i.e. the ability to place oneself in competence than in academic competence.4 Other another’s position. It has two major components: af- studies have also emphasized that empathy promotes fective or emotional empathy and cognitive empa- physician-patient satisfaction, treatment compliance, thy.2 Unlike sympathy which is just a feeling of com- better clinical outcome as well as prevents malprac- passion or concern for another; empathy is the true tices.5 Therefore, measuring empathy in medical stu- feeling and understanding of what another person is dents is becoming important. Studies in various going through. In the context of doctor-patient rela- countries have shown somewhat discordant results in tionship, empathy has been defined as “a predomi- empathy level in terms of clinical experience, choice nantly cognitive (rather than emotional) attribute that of specialty and gender.6-10 involves an understanding (rather than feeling) of patient’s experiences, concerns and perspectives, Medical curriculum in India differs from other coun- combined with a capacity to communicate this un- tries in that clinical rotation starts from 2nd year and there is no structured course in basic humanities. In

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 1 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 view of the importance of empathy in clinical prac- RESULTS tice for better patient care and paucity of literature The arithmetic mean (±SD) of empathy scores was from India, the present study was conducted with 98.89±12.9, the minimum empathy score being 54 the objectives of assessing the empathy level and its and the maximum being 130. determinants among undergraduate medical students.

Table 1: General profile of study subjects METHODOLOGY Variables No. (%)(N=351) The present study was conducted among the under- Gender st nd graduate medical students (MBBS students of 1 , 2 Male 138 (39.3) and 3rd year) studying at Dehradun, India. Permission Female 213 (60.7) from research and ethical committee of the institute Age (years) was taken before starting the study. The English ver- <22 335 (95.4) sion of Jefferson Scale of Physician Empathy- 22-24 16 (4.6) Student Version (JSPE-S) was used after obtaining MBBS year permission from the authorities of JSPES. It is a 20 1st 87 (24.8) item psychometrically validated instrument consist- 2nd 138 (39.3) rd ing of 20 statements on a 7 point Likert scale 3 126 (35.9) Area of interest (1=strongly disagree to 7=strongly agree), scores Medical 143 (40.7) thus ranging from 20 -140. Higher scores represent Surgical 149 (42.5) greater empathy level. Permission for including a Technical 29 (8.3) maximum of 400 participants was obtained from the Undecided 30 (8.5) authors of JSPES. All the students present in the respective classes were included in the study after obtaining their informed consent. Participants were Table 1 shows that out of total 351 students selected given 15 minutes to complete the questionnaire after for analysis, 213 (60.7%) were females and 138 providing them the requisite information. The partic- (39.3%) were males. Majority of the students were ipants were instructed not to write their names. Spe- <22 years of age. The representation was maximum nd rd st cial unique coding was given to each participant to from 2 year followed by 3 year and 1 year MBBS maintain anonymity and confidentiality. Participants students. 42.5% of the students wanted to make sur- with 80% response rate, i.e., answering at least 16 gical branches as their area of specialty followed items out of 20, were considered for data analysis. closely by medical branches (40.7%), 8.3% were After excluding the incomplete forms, the final sam- planning to opt for technical branches and the rest ple size was 351 (Fig. 1). (8.5%) were undecided.

Enrolled students of MBBS 1st, 2nd 450 Table 2: Relation of age and gender with empa- &3rd year thy level among undergraduate medical students

Present (355): Absent: Determinants Mean empathy score (±SD) p value Attendance included in study 95 Gender Male 96.77 (±11.8) 0.01* ≥80% <80% Exclude Female 100.26 (±13.5) Response rate (351) (4) d Age (years) <22 99.16 (±13.0) 0.07** Included for Exclude 22-24 93.26 (±9.5) analysis d * Equal variances assumed (Levene’s test p value: 0.09), independent samples t-test ** Equal variances assumed (Levene’s test p value: 0.15), inde- Figure 1: Inclusion and exclusion criteria pendent samples t-test

Tables 2 and 3 show the association between various Data were analyzed by using SPSS software (version- factors/determinants and empathy scores among 22). 10 items out of 20 were negatively worded and undergraduate medical students. The determinants of were reverse coded. Empathy scores were expressed empathy studied under the Jefferson Scale of Physi- as mean (±SD). Independent samples t-test and cian Empathy-Student Version (JSPE-S) were gen- ANOVA with post hoc test were used to find out der, age, area of interest for future specialty and the the determinants of empathy. Statistical significance year of study in MBBS curriculum. Homogeneity of was checked at 5% level of significance. variance was tested by Levene’s test. The mean empathy score was found to be more among females

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 2 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 than males and this difference was statistically signif- study done in Nagpur (99.25±13.81)11 but it was icant (p=0.005) as tested by independent samples t- lower as compared to another Indian study conduct- test. The mean empathy score was found to be more ed at Vijaywada (103.29±13.3).2 This difference among younger students but the difference in age might have arisen as the latter study included interns was not found to be statistically significant. Those and post graduate students as well. The range of em- students who wanted to do specialization in medical pathy score in the afore mentioned studies were 63- branches showed the highest mean empathy scores 125 and 47-136 respectively. The mean empathy followed by those who were undecided, which was score in Indian medical students was found to be less closely followed by surgical branches and the least as compared to some studies done in foreign coun- score was for technical branches, but these differ- tries like Australia (109.07±14.94),6 South Africa ences in mean empathy scores were not found to be (107±10.9)12 and Brazil (119.7±9.9).13 This could statistically significant. Area of interest for future point towards cross cultural differences in empathy specialty was also re-categorized as people-oriented level or difference in medical curriculum. Teaching and technology-oriented, excluding those who were humanities is not a part of medical curriculum in In- undecided. dia. The mean empathy score was found to be quite low (61.11±2.31) in a study performed in Iran.9 Low empathy levels were also found in some studies done Table 3: Relation of area of interest and MBBS among dental students.14, 15 year with empath level among undergraduate medical students Female students were found to be more empathetic than male students, the mean empathy scores being Determinants Mean empathy F statis- p 100.26 (±13.5) and 96.77 (±11.8) respectively. This score (±SD) tic value finding was supported by many earlier studies.2, 5, 8, 11, Area of interest 13, 16-24 Some authors have hypothesized that extrinsic Medical 99.79 (±12.7) 0.86 0.46* as well as intrinsic factors might be the reason for Surgical 98.70 (±13.4) Technical 95.63 (±12.5) this. Extrinsic factors include the role of females as Undecided 98.89 (±12.9) care taker while intrinsic factors include the biologi- MBBS year cal and genetic make-up.8, 12, 13, 21, 25 Correlation be- 1st 99.24 (±11.8) 3.36 0.04** tween activation of right hemisphere and empathy 2nd 100.72 (±12.9) was found exclusively in females in a study.26 How- 3rd 96.64 (±13.6) ever, there are some studies where the relation be- *Equal variances assumed (Levene’s test p value: 0.89), One way tween empathy and gender could not be appreciat- ANOVA; **Equal variances assumed (Levene’s test p value: ed.27-30 Hence, cultural and environmental influences 0.89), One way ANOVA Posthoc: 1st yr vs 2nd yr mean diff 1.5 p value 0.70; 1st yr vs 3rd yr might also be one of the factors determining empa- mean diff 2.6 p value 0.35; 2nd yr vs 3yr mean diff 4.1 p value thy. 0.04 This study revealed that empathy is more on initial clinical exposure but decreases as the clinical experi- Although the students with people-oriented branch ence increases. Some studies have shown that empa- preference had higher mean empathy score but the thy decreases with increasing clinical exposure difference was not found to be statistically signifi- among MBBS students.5, 16-18 Mostafa et al interpret- cant. It was found by applying one way ANOVA ed that empathy gradually increased after clinical that the difference between the mean empathy scores training in medical college.7 In a Brazilian study, em- of students of different MBBS years was significant pathy was found to be high throughout the medical but Scheffe post hoc test revealed that the difference course.13 No association was found between empa- was significant only between 2nd and 3rd year. It can thy and years of medical education in a study by be interpreted with this finding that empathy is more Murthy et al.2 These variations might point towards on initial clinical exposure but decreases as the clini- the differences in the medical curriculum in different cal experience increases. countries. This study did not find any conclusive association between future choice of specialty and em- DISCUSSION pathy. Similar results were found in some other studies too7,8 but the studies done in Brazil, Pune and The present study on measuring empathy among 351 Boston university show contradictory findings where undergraduate medical students (138 males, 213 fe- students preferring people-oriented branches were males), conducted by using the Jefferson Scale of more empathetic than those opting for technical Physician Empathy-Student Version (JSPE-S), branches.5, 13, 16 showed that the mean empathy score was 98.89±12.9 with minimum and maximum scores be- In conclusion, this study showed a slightly low mean ing 54 and 130 respectively. The mean empathy empathy score as compared to similar studies. Fe- score was comparable to that calculated in an Indian males were more empathetic than males. Empathy

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 3 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 level was shown to fall with increasing clinical expe- 14. Prabhu S, Kumar VS, Prasanth SS, Kishore S. Standing in rience. The association between empathy level and patients' shoes—survey on empathy among dental students in India. Journal of Education and Ethics in Dentistry. choice of future specialty could not be determined 2014;4(2):69. conclusively. 15. Babar MG, Omar H, Lim LP, Khan SA, Mitha S, Ahmad It was a small-scale study; the results may not be rep- SFB, et al. An assessment of dental students’ empathy levels resentative of empathy levels among all Indian medi- in Malaysia. International Journal of Medical Education. 2013;4:223-9. cal students. Multi-centric studies among Indian 16. Shashikumar R, Chaudhary R, Ryali VS, Bhat PS, Srivastava medical students are recommended for assessing the K, Prakash J, et al. Cross sectional assessment of empathy empathy level and its determinants. Longitudinal among undergraduates from a medical college. Medical jour- studies would be more helpful to identify the trend nal, Armed Forces India. 2014;70(2):179-85. of change in empathy level during the various phases 17. Khademalhosseini M, Khademalhosseini Z, Mahmoodian F. of medical education. Comparison of empathy score among medical students in both basic and clinical levels. Journal of Advances in Medical Education & Professionalism. 2014;2(2):88-91. REFERENCE 18. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, 1. Barrett-Lennard GT. The empathy cycle: refinement of a Isenberg GA, et al. The Devil is in the Third Year: A Longi- nuclear concept. J Couns Psychol. 1981;28(2):91-100. tudinal Study of Erosion of Empathy in Medical School. 2009;84(9):1182-91. 2. Murthy PS, Madhavi K, Hemantha Kumar Reddy G, Chaudhury S. Empathy in indian medical students: Influence 19. Costa P, Magalhães E, Costa MJ. A latent growth model sug- of gender and level of medical education on empathy scores. gests that empathy of medical students does not decline over Universal Research Journal of Medical Sciences. time. Adv Health Sci Educ Theory Pract. 2013;18(3):509-22. 2014;1(1):17-21. 20. Kataoka HU, Koide N, K. O, Hojat M, Gonnella JS. Meas- 3. Hojat M. Empathy in patient care: Antecedents, develop- urement of empathy among Japanese medical students: psy- ment, measurement, and outcomes. New York: Springer. chometrics and score differences by gender and level of 2007. medical education. Acad Med. 2009;84(9):1192-7. 4. Hozat M, Gonnella JS, Mangionet S, et al. Empathy in medi- 21. Tavakol S, Dennick R, Tavakol M. Empathy in UK medical cal students as related to academic performance, clinical, students: differences by gender, medical year and specialty competence and gender. Med Educ. 2002;36:522-7. interest. Education for primary care : an official publication of the Association of Course Organisers, National Associa- 5. Chen D, Lew R, Hershman W, Orlander J. A Cross-sectional tion of GP Tutors, World Organisation of Family Doctors. Measurement of Medical Student Empathy. J Gen Intern 2011;22(5):297-303. Med. 2007;22(10):1434-8. 22. Berg K, Majdan JF, Berg D, Veloski J, Hojat M. Medical stu- 6. Williams B, Brown T, McKenna L, M.J. B, Palermo C, dents' self-reported empathy and simulated patients' assess- Nestel D, et al. Empathy levels among health professional ments of student empathy: an analysis by gender and ethnici- students: a cross sectional study at two universities in Aus- ty. Acad Med. 2011;86(8):984-8. tralia. Advances in medical education and practice. 2014;5:107-13. 23. Shariat SV, Habibi M. Empathy in Iranian medical students: measurement model of the Jefferson scale of empathy. Med 7. Mostafa A, Hoque R, M. M, Rana MM, Mostafa F. Empathy Teach. 2013;35(1):e913-8. in Undergraduate Medical Students of Bangladesh: Psycho- metric Analysis and Differences by Gender, Academic Year, 24. Chen DC, Kirshenbaum DS, Yan J, Kirshenbaum E, Asel- and Specialty Preferences. ISRN psychiatry. 2014. tine RH. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34(4):305-11. 8. Magalhães E, Salgueira AP, Costa P, Costa MJ. Empathy in senior year and first year medical students: a cross-sectional 25. Wen D, Ma X, Li H, Liu Z, Xian B, Liu Y. Empathy in Chi- study. BMC Medical Education. 2011;11:52. nese medical students: psychometric characteristics and differences by gender and year of medical education. BMC Med 9. Khademalhosseini M, Khademalhosseini Z, Mahmoodian F. Educ. 2013;13:130. Comparison of empathy score among medical students in both basic and clinical levels. J Adv Med Educ Prof. 26. Rueckert L, Naybar N. Gender differences in empathy: the 2014;2(2):88-91. role of the right hemisphere. Brain Cogn. 2008;67(2):162-7. 10. Chen D, Lew R, Hershman W, Orlander J. A cross-sectional 27. Roh MS, Hahm BJ, Lee DH, Suh DH. Evaluation of empa- measurement of medical student empathy. Journal of Gen- thy among Korean medical students: a cross-sectional study eral Internal Medicine. 2007;22(10):1434-8. using the Korean Version of the Jefferson Scale of Physician Empathy. Teach Learn Med. 2010;22(3):167-71. 11. Kulkarni VM, Pathak S. Assessment of empathy among undergraduate medical students Journal of Education Technol- 28. Hong M, Lee WH, Park JH, Yoon TY, Moo nDS, Lee SM, ogy in Health Sciences. 2016;3(1):23-7. et al. Changes of empathy in medical college and medical school students: 1-year follow up study. BMC Med Educ. 12. Vallabh K. Psychometrics of the student version of the Jef- 2012;12:122. ferson Scale of Physician Empathy (JSPE-S) in final-year medical students in Johannesburg in 2008. South African 29. Lim BT, Moriarty H, Huthwaite M, Gray L, Pullon S, Gal- Journal of Bioethics and Law. 2011;4(2):63-8. lagher P. How well do medical students rate and communicate clinical empathy? . Med Teach. 2013;35(2):e946-51. 13. Santos MA, Grosseman S, Morelli TC, Giuliano ICB, Erd- mann TR. Empathy differences by gender and specialty pref- 30. Rahimi-Madiseh M, Tavakol M, Dennick R, Nasiri J. Empa- erence in medical students: a study in Brazil. Int J Med Educ. thy in Iranian medical students: A preliminary psychometric 2016;7:149-53. analysis and differences by gender and year of medical school. Med Teach. 2010;32(11):e471-8.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 4 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

A STUDY OF FETOMATERNAL OUTCOME IN ECLAMPSIA - A CASE CONTROL STUDY

Priyanka Chandrakant Patel1, Krina Krunal Kathawadia1, Hardevsingh Bachittarsingh Saini2

Author’s Affiliations: 1Assistant Professor, Dept. of Obstetrics & Gynecology, SMIMER, Surat, Gujarat; 2Professor Obstetrics & Gynecology SBKS MI & RC Sumandeep Vidyapeeth, Wagodia, Vadodara. Correspondence: Dr. Priyanka C. Patel Email: [email protected]

ABSTRACT

Introduction: India the perinatal and maternal outcome in eclampsia cases is still poor due to inadequate antenatal care in rural areas, financial restraints and non-availability of transportation facilities, and social taboos causing delay in management resulting in poor maternal and neonatal outcome. Methodology: The current Case control study was done among cases of Eclampsia admitted to the labour room of SSSH, Baroda in Gujarat. Total 70 patients of Eclampsia presented in this institution during the study period. Accordingly 140 women not having Eclampsia were included as control. Fetomaternal outcome of all Cases and Control were compared and analysed. Results: Out of 70 cases 56 (80%) were of Antepartum eclampsia and 46 (65.7%) were full term delivery. Out of total 46 live births among cases and 106 live births among controls, 40 (86.9%) Cases and 87(82.1%) Controls were fullterm (>37 weeks). Out of total 24 Still birth in cases and 34 still birth in controls, 18(75.0) Cases and 24(70.6%) Controls were preterm (<37 weeks). Among the cases, 34(48.6%) babies had birth weight between 1000-2000 grams against 53(37.8%) controls who belong to the same category. The incidence of low birth weight in eclampsia is attributed to prematurity & IUGR. The maternal mortality was high in the Case group i.e. 8.57%. There was no maternal mortality in the Control group. Causes of mortality include Cerebrovascular haemorrage, DIC with renal failure, HELLP Syndrome with Cerebral malaria, Hepatic encephalopathy and Pulmonary edema sec. to aspiration. Conclusion: The maternal and infant mortality was high in the eclamptic patients. Causes of mortality include Cerebro-vascular haemorrage, DIC with renal failure, HELLP Syndrome with Cerebral malaria, Hepatic encephalopathy and Pulmonary edema sec. to aspiration.

Keywords: Hypertensive disorders of pregnancy, Eclampsia, HELLP Syndrome, Infant Mortality

INTRODUCTION affected women can become clearer and the outcomes more predictable. Hypertensive disorders of pregnancy continue to be one of the leading cause of maternal and fetal mor- In developed countries, good antenatal care, aware- bidity and mortality. Eclampsia is a disorder unique ness regarding pregnancy complications and most to pregnancy and early puerperium, recognised as a important, early recognition of PIH with timely clinical entity since the time of Hippocrates. management results in better maternal and perinatal outcome. However, in India the perinatal and mater- The term Eclampsia is derived from a Greek word nal outcome is still poor due to inadequate antenatal meaning like a “flash of light”. It may occur abruptly, care in rural areas, financial restraints and non- without any warning manifestations. Preeclampsia availability of transportation facilities, and social ta- when complicated with convulsion and or coma is boos causing delay in management resulting in poor called eclampsia. maternal and neonatal outcome. In India, reported incidence of eclampsia varies from Majority of mothers to whom our hospital belong, 0.179 to 3.7 %.1,2,3 And maternal mortality varies are from rural or tribal areas, who are ignorant of the from 2.2 to 23 % of all eclamptic women.3,4,5 The es- outcomes related to PIH and lag behind in timated incidence of eclampsia in Western countries knowledge related to pregnancy, physiology and is 1 in 2000–3448 deliveries.6 complications and hence are the sufferers. This stim- There needs to be an initial placental trigger but it is ulated to carry out this study, the maternal and neo- maternal response that probably modifies the disease natal outcome in mothers with eclampsia and com- presentation and progression, management of the pare it with the normal patients.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 5 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 METHODOLOGY was shifted to the general ward and was fit for nursing. The current study was a Case control study, done among cases of Eclampsia admitted to the labour room of SSSH, Baroda in Gujarat. RESULTS Case: Patients of Eclampsia who fulfilled all of the Total 70 patients of Eclampsia presented in this insti- following criteria were included as cases in the study: tution during the study period. Accordingly 140 con- a) Patient convulsing first time during present preg- trols were included in the study. nancy; b)Patients BP ≥ 140/90 mmHg; c)Presence of proteinuria; d)Gestational age between 28-42 weeks; and e)Agree to give informed written consent. Table 1: Age group wise distribution of Cases Control: Patient immediately preceding each case and Controls and patient immediately succeeding each case not Age (yrs) Cases (%) (n=70) Controls (%) (n=140) having Eclampsia having similar Parity and Gesta- < 20 16 (22.9) 23 (16.4) tional age were included as controls. Permission to 21 – 25 33 (47.2) 80 (57.1) conduct the study was obtained from Ethical Com- 25 – 29 15 (21.4) 33 (23.5) mittee of Institute. 30 – 34 6 (8.5) 3 (2.1) >35 0 1 (0.7) After quick diagnosis by talking the vital signs and p-Value = 0.135 blood pressure, all the patients of eclampsia were first admitted to the labour room which had the following facilities- mouth gag, electric suction, oxygen Table 2: Parity wise distribution of Cases and cylinder, cot, veinflon for taking I.V. line, tray con- Controls taining drugs like magnesium sulfate, anti- hypertensives. One attendant was allowed to remain Parity Cases (%) n = 70 Controls (%) n = 140 with the patient. An I.V. line was secured and blood 1 46 (65.7) 88 (62.9) samples were taken for blood grouping and cross 2 12 (17.2) 26 (18.1) matching, and other investigation. 3 9 (12.9) 19 (13.6) >4 3 (4.2) 7 (5.4) Simultaneously, a detailed history in relation to con- p-Value = 0.980 vulsion was obtained from the patient’s relatives. This included the periods of amenorrhoea, headache, complaints of visual disturbance, excessive weight Table 3: Types of eclampsia in Cases (n=70) gain, nausea, vomiting and epigastric pain, abnormal Types No. (%) swelling of legs, puffiness of face and fever. Total Antepartum 56 (80.0) number of convulsions, place of first fit (whether oc- Intrapartum 2 (2.9) curred at home or hospital) and whether it was fol- Postpartum 12 (17.1) lowed by unconsciousness or not was enquired. The time interval between the onset of fits and arrival to the hospital was noted. Enquiry was made into the Table 4: Fetal Outcome in cases and controls antenatal care taken, the number of visits according Variables Cases(%) Controls(%) to the trimester and whether pre-eclampsia was de- Live Births n =46 n = 106 tected or not. Detailed obstetric history, personal his- Full Term 40 (86.9) 87 (82.1) tory, family history was taken as mentioned in Pre Term 6 (18.1) 19 (17.9) proforma. Still Births n =24 n = 34 Full Term 6 (25.0) 10 (30.4) The patient then underwent the thorough clinical ex- Pre Term 18 (75.0) 24 (70.6) amination to rule out convulsion due to other medi- Neonatal Birth Weight (Gms) n = 70 n = 140 cal disorders and in the event of doubt, physician 1001-1500 17 (24.3) 24 (17.1) opinion was also taken. The treatment is started as 1501-2000 17 (24.3) 29 (20.7) early as possible. Prophylactic antibiotics were given 2001-2500 26 (37.1) 46 (32.8) in all cases. Once the convulsions were under con- 2501-3000 9 (12.9) 35 (25.0) trol, steps were taken to initiate delivery. In majority >3000 1 (1.4) 6 (4.2) of cases with antepartum eclampsia, labour soon Mortality n = 70 n = 140 Neonatal 8 (11.4) 7 (5.0) starts after convulsions. The patient was observed Perinatal 28 (40.0) 39 (27.8) and treated for 24 hours after delivery or 24 hours after last convulsion in the eclampsia room. Subse- quently, transferred to the general ward. The baby The above table shows the distribution of patients in was kept in the nursery for 24 hours or more and both case & control group according to their age. then handed over to mother for feeding after she Maximum number of cases and controls were from

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 6 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 the age group of 21 years to 25 years. Both cases & Table 5: Neonatal morbidity among cases and control group are comparable with respect to age. controls The difference is statistically not significant. (p- Neonatal Morbidity Cases(%) Controls(%) Value-0.135) n = 70 n = 140 The above table shows parity wise distribution of Jaundice 8 (11.4) 5 (3.5) both case & control group. As shown in the above Septicemia 7 (10.0) 3 (2.1) table, majority of cases (65.7%) and controls (62.9%) Birth Asphyxia 10 (14.3) 7 (5.0) were primigravidae. Both cases and controls are Meconium Aspiration 2 (2.9) 1 (0.7) Intraventricular Hemorrhage 1 (1.4) 1 (0.7) comparable with respect to parity. The difference in Hypoglycemia 1 (1.4) 2 (1.4) parity between the cases & controls is statistically not Meningitis 1 (1.4) 0 significant. (p-Value 0.980) Prematurity 2 (2.9) 1 (0.7) Table 3 shows the distribution of types of Eclampsia. Total 32 (45.7) 20 (14.2) Table shows that out of 70 cases 56 (80%) were of p-Value = 0.01 Antepartum eclampsia, 02 (2.9%) were of Intrapar- tum eclampsia & 12(17.1%) were Postpartum eclampsia. It was very difficult to differentiate Antepar- Table 6: Maternal morbidity among cases and tum eclampsia and Intrapartum eclampsia, as usually controls on admission most of them had established labour. Morbidity Cases (%) Controls (%) However, with thorough history and clinical findings, (n = 70) (n=140) they were classified as mentioned in table. Severe Anemia 8 (11.4) 5 (3.5) DIC 2 (2.8) 0 Out of total 70 cases, 46 (65.7%) were full term de- Jaundice 5 (7.14) 2 (1.4) livery. As shown in table 4, out of total 46 live births PPH 1 (1.4) 0 among cases and 106 live births among controls, 40 Puerperal Infection (86.9%) Cases and 87(82.1%) Controls were fullterm UTI 3 (4.2) 2 (1.4) (>37 weeks). Out of total 24 Still birth in cases and WI 2 (2.8) 3 (2.1) 34 still birth in controls, 18(75.0) Cases and FM 4 (5.7) 3 (2.1) 24(70.6%) Controls were preterm (<37 weeks). ARF 1 (1.4) 0 Among the cases, 34(48.6%) babies had birth weight CCF 0 1 (0.7) between 1000-2000 grams against 53(37.8%) controls Breast Engorgement 4 (5.7) 7 (5.0) who belong to the same category. Babies weighing > Postpartum Psychosis 1 (1.4) 0 2000 grams constituted 36 (51.4%) in Case group & Total 23 (32.8) 23 (16.4) P value =0.001 87(62%) in Control group. The incidence of low birth weight in eclampsia is attributed to prematurity & IUGR. Table 7: Maternal mortality in cases (n = 70) The perinatal mortality in the Case group was Mortality Cases (%) 28(40%) against the Control group of 39(27.8%). Cerebrovascular haemorrage 1 (1.4) The neonatal loss in Case group was 08(11.4%) DIC with renal failure 1 (1.4) against 07(5.0%) in the Control group. The differ- HELLP Syndrome with Cerebral malaria 1 (1.4) ence between the two groups is statistically signifi- Hepatic encephalopathy 2 (2.8) cant. (P value 0.047) Pulmonary edema sec. to aspiration 1 (1.4) Total 6 (8.6) Table 5 shows that, 7 (10.0%) out of 70 babies in the

Case group had septicemia in comparison to 03 (2.1%) out of in Control group. All the septicemic Maternal morbidity in the form of Severe anemia babies were given antibiotics for 14 days according (11.4%) and puerperal infection (12.8%) constituted to the protocol of NICU. Out of which 05 babies in a majority. 8 patients (11.4%) came with severe ane- Case group were lost. mia requiring blood transfusions, out of which 2 patients developed DIC and died. 5 patients (7.1%) had 08 (11.4%) babies in the Case group and 05 (3.5%) Jaundice and 3 patients died because of hepatic en- babies in the Controls had hyperbilirubemia (Jaun- cephalopathy. One patient developed ARF and DIC dice). These babies were investigated and given pho- and expired within one day. Puerperial infection like totherapy accordingly. genital tract infection, UTI, Febrile morbidity and 10 (14.3%) babies in the Case group had birth as- wound infection constituted (12.8%). These patients phyxia and 7 (5.0%) in the Control group had birth were given appropriate antibiotics till the infection asphyxia. These babies were kept under observation was treated. As perinatal deaths were high, significant in the NICU. The difference between the two group mothers (5.7%) who delivered still births developed is statistically significant.(P value = 0.01) breast engorgement. Medical treatment was given to

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 7 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 these patients in the form of tight breast bandage Causes of mortality include Cerebro-vascular haem- and Injection Mixogen 1 amp stat, analgesics and an- orrage, DIC with renal failure, HELLP Syndrome tipiretics. Maternal morbidity in the Control group with Cerebral malaria, Hepatic encephalopathy and was significantly lower. The difference between the Pulmonary edema sec. to aspiration. Perinatal mor- two groups is statistically significant.(P value = 0.00) tality is published around 432.6/1000 with prematurity where IUGR remains the main culprit and is The above table shows the distribution of maternal considered to be responsible for most of the compli- mortality and the causes of death in both the case. cations. 27,28 Perinatal mortality was 40% in current The maternal mortality was high in the Case group study which is similar to Raji C et el.10 i.e. 8.57%. There was no maternal mortality in the Control group. REFERENCE DISCUSSION 1. Vanawalla NY, Ghamande S, Ingle KM. A five year Analysis of Eclampsia. J Obstet Gynecol India. 1989;39:513–5. Eclampsia was known to people since ancient times. 2. Suman G, Somegowda S. Maternal and perinatal outcome in The literature of ancient Egyptians and Chinese Eclampsia in a District Hospital. J Obstet Gynecol India. mention the danger of convulsions in pregnancy. 2007;57:324. Hippocrates stated that headache, drowsiness and 3. Sing K, Medhi R, Bhattacharjee AK, et al. Book of Abstract, convulsions are of serious significance in pregnant 53rd AICOG, Guwahati 2010. p. 17. women. 4. Chandriole N, Singh S, Dhillon BS. Eclampsia, care hood Maximum number of cases and controls were from and management practices at tertiary hospital in India the age group of 21 years to 25 years. This is in con- (ICMR), New Delhi. Book of Abstract AICOG, Guwahati; sistent with Sighal et al . 78.8% cases belonged to 20 2010. p. 33. - 25 years of age.7 as Same findings were also report- 5. Pal A, Bhattacharjee R, Bannerjee Ch, et al. Maternal mortali- ed by Sunita et al8 and Sarika et al9 discussed by other ty over a decade in a referral Medical College Hospital, West Bengal. Indian J Perinatol Reprod Biol. 2001;04:10–3. studies. 6. Douglas KA, Redman CWG. Eclampsia in the United King- As shown in the table 3, majority of cases (65.7%) dom. BJOG. 1992;99:355–6. and controls (62.9%) were primigravidae. Eclampsia 7. Rani SS, Anshu D, Nanda S. Maternal and Perinatal Out- is a disease of young primigravidae. As the parity income in Severe Pre - eclampsia and Eclampsia. J SAFOG ( creases the incidences of eclampsia decreases. In pre- South Asian Federation of Obstetrics and Gynecology), Sep- sent series 65.7% were primigravidae correlating with tember - December 2009;1(3):25 - 8 . the fact. Both cases and controls are comparable 8. Sunita TH, Desai RM . Eclampsia in a Teaching Hospital: with respect to parity. The difference in parity be- Incidence, clinical profile and response to Magnesium Sul- tween the cases & controls is statistically not signifi- phate by Zuspan’s regimen. IOSR Journal of Dental and cant. (p-Value 0.980) Medical Sciences (IOSRJDMS). 2013;4(2): 1 - 5. 9. Sarika C , Bharat R , Nerges M. Availability of Treatment for Majority of the cases (65.7%) were primigravidae, Eclampsia in Public Health Institutions in Maharashtra, India which is comparable to other studies.10,11,12 It indi- J Health Popul Nutr. 2013 March;31(1):86 - 95. cates that primigravidae are the main victim for ec- 10. Raji C, Poovathi M, Nithya D. Prospective study of feto- lampsia. Out of total 70 cases, 46 (65.7%) were full maternal outcome in eclampsia in a tertiary care hospital . Int term delivery. This result is in consistent with Raji C J Reprod Contracept Obstet Gynecol 2016;5: 43 29 - 34. 10 8 13 et al , Sunitha et al and Prabhakar et al. 11. Sarma HK, Talukdar B. Eclampsia: a clinical prospective This disorder is one of the leading causes of maternal study i n a referral hospital. Journal of Obstetrics and Gynae- cology Barpeta. 2014;1(1):57 - 61. mortality worldwide it varies from 1.8 - 27.5%. Ma- ternal mortality in our study was 8.6%. This result is 12. Pradeep MR , Shivanna L . Retrospective Study of Eclampsia 10 in a Teaching Hospital. Int J Recent Trends in Science and similar to Raji C et el in which 6.16% mothers died. Technology. 2013; 8(3):171 - 3. In our study 32.8% mothers were suffer from any of the complications. This is in consistent with Raji C et 13. Prabhakar G, Shinde MA, Jadhav CA. Clinical study of eclampsia patients at DR. V M. Government Medical Collage al. in which one third of patients suffer from compli- Solapur, India. IOSR Journal of Dental and Medical Scienc- cations.10 es. 2015;13(7):10 - 6 .

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 8 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

COMPARISON OF RECOVERY PROFILE AFTER THE USE OF DESFLURANE, SEVOFLURANE AND PROPOFOL IN DAY CARE LAPROSCOPIC SURGERIES

Reshma R Korat1, Vimal Karagathara2, Bhavin Patel3

Author’s Affiliations: 1Tutor, Dept. of Anaesthesia, SMIMER, Surat; 2Private practitioner, Anesthesia, BAPS Hospital, Surat; 3Private practitioner, Anaesthesia, Sterling hospital, Ahmedabad Correspondence: Dr Reshma R Korat Email: [email protected]

ABSTRACT

Objective: The study was conducted to compare the use of less soluble volatile anesthetics (Desflurane and Sevoflurane) as alternatives to Propofol for maintenance of general anesthesia in providing a more rapid emergence from anesthesia. Methodology: For the study 90 cases of ASA 1 and 2 physical status scheduled for laparoscopic surgery were randomly divided to one of three anesthetic groups by the chit method. Total 90 adult patients of ASA I and II between the age group of 18 – 70years of either sex posted for elective daycare laparoscopic were selected for the study. They were randomly divided into three groups Group 1 received Desflurane, Group 2 received Propofol and Group 3 received Sevoflurane. Results: There were total 30 patients in each group. In group of Desflurane and group of Sevoflurane least fall in blood pressure than group of Propofol. So Propofol causes maximum fall in blood pressure as compare to Desflurane and Sevoflurane. Following to vaporizer turn off the immediate recovery is seen in Desflurane group of patient. While delayed eye opening seen in Propofol group of patient and intermediate eye opening seen in Sevoflurane group. Conclusion: Desflurane provides faster recovery from anesthesia in patients undergoing laparoscopic surgeries than Sevoflurane and Propofol. However all three groups were hemodynamically stable during the intraoperative period.

Keywords: Propofol, Desflurane, Sevoflurane, fast track eligibility score

INTRODUCTION cations. Despite that there are many comparative studies with Propofol and inhalation agents, for the The number and variety of procedures done laparo- effects of PONV and on recovery criteria there scopically has rapidly increased in the past 15 years. aren't much with Desflurane, Sevoflurane and Availability of a variety of surgical techniques which Propofol. In this study, the effects of Desflurane, are minimally invasive has resulted in increased em- Sevoflurane and Propofol, as frequently used agents phasis on expansion of day care surgeries. For day in day-care surgery, on recovery in laparoscopic sur- care anesthesia applications the use of anesthetics geries has been comparatively investigated. that provide fast and smooth induction allow quick changes in depth while maintaining anesthesia, early recovery, less post operative nausea and vomiting, AIMS & OBJECTIVE less pain and good fast track eligibility score are recommended. Given the low blood gas partition coef- The objective of the study was to compare the use of ficient of Sevoflurane (0.69) and Desflurane (0.42) a less soluble volatile anesthetics (Desflurane and more rapid emergence from anesthesia is expected Sevoflurane) as alternatives to Propofol for mainte- compared with traditional inhalational agents like nance of general anesthesia in providing a more rapid Isoflurane.1 emergence from anesthesia with respect to intra operative hemodynamics, time for spontaneous respira- Considering these characteristics, for fast induction tion, time for eye opening, time of seat and walk, in and early recovery based on low blood/gas partition patients undergoing day-care laparoscopic surgeries. coefficients, new inhalation agents are being used as alternatives to Propofol in day-case anesthetic appli-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 9 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 METHODOLOGY elective daycare laparoscopic were selected for the study. They were randomly divided into three groups For the study, after permission of institutional ethical Group 1 received Desflurane, Group 2 received committee, 90 cases of ASA 1 and 2 physical status Propofol and Group 3 received Sevoflurane. scheduled for laparoscopic surgery in Sterling Hospi- tal, Ahmedabad, Gujarat were randomly divided to There were total 30 patients in each group. Table 1 one of three anesthetic groups by the chit method. shows gender wise distribution of patients. Patients in the age group 20 to 70 years; ASA 1 and ASA 2 patients; and patients willing to give informed Table 1: Comparison of Gender distribution of written consent were included in the study. patients studied gender Patients with clinically significant cardiovascular, res- Sex Desflurane Propofol Sevoflurane piratory, hepatic, renal, neurologic, psychiatric or Male 16 14 16 metabolic disease; pregnant women; cases with mor- Female 14 16 14 bid obesity; those with a history of alcohol and drug Total 30 30 30 abuse; and patients not willing to give consent were excluded from the study. Table 2: Comparison of Hemodynamic profile between three groups of patients studied Total 90 envelopes with equal representation of all 3 groups were made. General anesthesia was induced Profile Desflurane Propofol Sevoflurane with IV midazolam 0.03mg/kg, Propofol 1.5- Pulse 2.5mg/kg, Fentanyl 2μg/kg and Ondansetron 4mg. 0 min 75.3+/-3.6 75.03+/-3.5 73.8+/-3.1 15 min 83.0+/-6.8 82.33+/-7.7 84.2+/-6.02 Laryngoscopy and tracheal intubation was facilitated 30 min 75.7+/-5.03 75.13+/-4.6 76.86+/-4.09 with Rocuronium 0.09mg/kg. 45 min 66.8+/-5.04 67.13+/-3.66 69.6+/-4.2 Patients were explained regarding study in detail and 60 min 66.3+/-4.7 65.53+/-5.08 69.2+/-3.6 after obtaining written consent in the presence of Systolic blood pressure one witness, they had given bowl of chit to select the 0 min 135.9+/-12.08 141.0+/-15.6 137.4+/-12.37 15 min 117.9+/-6.69 107.4+/-8.6 119+/-14.3 group randomly. This chit was collected by observer 30 min 121.5+/-8.9 119.2+/-8.6 117+/-10.34 and selected drug was given after proper care to ad- 45 min 126.9+/-9.1 127+/-8.9 124.6+/-9.1 ministrator in closed enveloped without label. 60 min 131.4+/-7.5 132.8+/-9.7 130.5+/-9.7 Anesthesia was maintained initially with either Des- Diastolic blood pressure 0 min 76.2+/-7.9 76.8+/-8.9 76.0+/-8.3 flurane 3%(group 1), Sevoflurane 1- 2%(group 2), or 15 min 67.3+/-5.7 59.9+/-5.6 68.8+/-8.1 Propofol 100 μg/kg/min (group 3) in combination 30 min 71.6+/-7.1 67.2+/-7.1 69.1+/-7.9 with N2O 60% in O2.Concentration of maintenance 45 min 72.7+/-7.5 71.1+/-6.4 71.5+/-8.0 anesthetic varied to maintain hemodynamic variables 60 min 74.5+/-5.9 74.2+/-5.6 73.4+/-8.4 within 15% of pre induction values i.e. Desflurane 2- Spo2 6%, Sevoflurane 0.6-1.75% and Propofol 50-150 0 min 97.93+/-.78 98.16+/-0.79 98.0+/-0.83 μg/kg/min.All patients were mechanically ventilated 15 min 97.83+/-1.2 98.0+/-1.1 97.94+/-1.1 to maintain end tidal CO2 within 27-32 mm of mer- 30 min 97.9+/-0.92 98.1+/-0.98 97.84+/-1.0 cury. 45 min 98.03+/-1.1 98.06+/-1.2 98.06+/-0.9 60 min 97.93+/-1.1 97.96+/-1.1 98.1+/-1.1 In all cases, Desflurane, Sevoflurane and Propofol EtCO2 was discontinued when the laparoscope was re- 0 min 32.9+/-2.0 33.4+/-1.8 32.8+/-1.3 moved. The N2O was continued till the last suture. 15 min 28.9+/-2.9 28.2+/-2.2 29.0+/-1.8 To minimize the risk of residual neuromuscular 30 min 27+/-2.7 26.9+/-2.5 26.9+/-1.9 blockade after surgery, reversal of neuromuscular 45 min 27.1+/-3.0 27.2+/-2.7 27.5+/-2.3 blockade was provided by Neostigmine 50µg/kg and 60 min 27.4+/-2.9 27.0+/-2.3 27.0+/-2.2 Glycopyrrolate 8µg/kg. Table 2 shows that after induction of anesthesia Time for spontaneous breathing, eye opening, and blood pressure falls in all three group. But in group extubation were measured from time of termination of Desflurane and group of Sevoflurane least fall in of anesthetic gas or Propofol infusion. blood pressure than group of Propofol. So Propofol All results were recorded in data collection sheet and causes maximum fall in blood pressure as compare data was entered and analysed using Microsoft excel. to Desflurane and Sevoflurane. All the three groups of study have shown that there is not more than 1% fluctuation in oxygen saturation RESULTS by pulse oxymetry. Maximum stabilization has been Total 90 adult patients of ASA I and II between the seen with Propofol as compare to Desflurane and age group of 18 – 70years of either sex posted for Sevoflurane.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 10 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Table 3: Comparison of eye opening as early re- were 1.5+/-0.58, 8.0+/-0.74 and 3.6+/-1.20 minutes covery between three groups of patients studied respectively. It is significantly shorter in Desflurane group (p <0.001). Eye opening (mins) Desflurane Propofol Sevoflurane 1 14 0 1 In our study the Desflurane group took significantly 2 15 0 5 shorter time for extubation when compared with the 3 1 0 7 other two groups. 4 0 0 11 5 0 0 4 Gulcan Erk et al3 compared the effects of Desflu- 6 0 0 2 rane, Sevoflurane and Propofol on recovery charac- 7 0 8 0 teristics and PONV in laparoscopic surgeries. They 8 0 14 0 found that extubation and eye opening times (early 9 0 8 0 recovery) were meaningfully lower in Desflurane group and no significant differences were observed Table 4: Comparison of time to walk as late re- in orientation, sitting and walking times (delayed recovery between three groups of patients studied covery). In our study also the Desflurane group had shorter early recovery times. Time to walk (hrs) Desflurane Propofol Sevoflurane 3 00 1Dajun Song4 et al found that compared with the 4 00 2Propofol group, the times to awakening and to 5 17 0 4 achieve a recovery score of 10 were significantly 6 12 0 8 shorter, and the percentage of patients judged fast- 7 11 7track eligible on arrival in the PACU was significantly 8 02 6higher, in the Desflurane and Sevoflurane groups 9 0 10 2 (90% and 75% vs 26%)after laparoscopic tubal liga- 10 0 14 0 11 03 0tion surgery. They concluded that compared with Propofol, Desflurane and Sevoflurane resulted in a higher percentage of outpatients being judged eligible Table 3 suggests that following to vaporizer turn off for fast tracking. the immediate recovery is seen in Desflurane group 5 of patient. While delayed eye opening seen in Jeffrey L. Apfelbaum, MD et al in a study to com- Propofol group of patient and intermediate eye pare post anesthetic and residual recovery of Desflu- opening seen in Sevoflurane group. rane versus Propofol anesthesia found that awakening and early psychomotor recovery for as long as 1 In late recovery criteria early walking are seen in Des- h after anesthesia is faster after Desflurane than after flurane while it was delayed with Propofol and in- Propofol, but there was no difference in time to termittent with Sevoflurane. home readiness or in residual effects thereafter between Propofol and Desflurane with N2O in O2. 6 DISCUSSION S. Gergin et al in a comparative study of hemodynamic, emergence and recovery characteristics of In our study hemodynamic variables (heart rate, sys- Sevoflurane with those of Desflurane in nitrous ox- tolic BP and diastolic BP) were maintained within ide anesthesia found that time to extubation, recall of ±15% of baseline values in Desflurane and Sevoflu- name and handgrip on command were shorter in the rane group, in Propofol group maintain within +/- Desflurane group (p<0.01) and concluded that Des- 30% adjusting the maintenance anesthetic concentra- flurane offers a transient advantage compared with tion. Concentration of Desflurane varied between 2- Sevoflurane with respect to early recovery although 7%, Sevoflurane 1-3.5% and Propofol infusion 60- the duration of anesthesia was longer in the Desflu- 150μg/kg/min. Intra operative analgesia was provid- rane group. ed with supplemental doses of fentanyl 7 (0.3μg/kg/hr) in all the three groups. Philippe Juvin, MD et al compared postoperative recovery for 36 obese patients randomized to receive Gulcan Berkel2 et al in their study to compare hemo- either Desflurane, Propofol, or Isoflurane to main- dynamic parameters and recovery characteristics be- tain anesthesia during laparoscopic gastroplasties and tween Desflurane and Sevoflurane in patients under- found that immediate recovery occurred faster, and going laparoscopic surgeries concluded that both was more consistent, after Desflurane than after Desflurane and Sevoflurane maintains hemodynamic Propofol or Isoflurane. They concluded that in mor- stability during the intraoperative period. They also bidly obese patients, postoperative immediate and found that early recovery is rapid in Desflurane intermediate recoveries are more rapid after Desflu- group. rane than after Propofol or Isoflurane anesthesia. Time taken for eye opening: Time for eye opening in Desflurane, Propofol and Sevoflurane groups

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 11 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Michael H. Nathanson et al8 compared the recovery were hemodynamically stable during the intraopera- characteristics of Desflurane and Sevoflurane when tive period. used for maintenance of ambulatory anesthesia. They concluded that use of Desflurane led to a more rapid emergence and shorter time to extubation compared REFERENCE to Sevoflurane. 1. Edmond I Eger II, MD, Diane Gong, BP, Donald D. Ko- Edmond I Eger II1 in their study documented the blin, PhD, MD, Terri Bowland, BY,Pompiliu Ionescu, MD, Michael J. Laster, DVM, and Richard B. Weiskopf, MD. The differences in kinetics of 2 h and 4 h of 1.25 mini- Effect of anesthetic duration on kinetic and recovery charac- mum alveolar anesthetic concentration (MAC) of teristics of desflurane versus sevoflurane, and on the kinetic Desflurane (9.0%) versus (on a separate occasion) characteristics of compound A, in volunteers. Anesth Analg Sevoflurane (3.0%), both administered in a fresh gas 1998; 86:414-21. inflow of 2 L/min.They concluded that regardless of 2. Miller RD,Anesthesia for laparoscopic surgery. Millers Anes- the duration of anesthesia, elimination is faster and thesia, 7th editon. Churchill Livingstone; 2010;P 2185–2196. recovery is quicker for the inhaled anesthetic Desflu- 3. Pollard BJ, Elliott RA, Moore EW. Anesthetic agents in adult rane than for the inhaled anesthetic Sevoflurane. day case surgery. EJA 2003; 20:1 - 9. M. Bock et al9 studied the potency and recovery 4. Song D, Joshi PG, Farcsý F, White PF. Fast - track eligibility characteristics of Rocuronium during 1.25 MAC of after ambulatory anesthesia: A comparison of desflurane, sevoflurane, and propofol. Anesth Analg 1998; 86: 267-73. Isoflurane, Desflurane, and Sevoflurane or Propofol anesthesia in 84 patients using electromyography. 5. Jeffrey L. Apfelbaum, MD, J. Lance Lichtor, MD, Bradford S. Lane, BA, Dennis W. Coalson, MD, and Kari T. Korttila, They found that there were no significant differences MD, PhD. Awakening, Clinical Recovery, and Psychomotor between the three potent inhalation anaesthetics in Effects After Desflurane and Propofol Anesthesia. Anesth relation to potency, infusion requirements or recov- Analg 1996; 83:721-725. ery characteristics of Rocuronium. 6. S. Gergin, B. Cevik, G. Yildirim, E. Ciplakligil & S. Time taken to seat and walk: In our study Des- Colakoglu : Sevoflurane Vs Desflurane: Haemodynamic Pa- rameters And Recovery Characteristics . The Internet Journal flurane took significant less time to seat and walk, of Anesthesiology. 2005;9(1):46-54 Sevoflurane take more time to seat and walk com- 7. Philippe Juvin, MD, Christophe Vadam, MD, Leslie Malek, pare to Desflurane but less time than Propofol. Time MD, Herve´ Dupont, MD,Jean-Pierre Marmuse, MD, and to seat for Desflurane, Sevoflurane and Propofol are Jean-Marie Desmonts, MD. Postoperative recovery after des- 3.5+/-0.57, 3.7+/-1.1 and 7.6+/-0.8, respectively flurane, propofol, or isoflurane anesthesia among morbidly (p=0.001). Time to walk for Desflurane, Sevoflurane obese Patients: A prospective, randomized study. Anesth and Propofol are 5.7+/-0.57,9.5+/-0.89 and 6.7+/- Analg 2000; 91:714–9. 1.4, respectively (p=0.00). So Propofol took delayed 8. Michael H. Nathanson, MRCP, FRCA, Brian Fredman, MB, recovery from anesthesia as compared to Desflurane Bch, Ian Smith, FRCA, and Paul F. White, PhD, MD, and Sevoflurane. FANZCA. Sevoflurane versus desflurane for outpatient anesthesia:A comparison of maintenance and recovery profiles. Anesth Analg 1995; 81:1186-90. 9. M. Bock, K. Klippel, B. Nitsche, A. Bach, E. Martin and J. CONCLUSION Motsch. Rocuronium potency and recovery characteristics Desflurane provides faster recovery from anesthesia during steadystate desflurane, sevoflurane, isoflurane or in patients undergoing laparoscopic surgeries than propofol anesthesia. Br J Anaesth 2000; 84: 43–7. Sevoflurane and Propofol. However all three groups

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 12 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

PLAIN RADIOGRAPHY & MRI CORRELATION IN SOFT TISSUE INJURIES OF THE KNEE JOINT

Rahul H Sharma1, Hinal Bhagat2, Girish Ghodadara1, Nirali Patel1

Author’s Affiliations: 1Resident, 2Assistant Professor, Department of Radio-diagnosis and Imaging, Government Medi- cal College and New civil Hospital, Surat, Gujarat Correspondence: Dr Rahul H Sharma Email: [email protected]

ABSTRACT

Introduction: The primary aim is to identify and establish new signs in plain radiography of the knee joint that could indicate soft tissue abnormalities that are established on Magnetic Resonance Imaging (MRI). To correlate the plain radiographic features to that of the MRI findings which is the gold standard in the evaluation of the knee disorders. Methodology: A prospective cross sectional study was done on a total of 50 patients including both the sexes and of all age groups who presented with knee joint pain and subsequently underwent plain radiographic evaluation followed by MRI of the knee joint. The data is analyzed and the findings on plain radiographs correlated with that of MRI. Results: The most common soft tissue injuries as identified on MRI of the knee joint were that of Anterior Cruciate Ligament (ACL) and medial meniscus (MM). Knee joint effusion was found to be a common occurrence in cases of trauma. These findings were also identified on plain radiographs. Conclusion: Sign complexes on plain radiograph with regard to joint space, inter condylar region of tibia, tibial plateaus, soft tissue planes at the tibio femoral joint, supra and infra patellar regions on lateral radiograms, and calcifications in soft tissue planes indicate various soft tissue injuries of the knee as detected and confirmed on MRI. Thus plain radiograph stands as a primary imaging modality in diagnosing not only the osse- ous abnormalities of the knee joint but also soft tissue abnormalities in comparison to MRI. Keywords: Soft tissue knee injuries, Plain radiography, Sign complexes, MRI Knee joint, ACL injury.

INTRODUCTION resolution images with detailed information concerning the bone marrow, cortex, cartilage, menisci, liga- Knee joint is particularly vulnerable to injury because ments, tendons and surrounding synovium.7 It ena- of its unique architectural arrangement of bony, bles multiplanar imaging and many a times obviates muscular, ligamentous, and meniscal structures and the need for invasive procedures like arthroscopy.8 its key role in ambulation and support.1 Radiography Therefore the objectives of the present study was to is the first step in the evaluation of the knee joint identify the plain radiographic signs and correlate disorders as it is universally available, quick and in- with MRI findings in knee joint disorders.9 This expensive and can yield many diagnostic clues.2 It study aims to identify and establish new sign com- can readily reveal fractures, osteochondral defects, plexes in plain radiography that could indicate soft bony lesions, joint effusions and joint space narrow- tissue abnormality that are established on MRI.10 ing and bone mal-alignment.3. However, some fractures and most soft tissue injuries about the knee have subtle radiographic findings and may be diffi- METHODOLOGY cult to detect even with optimal radiographic view.4 Due to certain limitations of the plain radiography in The present cross sectional study included 50 out- evaluation the soft tissues, it is superseded by other patients visiting our medical institute with knee pain imaging modality like the MRI.5 Radiographic fea- and subjected to investigations of plain radiography tures of several subtle, yet detectable knee injuries are and MRI were included in the study. The study was studied, with a goal to emphasize the analysis of plain approved by the institutional ethical committee. The radiographic findings and correlation of radiographic study included patients belonging to all ages and results with those of magnetic resonance imaging both sexes. Patients with bony ankylosis, fibrous an- (MRI).6 In the recent days MRI is the gold standard kylosis, frank fractures of the bones of knee joint and in imaging soft tissues of the knee. It provides high bone tumors of the knee were excluded..

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 13 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Plain radiograph of the knee joint is performed using 35 (70% of 50) cases on MRI of which, 26(74% of a 500mA Siemens machine using a 24 x 30cm com- 35 cases) had evidence detectable on plain radio- puter radiography cassette with 56kV and 10mAs. graphs. Antero-posterior (A-P) view in standing position is Injury to lateral meniscus (LM) was evident in 18 taken for both the knee joints. Subsequently, A-P (36% of 50) patients on MRI whereas plain radio- supine and trans-lateral views are taken for the af- graphic signs indicating injury to LM are identified in fected knee joint. 10 (56% of 18) cases which was statistically signifi- MRI knee was done using a MAGNETOM Essenza cant. FIve (10%) cases revealed tear in both the ante- 1.5 Tesla MRI Scanner from SIEMENS at Aatma- rior and posterior horns of varying grades on MRI Jyoti MRI Centre, New Civil Hospital, Surat. Proton and all (100%) of them are identified on the plain ra- density weighted sequence in saggital plane (PDW- diographs. sag), PDW-m spin gradient inversion recovery in Out of 50 cases 4 (8%) cases revealed injury to the saggital plane (SPIR-sag), short T1 inversion recov- medical collateral ligament (MCL) on MRI of which ery in coronal plane (STIR-coronal), T2-coronal, T1- all 4(100% of those identified on MRI) cases had coronal, T1-axial, STIR-axial, STIR-axial sequences signs indicating the same on plain radiographs. On with thin sections were obtained. MRI 10 (20% of 50) cases revealed injury to the lat- Statistical Analysis: The data is analyzed by propor- eral collateral ligament of which 9 (90% of 10) cases tions and chi square test. were detected on plain radiographs which was statistically significant.

Among 50 patients in the study, 28 (56%) cases re- RESULTS vealed reduction in the joint space on MRI, whereas The present study consisted of 38 males and 12 fe- 20 (71% of 28) cases showed reduced joint space on male patients. It was observed that the maximum plain radiographs which was statistically significant. number of patients (23 cases) belonged to the age Reduction in the tibio femoral joint space medially group of 21-30 years followed by the age group of was noted in 20(40% of 50) patients on MRI, where- 31-40 which consisted of 11 cases. Out of 50 cases, as 18(36% of 50) cases showed the same on plain ra- 39 (78% of 50) of them had abnormal ACL on MRI diographs. whereas 35 (90% of 39) revealed signs of ACL injury Knee joint effusion was noted in 41(82%) cases of on plain radiographs. 50 patients on MRI, of which 35 (86% of 41) cases were also detected on plain radiographs which was statistically significant. Moderate and massive joint Table 1: Age and sex wise distribution of cases. effusion was noted in 12 and 2 patients respectively, Age Group (Years) Male Female Total (%) was also detected on plain radiographs. 1 – 10 1 0 1 (2.0) 11 – 20 4 2 6 (12.0) Six (12%) cases out of 50 revealed changes in the 21 – 30 15 8 23 (46.0) femur on MRI. Of the above mentioned 6 cases, 4 31 – 40 7 4 11 (22.0) revealed medial condyle marrow edema on MRI, of 41 – 50 4 2 6 (12.0) which none of them revealed the signs on plain radi- 51 – 60 2 0 2 (4.0) ograph indicating the same. Similarly, 2 cases having 61 – 70 1 0 1 (2.0) geodes in the lateral condyle on MRI were incon- spicuous on plain radiographs. Among the 50 cases, Twelve (24% of 50) cases had abnormal contour 18 (36%) had changes in tibia on MRI whereas 13 without discontinuity of the ligament fibres on MRI, (72% of 18) cases showed changes in tibia on plain out of which 9 were identified on plain radiograph, radiographs. accounting for 75% of that identified on MRI. It was The osteophytes in the medial and lateral condyle of observed that 20 (40% of 50) cases had discontinuity the femur and tibia were identified on both MRI and of ACL fibres on MRI, out of which 17 (85% of 20) plain radiography and had a strong statistical signifi- cases revealed the features on plain radiographs. Of cance. Similarly three( 6%) cases showed fracture lat- the 50 cases, 8 (16%) of them had discontinuity of eral tibial condyle on MRI which was identified on ACL fibres with buckling of posterior cruciate liga- plain radiograph. In 2 (4% of 50) cases bone marrow ment (PCL) on MRI and all these cases were also edema/contusion, was identified on MRI whereas identified on plain radiographs indicating a statistical- none of them were identified on plain radiographs. ly significant correlation. The changes in joint space were clearly depicted in Eight patients who presented with only PCL buck- 16 cases (32%) in the plain radiography which were ling on MRI, only 2 of them (25%) were identified less obvious on MRI due to the supine positioning of on plain radiograph which was not statistically signif- the patient during the procedure. icant. Medial meniscus (MM) injury was detected in

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Fig. 1(a) MRI of a 24 year old male patient showing ACL Fig. 3(a) MRI of 26 year old male patient showingmedial strain revealing the abnormal contour of the ACL (arrow) collateral ligament injury (arrow), whereas the correspond- and the corresponding AP view of plain radiograph is ing plain radiograph (b) showing calcification at the at- shown in Fig. 1(b) AP view of plain radiograph of a 24 tachment of MCL to the medial femoral condyle (Pella- year old male patient showing prominence of medial inter- grini steida syndrome) Fig. 3(b) The plain radiograph of 26 condylar eminence (arrow). year old male patient showing calcification at the attachment of MCL to the medial femoral condyle

Fig. 2(a) MRI of 26 year old male patient showing grade Fig. 4(a) MRI showing knee joint effusion in a 48 year old III tear of lateral meniscus posterior horn (arrow) Fig. 2(b) female patient which appears as hyperintense areas (ar- The plain radiograph of 26 year old male patient showing rows) on T2 image (b) plain radiograph showing fullness/ grade III tear of lateral meniscus posterior horn on the increased density in the supra patellar region on lateral MRI (Fig. 4(a)) shows decreased lateral tibio femoral joint projection (arrow) and (c) lateral displacement of the soft space (black arrow), with indistinct lateral fat planes (white tissues at the tibio femoral joint on AP view of a 40 year arrow) old female patient (area of increased density shown by an arrow)

DISCUSSION planes, indistinct fat planes, enlargement of joint space, compression fractures can be appreciated. Radiography is the first step in the evaluation of the knee joint disorders. It can readily reveal fractures, The sagittal plane is most important plane in as- osteochondral defects, bony lesions, joint effusions, sessing the menisci, with a coronal plane providing joint space narrowing and bone mal-alignment. The supportive rather than new information and the axial knee is the largest, complex, bicondylar, synovialjoint plane increasing the accuracy of the sagittal and cor- in the body.3 The soft tissues around the knee com- onal planes when combined.5-7 The medial and lateral prise: fibrous capsule, menisci, cruciate ligaments, menisci, the transverse ligament, and the menisco collateral ligaments and medial and lateral stabilizing femoral ligament appear homogenously dark on all structures of the knee. The injuries involving these pulse sequences. The vascular and avascular zones structures along with bone and bone marrow are well cannot be distinguished on MRI.8 identified on the MRI. In order to evaluate internal In primary healthcare setups where MRI facility is derangement adequately, the axial, coronal and sagit- not available, the plain radiography becomes the key tal planes using thin sections (3mm thick) with a in analyzing the changes in the soft tissues along with combination of T1- and T2- weighted sequences, the well-established changes in the hard bony tissues. short tau inversion recovery (STIR) or T2 –weighted MRI is an expensive, not readily available investiga- image with fat suppression are required.4 Tears in the tion at the level of primary health care centres. How- structures or discontinuity in the fibres, ede- ever MRI is a noninvasive gold standard investiga- ma/contusion or effusion in the joint space, sclero- tion in establishing soft tissue injuries of the knee sis, geodes, cysts, osteophytes and fracture can all be joint. appreciated on MRI. Similarly on the plain radiographs, the displacement of synovial fluid, spiking of The objective of our study was to establish new signs the intercondylar eminence, displaced soft tissue on plain radiography of the knee joint that would indicate soft tissue injury, thereby obviating the need

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 15 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 for expensive, not readily available investigations like displaced fat planes with increased density on AP MRI at a primary level. On reviewing the literature it films. was found that our study is first of its kind (unique)

in establishing signs on plain radiography that indicate soft tissue injury of the knee joint. CONCLUSION Plain radiographs are 91% sensitive and 86% specific Knee joint pain is a common complaint patients pre- for osteoarthritis when combined with criteria indi- sent with, especially in middle and old ages. The cating osteoarthritis, including any of the following: causes can be various being bony or soft tissue inju- age more than 50 years, crepitus and morning stiff- ries. Radiology plays a major role in diagnosing the ness of 30 minutes or less.9 cause of pain and thereby in its management. The present study was done to identify signs on plain ra- Lateral condylar depression and widening, as meas- diography that indicate soft tissue injuries of the knee ured on plain radiographs was helpful in identifying joint that are otherwise established on MRI and thus the soft tissue injury and planning open or artho- correlate signs on plain radiographs with that of scopic treatment methods in centres with limited MRI. Specific observations regarding the knee joint availability of MRI.10 Localized development of knee space, tibial inter condylar eminence, the bone densi- osteoarthritis can be predicted from MR imaging a ty, soft tissue planes at the tibio femoral joint medial- decade earlier.11 Study to correlate the clinical as- ly and laterally, density at the suprapatellar and infra sessment, radiographic and MRI findings revealed patellar region, compression fractures of the tibial that MRI was far superior to plain radiography and plateaus / femoral condyles/ inter condylar emi- better than clinical assessment and has a high sensi- nence reveal invaluable signs revealing injury to the tivity, accuracy and positive predictive value.12 menisci, cruciate ligaments, collateral ligaments, knee The six sign complexes that where observed on plain joint effusion when carefully assessed and interpreted radiography would be of great value in diagnosing on the plain radiographs. Thus though MRI today is soft tissue pathologies where the MRI facility is not the standard modality to diagnose soft tissue injuries available. They are: of the knee joint, plain radiography a readily and universally available investigation at all levels of health 1. ACL: Signs on plain radiogram that indicate ACL care systems certainly does reveal certain signs that injury are spiking of intercondylar eminence, with indicate injury to the soft tissues of the knee. either sclerotic margin or irregular margin with or without underlying osteopenia, fracture of intercondylar eminence indicates ACL injury. REFERENCE 2. Medial meniscus injury/tear: Signs on plain ra- 1. Gerald W. Capps, W. Hayes (1994) easily missed injuries diogram that indicate medial meniscus injury/tear are around the knee. Radiographics 14: 1191-1210. reduced tibio-femoral joint space medially, sclerosis 2. Terry R. Youcham, Norman W. Ketter, Michael S. Barry, of medial tibial plateau, with laterally displaced soft Melanie D. Osterhouse, Robert J. Longenecker, Claude tissue planes. Pierre Jerome and Lindsay J. Rowe. (2005): Diagnostic imaging of the musculo skeletal system. Essentials of skeletal ra- 3. Lateral meniscus: Signs on plain radiogram that diology 3rd edn, vol 1, Lippincott Williams& Wilkins, USA, indicate lateral meniscus injury/tear are sclerosis of pp 554. lateral tibial plateau, lateral tibial condyle, fracture, 3. Omar Faiz, David Moffat. (2002): The knee joint and poplit- laterally displaced soft tissues at the tibio-femoral eal fossa. In: Omar Faiz, David Moffat (ed). Anatomy at a joint and decrease in lateral tibio-femoral joint space. glance. University of Cardiff, Blackwell science Ltd, UK, pp109-111. 4. Medial collateral ligament: Signs on plain radiogram that indicate injury to medial collateral ligament 4. Bradley WG. (2001): Knee pain. Applied Imaging: Applica- tions in MRI 2(1):1-4. are displacement of medial soft tissue planes at medial tibio-femoral joint, calcification at medial femo- 5. Magee T, Williams D. (2004): Detection of meniscal tears ral condyle at the site of attachment of medial collat- and marrow lesions using coronal MRI. AJR Am J Roent- genol 183:1469-1473. eral ligament. 6. Resnick D. (2002): Internal Derangement of the joints, 4th 5. Lateral collateral ligament: Signs on plain radio- ed. WB Saunders, Philadelphia gram that indicate injury to lateral collateral ligament 7. Tarhan NC, Chung CB, Mohana-Borges AV, Hughes T, are indistinct lateral fat planes at the tibio-femoral Resnick D. (2004): Meniscal tears: role of axial MRI alone joint, laterally displaced lateral soft tissue planes. and in combination with other imaging planes. AJR Am J Roentgenol 183(1):9-15. 6. Signs on plain radiogram that indicate joint effusion are increased density in the suprapatellar and 8. Hauger O, Frank LR, Boutin RD, et al. (2000): Characteriza- tion of the “red zone” of knee meniscus: MR imaging and infrapatellar regions on lateral x rays. Also laterally histologic correlation. Radiology 217:193-200.

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9. Jackson, J. L., P. G. O’Malley and K. Kroenke. (2003): Eval- 12. Diagnostic efficacy of magnetic resonance imaging in evalua- uation of Acute knee pain in Primary Care. Ann Intern Med tion of injured knee. Available on: http://pjmhsonline.com/ 139 (7): 575-588. JanMar2013/diagnostic efficacy of MRI in evaluation of injured knee.htm Last Accessed 1st September 2013. 10. Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, Lorich DG. (2006): Prediction of soft tissue inju- 13. Ian G. Stiell, G A. Wells, Ian McDowell, Gary H. Greenberg, ries in Schatzker II tibial plateau fractures based on meas- R. Bouglas McKnight, A.Adam Cwinn, James V. Quinn. urements of plain radiographs. J Trauma 60(2): 319-323. Ashley Yeats. (1995): Use of radiography in acute knee injuries: Need for clinical decision rules. Acad. Emerg. Med 2:

11. Huetink K, Nelissen RG, Watt I, van Erkel AR, Bloem JL. 966-97. (2010): Localized development of knee osteoarthritis can be predicted from MR imaging findings a decade earlier. Radi- ology 256 (2), 536-46.

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STUDY OF IMPACT OF GLYCOSYLATED HEMOGLOBIN ON ACUTE CARDIAC STATES

Pratik S Savaj1, Trupti R2, Praful Chhasatia2

Author’s Affiliations: 1Resident; 2Physician, Dept. of Medicine, Venus Hospital Surat, Gujarat Correspondence: Dr Praful Chhasatia Email: [email protected]

ABSTRACT

Objectives: To find out the impact of HbA1c levels on the severity and short term complications of patients with heart disease admitted to the Intensive Care Unit (ICU) of Smt. Rasilaben Sevantilal Shah Hospital, Su- rat. Methods: 100 patients admitted to ICU with acute cardiac states (STEMI, NSTEMI, UA, DCM, Acute LVF) were prospectively studied. Patients were divided into 2 groups – group A (Diabetics) and group B (Non- Diabetics) and patients were followed up till the time of discharge. Results: Out of the 100 patients, 58 were Diabetic and 42 were Non Diabetic. The mean HbA1c of Diabetics was 8.9 ± 1.8% and that of Non-Diabetics was 6.03 ± 1.1%. Risk factors like dyslipidemia, hypertension, obesity, previous history of heart disease were found more in Diabetic group than in Non-Diabetic group. Histo- ry of tobacco chewing, smoking, alcohol, positive family history of heart disease, were more in Non-Diabetic group. Complications like cardiogenic shock, accelerated hypertension, arrhythmias and re-infarction occurred significantly more in patients with patients with HbA1c > 7. Mortality is high in patients with HbA1C>7 (15.5%). STEMI, NSTEMI, UA were seen in a significantly higher proportion of patients with poor glycemic control (HbA1c > 7%) compared to patients with HbA1c level < 7%. In Non-Diabetics 39/42 (92.7%) Pa- tients had HbA1c levels > 5%, 61.8% of whom had HbA1c levels of >5.6%. Conclusion: Severity and complications of heart disease were significantly higher in diabetics and showed a significant correlation with HbA1c. A large number of nondiabetics presenting with acute cardiac states i.e. 92.7%, had HbA1c values > 5%.

Key words: Diabetes, Cardiovascular disease, HbA1c

INTRODUCTION clinical diabetes. The present study was undertaken to find out the correlation between HbA1c levels and Diabetes is considered a highly ‘vascular disease’ with the severity and complications of patients admitted both micro vascular and macro vascular complica- with acute cardiac states to the Intensive Care Unit tions. Macro vascular complications start taking place of Smt. Rasilaben Sevantilal Shah Venus Hospital, long before the patient has overt diabetes. Hypergly- Surat, Gujarat. cemia is an independent risk factor for cardiovascular disease. Hyperglycemia accelerates the process of Objective: Objective of this study was to find out atherosclerosis by the formation of glycated proteins impact of HbA1c levels on severity and short term and advanced glycation end products, which act by complications of patients with acute cardiac states. increasing the endothelial dysfunction. HbA1c could be considered a good marker of glycated proteins and its assay has been used as a measure of glycemic METHODOLOGY control in several landmark trials. The Framingham Study population: 100 patients admitted to inten- study has shown that the cardiovascular mortality is sive care unit of Smt. Rasilaben Sevantilal Shah Hos- twice in Diabetic men and four times in Diabetic pital, Surat with Acute Cardiac States during January women when compared to their Non Diabetic coun- 2013 to December 2013 ( after taking informed con- terparts. HbA1c levels of more than 7% are associat- sent) ed with a significant increase in the risk of cardiac events and deaths. Interestingly, this correlation be- Inclusion criteria: Patients with acute cardiac states tween higher HbA1c levels and increased cardiovas- includes ST elevation MI (STEMI), Non ST Eleva- cular morbidity occurs even before the diagnosis of tion MI (NSTEMI), unstable angina (UA), Dilated

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 18 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Cardiomyopathy (DCM) and acute left ventricular like tobacco chewing (19%), smoking (33.3), alcohol failure (LVF). In patients without prior history of di- (9.5%), were more observed in non-diabetic group. abetes, a diagnosis is made, if they had fasting blood In our study past history of IHD (56.8%), past histo- sugar >126 mg/dl or random blood sugar >200 ry of PVD (3.4%) were more in diabetic group and mg/dl on two or more determinations along with an past history of stroke (11.9%) and positive family HbA1c of 7% or more. Those patients who required history of IHD (16.6) were more in non-diabetic diet controls or insulin while in the hospital for con- group. No history of PVD was found in non-diabetic trol of blood sugar value were also included in the group. Diabetic group even when the HbA1c was <7%

Exclusion criteria: Patients with sepsis, heamoglo- Table 1: Distribution of Cardiac emergencies binopathy and hyperthyroidism were excluded from among diabetic and non-diabetic Patients the study. Patients in whom HbA1c levels could not be obtained were also excluded from the study. Cardiac Diabetics Non Diabetics Total Emergencies (%) n=58 (%) n=42 All cases of acute cardiac states with HbA1c meas- STEMI 9(15) 6(14.2) 15 urement were interviewed by using pre-test ques- NSTEMI 11(18.9) 5(11.9) 16 tionnaire for information collection. Data was en- UA 14(24.1) 6(14.2) 20 tered in Microsoft XL and analyzed as well as tabu- DCM 5(8.6) 5(11.9) 10 lated. ALVF 19(32.7) 20(47) 39

Table 2: Distribution of symptoms among dia- RESULTS betic and non-diabetic patients Symptoms Total of 100 cases of acute cardiac emergencies Symptoms Diabetics Non Diabetics Total (STEMI, NSTEMI, UA, LVF) admitted in ICU of (%) n=58 (%) n=42(%) Smt. Rasilaben Sevantilal Shah Venus Hospital, Surat Chest pain 33(56.8) 29(69) 62 from January 2013 to December 2013 were included Breathlessness 30(51.7) 21(50) 51 in the study. In our study maximum patients were Palpitations 7(12) 8(19) 15 (22%) observed in age group of 45-49 with male Pedal edema 26(44.8) 14(33.3) 40 dominancy (69%). Our study shows that males were Syncope 3(5.17) 0(0) 3 more seen with acute cardiac emergency than female. In both the age groups acute LVF was the most Table 3 -Distribution of HbA1c level in diabetics common cardiac emergency (39%) followed by un- and non-diabetics stable angina (20%), NSTEMI (17%), STEMI (14%) and DCM (10%). HbA1c in No. (%) HbA1c in Non No. (%) Diabetics n=58 Diabetics n=42 In our study patients of Acute Coronary Syndrome <7 13(22.4) <5 3(7.1) (STEMI, NSTEMI, and UA) were more observed in 7-8.9 19(32.7) 5-5.5 13(30.9) diabetic group than non-diabetic group. In diabetic 9-10.9 17(29.3) 5.6-6 12(28.5) group patients with STEMI were 15%, NSTEMI >11 9(15.5) >6 14(33.3) were 18.9%, UA were 24.1% while in nondiabetics patients with STEMI was 14.2%, NSTEMI was In our study among the diabetic group HbA1c was in 11.9%, and UA was 14.2%, while patients with DCM highest number of patients in between 7 to 8.9 and LVF were higher in non-diabetic group. In (32.7%) followed by HbA1c of 9 to 10.9 (29.3%) fol- nondiabetics patients with DCM was 11.9% and lowed by HbA1c<7(22.4%) and HbA1c>11(15.5%). LVF was 47% while in diabetics patients with DCM In non-diabetic group, maximum patients (33.3%) was 8.6% and LVF was 32.7% were observed having HbA1c >6 followed by In our study chest pain was the most common com- HbA1c of 5 to 5.5(30.9%) followed by HbA1c of 5.6 plaint (62%) followed by breathlessness (51%) and to 6(28.5%) and HbA1c<5 (7.1%). pedal edema (40%), palpitation (15%) and syncope In our study patients with STEMI (17.7%), NSTEMI (3%). In Diabetic group breathlessness (51.7%), pe- (17.7%), UA (24.4%) more observed in patients with dal edema (44.8%), syncope (5.17%) were seen more HbA1c>7 while DCM (12.7%) and acute LVF than in the non-diabetic group. In non-diabetic (43.6%) was more observed in patients with group chest pain (69%), palpitations (19%) were HbA1c<7. In our study mortality was higher in pa- higher than in the diabetic group. None of the patients with HbA1c>7 (15.5%) as compared to patients with non-diabetics had complaint of syncope. tients with HbA1c<7 (5.4%). In our study hypertension (72.4%), hyperlipidemia (65.5%), obesity (46.5%) were the most common risk factors observed in the diabetic group. Risk factors DISCUSSION

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 19 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 India leads the world with the largest number of dia- Mansour et al study in non-diabetics history of betic subjects earning the dubious distinction of be- smoking was seen in 34.6% while in diabetics it was ing termed the “diabetes capital of the world”. 1 Ac- 32.3%. So from our study it can be well explained cording to the Diabetes Atlas 2006 published by the that diabetic people are more prone to develop car- International Diabetes Federation, the number of diovascular morbidity and mortality due to the asso- people with diabetes in India currently is around 40.9 ciated risk factors like hypertension, obesity, million and is expected to rise to 69.9 million by dyslipidemia. 2025 unless urgent preventive steps are taken.2 Heart In this study, HbA1c >6 was seen in 33% of non- disease in patients with Diabetes Mellitus (DM) is diabetic patients which is similar to Vinita Elizabeth different from that in Non-Diabetics. Diabetics de- Mani et al study, HbA1c >6 was seen in 35% pa- velop coronary artery disease (CAD) earlier, and tients indicating a large number of subjects with pre- have more extensive atherosclerosis. Several previous diabetes in this group. Mean HbA1c in non-diabetic studies have shown that the prevalence of coronary group was 6.03 ± 1.19 which is higher than that of artery disease (CAD) is higher in patients with diabe- mean HbA1c levels of normal population. It is well tes. In our study Male preponderence was noted. In known that the macro vascular complications start our study 69% of the patients were male and 31% taking place at lower blood sugar levels than the di- were female (M:F = 2.2:1). In Liu et al study 67.7% agnostic cut of values for diabetics which is proven were male and 32.3% were female (M:F = 2.09:1).3 by our study. Dilley et al study conducted in Asian In Abbas Ali Mansour et al study 61.6% were male Indians with normal glucose tolerance (NGT), found and 38.4% were female (M:F = 1.6:1).4 This is well a strong correlation of HbA1c and cardiovascular explained by cardio protective action of estrogen and risk factors.8 NGT (normal glucose tolerance) sub- high prevalence of addiction like smoking and alco- jects with three or more metabolic abnormalities had hol in male. Mean age in diabetic patients was the highest HbA1c levels and an HbA1c cut of point 53.36±10.67 and in non diabetic it was 52±10.24. In of 5.6% was found to have the highest accuracy in Abbas Ali Mansour et al study141 mean age in dia- predicting both metabolic syndrome and coronary betic patients is 63±14.6 and in nondiabetic it is artery disease. 61.1±11.3 In this study in non-diabetic patients, mortality was In this study symptoms among diabetic group like 7.2% while in diabetic patients, mortality was 12.7%. breathlessness (51.7% vs 50%), pedal edema (44.8% In Vinita et al study mortality in non-diabetic was vs 33.3%) and syncope (5.17%) were more seen as 5.4% while in diabetics it was 8.7%. Overall, in both compared to non-diabetics. In Vinita et al studyalso the studies, mortality was higher in the diabetic in diabetics breathlessness (44.6% vs 18.6%), pedal group. edema (21.7% vs 3.7%) and syncope (4.34%) were more frequently seen as compared to non-diabetic.5 In patients with HbA1c>7 mortality was 15.4% and in HbA1c<7 it was 5.4%. In Abbas Ali Mansour et al In this study in non-diabetic group, chest pain (69% study mortality in patients with HbA1c>7 was 7.6% vs 56.8%), palpitations (19% vs 12%) were more while in patients with HbA1c<7 was 3.8%. Overall seen as compared to diabetic people, In Vinita et al from both the studies it is apparent that mortality is study in nondiabetic group chest pain (75.7% vs higher in patients with poor glycemic control. 52.2%), palpitations (21.6% vs 10.8%) were more Khawet et al found a continuous and significant rela- frequently seen. tionship between HbA1c, cardiovascular events and The present study results show significant divergenc- allcause mortality, whereby persons with HbA1c < es in the risk factors between diabetics and non- 5% had the lowest rates of cardiovascular disease and diabetics. A significantly higher proportion of diabet- mortality.9 They found a one-percentage point in- ics had additional cardiovascular risk factors like hy- crease in the HbA1c to be associated with a relative pertension (72.4% vs 54.7%), hyperlipidemia (65.5% increase in risk of death of 1.24 in men and 1.28 in vs 28.5%) and obesity (46.5% vs 7.1%) when com- women. Selvinet et al found no risk of CAD in pa- pared with non-diabetics. In Vinita et al study130 in tients with HbA1c < 4.6%. However for every 1% diabetic patients had higher cardiovascular risk fac- increase in HbA1c over 4.6%, there was a 2.5 times tors like hypertension (68.5% vs 50.5%), hyper- increased risk of cardiovascular disease.10 lipidemia (43.5% vs 20%) and obesity (34.7% vs

6.7%). In Brezinkaet et al also demonstrated that diabetic people was having higher risk factors like hy- CONCLUSION pertension, hyperlipidemia, and obesity.6 Lu WQ et Severity and complications of heart disease were sig- al also demonstrated higher proportion of hyperten- nificantly higher in diabetics and showed a significant sion, obesity and dyslipidemia among diabetic peo- correlation with HbA1c. A large number of nondi- ple.7 In non-diabetics history of smoking was seen in abetics presenting with acute cardiac states i.e. 33% while in diabetics it was 12%. In Abbas Ali 92.7%, had HbA1c values > 5%. Acute cardiac

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 20 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 emergencies are more severe and have worse out- REFERENCE comes in diabetic patients.The severity of complica- 1. Mohan V Shanthirani CS ,Deepa et al.Urabandiffernces in tions has significant correlation with glycosylated the prevanlence of the metabolic syndrome in southern in- hemoglobin levels. A large number of non diabetic dia.The Chennai urban population study (No.4)Diabet Med patients had higher glycosylated hemoglobin levels 2001;18:280-7. than general population, thus establishing a correla- 2. Ford ES: Prevalence of the metabolic syndrome defined by tion between acute cardiac emergencies and glycosyl- the International Diabetes Federation among adults in the ated hemoglobin levels even in non-diabetic patients. U.S. Diabetes Care 28:2745, 2005[PMID: 16249550] 3. Lui J, Zhao D, Liu Q, Wang W et al. Study on prevalence of There are many patients in our society who are suf- diabetes mellitus among acute coronary syndrome in patients fering from diabetes mellitus but are undiagnosed. in multiprovincial study in china. PubMed [PIMD Many of them are diagnosed to have diabetes at the 19040029]. time of acute cardiac emergency. Earlier diagnosis 4. Abbas Ali Mansour and Hameed LaftahWanoose. Acute and treatment of diabetes mellitus could have pre- phase hyperglycemia among patients with Acute coronary vented these emergencies. Hence regular screening syndrome: prevalence and prognostic significance. Oman for diabetes mellitus should be carried out in the Med J.Mar 2011;26(2):85-89 general population especially in people above the age 5. Vinita Elizabeth Mani, Mary John, Rajneesh Calton et al. of forty having family history of diabetes mellitus. Impact of HbA1c on Acute Cardiac States. JAPI 2011; 59:1- Patients with diabetes mellitus having higher glyco- 3. sylated hemoglobin levels have higher incidence of 6. Brezinka V, Padmos I. Coronary heart disease risk factors in acute coronary syndromes and have worse outcomes. women. Eur Heart J 1994;15:157184. Tight control of diabetes mellitus helps in prevention 7. Lu WQ, Resnick HE, Jablonski KA, et al. E_ects of glycemic of the acute cardiac complications in diabetic pa- control on cardiovascular disease in diabetic American Indi- tients Hence all the patients with diabetes mellitus ans. The Strong Heart Study. Diabet Med 2004;21:311-7. should aim to have excellent diabetic control with 8. Dilley J, Ganesan A, Deepa R, et al. Association of A1c with exercise, diet and drugs. The aim should be to keep cardiovascular disease and metabolic syndrome in Asian In- HbA1C at least below 7. As per the American Dia- dians with normal glucose tolerance. Diabetes Care betic Association guidelines, in younger patients, one 2007;30:1527-32. should aim at glycosylated hemoglobin levels below 9. Khaw KT, Wareham N, Bingham S, et al. Association of 6.5. hemoglobin A1c with cardiovascular disease and mortality in adults: The European Prospective Investigations into cancer in Norfolk.Ann Intern Med 2004;141:413-20 10. Selvin E, Marinopoulos S, Berkenblit G, et al. Meta-analysis: Glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med 2004;141:421-31.

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COMPARATIVE STUDY OF INTRAVENOUS INFUSION OF CLONIDINE AND/OR MAGNESIUM SULPHATE ON HAEMODYNAMIC STRESS RESPONSE TO TRACHEAL INTUBATION AND PNEUMOPERITONEUM DURING LAPROSCOPIC SURGERY

Palak P. Sheth1, Bhavna Soni2, Keyur Kapadia3

Author’s Affiliations: 1Resident; 2Associate professor; 3Ex-resident, Dept. of Anesthesia, SMIMER, Surat, Gujarat Correspondence: Dr Palak P. Sheth Email: [email protected]

ABSTRACT

Introduction: Laryngotracheal intubation and co2 pneumoperitoneum in laproscopic surgery is associated with significant stress response. In this prospective, randomized study, we investigated the efficacy of magnesium sulfate and clonidine to prevent adverse hemodynamic stress response. Methodology: 60 patients of either sex (18-60yrs) undergoing elective laproscopy surgery were randomly divided in two groups. 1. In Goup C, IV infusion of Inj clonidine 1.5 µg/ kg while in group M, Inj magnesium sulphate 50mg/kg diluted in 100ml NS over 15 min was started 30 min before surgery and intraoperatively, IV infusion of clonidine 1µg /kg/hr and magnesium sulphate 10mg/kg/hr was started respectively before creation of pneumoperitoneum. Results: Mean heart rate was significantly high immediately after intubation in group M compared to group c and significantly less in clonidine group before and immediately after pneumoperitoneum. No significant difference was observed in mean blood pressure in both groups. Time for rescue analgesic was prolonged in group M. Sedation, extubation time and discharge time was significantly longer in group M. Conclusion: Administration of clonidine and magnesium sulfate produces hemodynamic stability during intubation and pneumoperitoneum in laproscopic surgery.

Keywords: clonidine, magnesium sulfate, laproscopic surgery, hemodynamic response

INTRODUCTION tolerated in healthy individuals, but hazardous in patients with cardiovascular disease, raised “Jacobeus” applied technique to insufflate air in intraocular and intracranial pressure.2 Such abdomen of human being in 1910 (Sweden) and hemodynamic changes are also associated during named the procedure “laproscopy”. 1968, Semm was laproscopic procedure result from co2 insufflation as the first to develop CO2 pneumo-insufflator for consequences to hypercarbia induced release of pneumoperitoneum. Laparoscopic procedure results catecholamine, vasopressin or both. In this in multiple benefits compared with open procedure prospective randomized study we compare due to better maintenance of homeostasis, less effectiveness of intravenous infusion of clonidine trauma, smaller scar, less postoperative pain and and/or magnesium sulphate to attenuate pulmonary impairment, reduction in postoperative hemodynamic stress response to tracheal intubation ileus, earlier ambulation, and shorter hospital stay. and CO2 insufflations in patients undergoing The pressure response to tracheal intubation has laparoscopic surgery. been recognized by King and his colleague in 1951.

The increase in blood pressure is usually transitory and is thought to be result of laryngotracheal METHODOLOGY stimulation which results in reflexive After approval from institutional ethical committee, sympathoadrenal stimulation.1 It may result into written informed consent was obtained from each increase in myocardial oxygen demand which may patient. Sixty patients aged 18 to 60 years, belonging cause myocardial ischemia, left ventricular failure or to ASA grade I & II physical status, scheduled for cerebral haemorrhage. These changes may be well elective laparoscopic surgery were randomly divided

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 22 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 in two groups: Group C (clonidine) and Group M discharge and any complications like hypotension, (magnesium sulfate). Patients with Cardiovascular, bradycardia, hypoxia were recorded every 15 minute respiratory, renal, liver, neuromuscular, endocrine initially for 2 hours. diseases and in whom laparoscopy converted in to Statistical Analysis: The results obtained from the open laparotomy were excluded from the study. study were presented in tabulated manner. The Thorough preoperative anesthetic evaluation was results are expressed as mean SD. The data were done on the day before surgery. All patients received analysed by using student’s t-test. Categorial data was tab alprazolam 0.5 mg in the night before surgery compared using chi-square test. P value<0.05 was and kept NBM overnight. On the day of surgery, in considered statistically significant and p<0.01 was the recovery room, vitals were confirmed. After highly significant. Statistical analysis was done using securing iv line, Inj Ringer lactate 5ml/kg/hr was SPSS software. started to all patients and premedicated with Inj glycopyrrolate 0.004mg/kg and Inj butorphenol 1mg IM ,30 min before surgery. IV infusion of Inj RESULTS clonidine 1.5 µg/ kg in group C while Inj magnesium sulphate 50mg/kg diluted in 100ml NS over 15 min Both groups were comparable with respect to age, in group M was started 30 min before surgery. In sex, body weight, duration of surgery and duration of operation theatre after preoxygenation for 3min with pneumoperitoneum (p>0.0.5) (Table 1). 100% oxygen, all patients were induced with Basal mean heart rate in Group C (86.4 ± 6.9 per injection propofol 2mg/kg and injection succinyl minute) and in group M (89 ± 7.5 per minute) was choline 2mg/kg intravenously and intubated with comparable and statistically not significant (p>0.05). cuff endotracheal tube within 30seconds. Before induction and after intubation mean HR was All patients were maintained with oxygen, nitrous increased in both the groups but rise in HR was less oxide, isoflurane and injection vecuronum bromide and statistically highly significant in group C 0.06mg/kg and infusion of injection propofol (P<0.01) compared to group M, while before and 100µg/kg/min. immediately after pnemoperitoneum, mean HR was reduced in both the groups but more in group C Intraoperatively Group (C) and group (M) were which was statistically highly significant (p<0.01). received, IV infusion of clonidine 1µg /kg/hr and magnesium sulphate 10mg/kg/hr respectively before No significant difference was observed in mean creation of pneumoperitoneum. Veccuronium arterial blood pressure intra and post operatively. bromide was supplemented when TOF stimulation Time for postoperative analgesic requirement was shows two twitch responses on PNS. earlier in group C (82.16±13.6) min as compared to Intraoperatively, pulse rate, mean arterial blood group M (146.33±19.56) min which was statistically pressure, SPO2, ETCO2 , ECG were monitored highly significant (P<0.01). Postoperatively up to before induction, after intubation, before and after two hours sedation score was high in group M pneumoperitoneum then every ten minute till the (3.6±0.4 to 2.5±0.5) compared group C (3.03±0.4 to surgery is over and after extubation. 2±0.18) which was statistically highly significant (P<0.01) so more sedation was observed in During surgery, intraabdominal pressure was magnesium group and had longer time (12.8min) for maintained between 11 to 15 mm of hg and recorded extubation as compared to clonidine group (6.1min). every 10min after creation of pneumoperitoneum. At Recovery of patients from anaesthesia and discharge the end of surgery, all infusions were stopped to ward was earlier in clonidine group (90 min) immediately after release of pneumoperitoneum. compared to magnesium group (120 min). So, When TOF stimulation shows all 4 twitch response patients were discharge to home earlier in clonidine on PNS, patients were reversed. Postoperatively, group as compared to magnesium group. No other mean pulse rate, mean blood pressure, Ramsay score side effects like hypertension, hypotension, nausea for sedation, VAS score for pain, nausea and and vomiting, respiratory depression, shivering were vomiting score, Aldrete score for recovery room observed in patients of both the groups.

Table 1: Patient characteristics given as mean (SD) Parameter Group C (n=30) Group M (n=30) p Value Age (Years) 35±9.47 31±12.2 0.16 Gender (Male / Female) 11 / 19 7 / 23 0.26 Weight (Kgs) 52.03±11.4 47.8±10.4 0.14 Duration of Surgery (in minutes) 97.33±22.99 88.83±22.27 0.15 Duration of Pneumoperitoneum (in minutes) 75.16±22.68 67.00±21.67 0.16

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 23 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Table 2: Mean heart rate (per minute) given as and observed significance incidence of bradycardia mean SD and hypotension in their study. Altan and turgut et al in 2005 4 used 3mcg/kg of clonidine IV over 15 min Time Group C Group M p Mean ± SD Mean ± SD Value before induction and 2mcg/kg /hr by continuous Baseline 86.46 ± 6.96 89.06 ± 7.55 0.12 infusion during surgery and observed similar Intraoperative Period findings. In this study, we reduced the dose of Before induction 88.4 ± 10.15 93.2 ± 14.6 0.02 clonidine 1.5 mcg/kg IV over 15 min in 100ml NS, After intubation 90.03 ± 10.8 96.9 ± 2.3 0.01 30min before induction as well as 1mcg/kg/hour Before PP 79.76 ± 9.71 88.6 ± 10.9 0.001 infusion before pneumoperitonium and didn’t After PP 77.5 ± 11.9 86.5 ± 12.15 0.005 observe any such side effects. 10 min 79.3 ± 13.6 86 ± 10.7 0.03 30 min 80 ± 12.4 83.1 ± 9.6 0.2 Elsharnouby et al in 20065 used magnesium 60 min 74.9 ± 8.9 76.7 ± 11.9 0.5 40mg/kg IV before induction and 15mg/kg/hr by 90 min 67.8 ± 6.7 74.8 ± 5.5 0.07 continuous infusion intraoperatively. They noticed 120 min 71.8 ± 3.3 more episode of hypotension using this dose of Postoperative Period magnesium. While bhattacharjee, et al in 20102 used 30 min 81 ± 8.6 81.1 ± 8.7 0.9 intravenous magnesium sulphate (30mg/kg before 60 min 81 ± 8.0 81.8 ± 8.7 0.7 induction and 10mg/kg/hr infusion intraoperatively). They noted that HR was significantly Table 3: Mean arterial pressure (mm of hg) giv- lower in both the groups. We used IV magnesium in en as mean SD a dose of 50mg/kg as a bolus preoperatively and reduced IV magnesium infusion to 10mg/kg/hr Time Group C Group M p intraoperatively and observed that none of the Mean ± SD Mean ± SD Value patients developed bradycardia/ tachycardia and Baseline 87 ± 7.3 88 ± 7.4 0.6 Intraoperative Period hypotension/ hypertension which was comparable 6 Before induction 88 ± 8.3 91 ± 8.2 0.1 with the study of D. Jee, D.lee et al in 2009. After intubation 85 ± 11.1 90 ± 10.8 0.07 So both clonidine & magnesium sulphate prevent the Before PP 83 ± 11.6 85 ± 11.8 0.5 stress response to laryngoscopy & pneumo- After PP 89 ± 13.6 93 ± 12.8 0.2 peritoneam but clonidine is more effective then 10 min 92 ± 13.7 94 ± 12.9 0.5 30 min 92 ± 12.1 92 ± 11.9 0.9 magnesium sulphate which can also be supported by 60 min 89 ± 11.7 91 ± 8.7 0.5 study of Abbady A. Ahmed et al in 2009 and Kalra, 120 min 87 ± 11.6 - - Anil verma, et al in 2012. After extubation 93 ± 6.4 94 0.7 Clonidine stimulates alpha-2 adrenergic inhibitory Postoperative Period 30 min 90 ± 7.9 87 ± 6.2 0.7 neurons in the medullary vasomotor centre, results 60 min 88 ± 6.9 89 ± 6.2 0.5 decrease in the sympathetic nervous system outflow from the CNS to the peripheral tissue, which is manifested as peripheral vasodilatation and a DISCUSSION decrease in systolic BP, HR and cardiac output.7 Stress response under general anaesthesia has been Magnesium sulphate blocks the release of universally recognized phenomenon. Direct catecholamines from adrenergic nerve terminals and laryngoscopy and passage of endotrachial tube are adrenal glands associated with tracheal intubation noxious stimuli that can provoke adverse (stress) moreover magnesium sulphate produce response.3 Hemodynamic changes observed during vasodilatation by acting directly on blood vessels and laparoscopy results from the combine effects of attenuates vasopressin stimulated vasoconstriction position of patients require for laparoscopy, which ultimately modulate hypertension and hypercarbia from the absorbed CO2 used for tachycardia and neurohumoral response in patients 4 pneumoperitoneum, raised intraabdominal pressure during CO2 pnemoperitoneum. and general anesthesia.3 In present study, sedation and extubation time as Various methods have been used to attenuate stress well as postoperative analgesia was more in response like: Alpha2-adrenergic agonists, beta- magnesium group. So, recovery of patients from blocking agents, opioids, vasodilators, magnesium anaesthesia and discharge from RR to ward and sulphate etc. In present study, effect of clonidine and home readiness is prolonged in magnesium group as /or magnesium sulphate is compared to attenuate compared to clonidine group. Results of Kalra, Anil hemodynamic stress response. Verma, et al in 2012 and Ray M, Bhattacharjee D et Ray M, Bhattacharjee D et al 20102 used 3mcg/kg of al 2010 were consistent with the present study. clonidine IV over 15 min before induction and Perioperative application of magnesium sulphate is 1mcg/kg /hr by continuous infusion during surgery associated with better analgesia, reduced PONV and

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 24 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 shivering, less discomfort and better quality of sleep vecuronium on neuromuscular block, CNS thus improved patients satisfaction but compare to depressant effect, and direct interaction with calcium clonidine , CNS depressent effects and synergestic ions needs careful management particularly in effect of magnesium sulphate with vecuronium on patients with impaired renal function or atria- neuromuscular junction may be contributing factor ventricular conduction disturbances. for prolong recovery in magnesium group.

α2a receptors mediate sedation, analgesia and REFERENCE sympatholysis, are founded densely in the pontine locus coeruleus which is an important source of 1. Koinig H, Wallner T, Marhofer P, et al. Magnesium sulfate sympathetic nervous system innervation of the reduces intra- and postoperative analgesic requirements. Anesth Analg 1998; 87: 206–10. forebrain and a vital modulator of vigilance. The sedative effects of clonidine most likely reflect 2. Ray M, dhurjoti bhattacharjee, et al studied the effect of intravenous magnesium sulphate and clonidine on 7 inhibition of this nucleus. anaesthetic consumption, hemodynamic and postoperative recovery in upper limb orthopaedic surgery under general Magnesium has a depressant effect at synapses by anaesthesia. Indian J. anaesth 2010;54:137-41. relative competition between calcium and 3. Miller Ronald D: anaesth for laparoscopic surgery: magnesium, mainly inhibiting presynaptic release of anaesthesia textbook :Churchill Livingstone;7th edition;2185- acetylcholine at neuromuscular junction. It has an 2197. antagonist effect at NMDA receptors thus 4. Altan A, Turgut N et al studied the effect of clonidine and decreasing stimulus for excitatory postsynaptic magnesium sulphate on anaesthetic consumption, hemo- potentials (EPSP) which indicate intrinsic analgesic dynamic and postoperative recovery. Br j anaesth 2005; 94: properties.4 NMDA receptors play a significant role 438-41. in neuronal plasticity and processes leading to central 5. Elsharnouby1 N. M, and M. M. Elsharnouby. Magnesium sensitization to pain. Thus magnesium has been sulphate as a technique of hypotensive anaesthesia. British shown to be useful in the reduction of acute Journal of Anaesthesia 2006;96 (6): 727–31. postoperative pain, analgesic consumption, or both. 6. Jee D., Lee D, Yun S. and Lee C. Magnesium sulphate attenuates arterial pressure increase during laparoscopic Clonidine also produces drowsiness by modifying the cholecystectomy. Br J Anaesth. 2009 Oct; 103(4):484-9. potassium channels in the CNS and thereby 7. Stoelting K.: Pharmacology and physiology in Anaesthesia hyperpolarize the cell membrane may be the practice. Anaesthesiology textbook (Lippincott Williams & mechanism but CNS effect of magnesium was more Wilkins); 4th ed. Cha-15, Antihypertensive drugs: 340-345 than clonidine. 8. Abbady A. Ahmed et al studied the treatment of stress response to laryngoscopy and intubation with magnesium sulphate. el-minia med. bull 2009;20(2). 9. Fawcett W.J. et al Magnesium: Physiology and CONCLUSION pharmacology. British Journal of Anaesthesia 1999; 83 (2): Administration of IV Clonidine 1.5mcg/kg was more 302-20. effective than IV magnesium sulphate 50mg/kg 10. J.H Ryu, M.H kang et al studied the effects of magnesium given 30 min before induction to suppress sulphate on intraoperative anaesthetic requirement and postoperative analgesia in gynaecological surgery receiving hemodynamic stress response to laryngoscopy and TIVA. British journel of anaesthesia 2008;100(3):397-403. tracheal intubation. 11. Kalra NK, Verma A, Agarwal A, Pandey HD. Comparative Administration of clonidine and/or magnesium study of intravenously administered clonidine and sulphate infusion just before pnemoperitonium magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy. J Anaesthesiol Clin effectively and equally attenuates hemodynamic Pharmacol.2011 Jul-Sep; 27(3): 344–48. stress response to pneumoperitonium. 12. Manorama singh. Stress response and anaesthesia. Perioperative use of magnesium sulphate provides Ind.J.anaesth.2003:47(6):427-433 postoperatively prolong analgesia and more sedation 13. Rajagopal, Paul: Anatomy And Physiology Of Airway And than clonidine without respiratory depression or any Breathing; Indian J. Anaesth. 2005; 49 (4) : 251 - 256 other adverse effects. Recovery of patients from 14. Sameenakousar, Mahesh et al studied the effect of fentanyl anaesthesia and discharge to ward and home and clonidine for attenuation of the hemodynamic response to laryngoscopy and tracheal intubation. JCDR 2012; 4988: readiness were earlier in clonidine group compared 2587. to magnesium group. 15. Singh M, chaudhry A et al studied the effect of intravenous So, both clonidine and magnesium sulphate can be and intramuscular clonidine to attenuate hemodynamic changes during laparoscopic cholecystectomy.saudi J anaesth used as an effective adjuvant to general anaesthesia 2013:7:181-6. reduce pain, analgesic consumption and stress 16. Wylie and Churchill Davidson’s: Intra-abdominal response to intubation and pneumoperitonium in laparoscopic surgery; anaesthetic implication; a practice of patients undergoing laparoscopic surgery. But, anaesthesia: 7th edition:893-904. Synergetic effect of magnesium sulphate with

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A STUDY OF DIPHTHERIA CASES AMONG HOSPITAL ADMISSIONS IN AHMEDABAD

Hiral H Shah1, Bijal H Shah2, Deepa A Banker3, Meet A Leuva4, Meghavi Patel4, Darshan S Patel4

Author’s Affiliations: 1Associate Professor Dept. of Pediatrics, AMC- MET, Ahmedabad; 2Associate Professor; 3Professor; 4Resident, Dept. of Pediatrics, NHL Municipal Medical College, Ahmedabad, Gujarat Correspondence: Dr Bijal S. Shah Email: [email protected]

ABSTRACT

Introduction: Even after 20 years of UIP diphtheria is still prevalent showing up and down trends in India. India contributes about 19 to 84% of total burden worldwide and many of time it is unidentified and notified. Present study is aimed to study Diphtheria cases in a tertiary care hospital Ahmedabad from January 2012 to December 2015 Methodology: Total 74 confirm throat swab smear or culture for C Diphtheria positive patients were included in study. Their age, immunisation status, response to treatment in form of throat swab clearance of bacilli, complications and mortality was noted and analysed. Results: 38(51.35%) were from 5-10 years age groups. Inappropriate booster doses and waning immunity in older age is responsible for shifting of age pattern . 9% of cases were fully immunised and had very milder form of disease. 56.65% were unimmunised had more severe form, complications, delayed clearance of throat bacilli and mortality. 90% patients throat swab cleared within 72 hours of starting treatment showing sensitivity of bacilli to slandered treatment. 12(18.9%) patients were expired mostly due to cardiac complications. Conclusion: Thus strengthening of routine immunisation, early identification and timely intervention can definitely overcome the resurgence of disease.

Keywords: Diphtheria, Immunisation, VPD, Diphtheria myocarditis, epidemic

INTRODUCTION Present study was done at a tertiary care centre of ahmedabad aimed to study Diphtheria cases trends. In 21st century with emergence of newer diseases like swine flu, zeka virus, HIV we have a false security of declining incidence of vaccine preventable diseas- METHODOLOGY es(VPD) .Diphtheria , a very common VPD ,still persistent in India without much decline in last dec- It was cross sectional observational study done over ade.1,2 After introduction of UIP in 1985 there was a the period of three years January 2012-december sudden decline in incidence of diphtheria by 1999 2015 in a tertiary care centre, teaching hospital and over worldwide including India (about 79%).But af- medical college of Ahmedabad. Ethical approval was ter 2000 there are different outbreaks at different dis- taken. tricts of India.3, 4, 5.India still contributes 18-84% of Aim of the study was to study age of occurrence, overall world load of Diphtheria. 6, 7, It is still endemic immunisation status, complications, mortality and in our country. The last decade has seen resurgence response to standard treatment in form of throat of diphtheria in both developed and developing swab clearance of bacilli. countries where it was previously well controlled 8,9 it is believed that these data are only tip of the iceberg, All the C.diphtheria swab/smear positive cases were still identification and notification of all cases is lack- included in study. Informed consent was taken. De- ing.10,11 Diphtheria vaccination is a one of the very tail history including age, sex, demographic profile, safe and most effective method of preventing cases clinical complains were noted as per profor- and outbreaks.12,13,14, provided it is completed with all ma.Immunisation history was taken in details. Ac- boosters. Control of disease can be obtained by cording to standard UIP guidelines if child had taken strong awareness amongst people for routine im- all vaccines up to his/her age was considered as fully munisation, mass immunisation campaigns. immunised. Even a single dose is remained child was considered as partially immunised. And child who

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 26 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 had not taken any immunisation at al considered as Maximum no of patients were 5-10 yrs (51.35%) unimmunised. Patients were investigated further and showed us recent shift in age of patients from less managed as per standard protocols. Bacterial clear- than 5 year age children to older age groups. ance was observed by throat swab routine microsco- 32 (44%) patients were from urban slums and py at 24 hours interval and throat swab clearance 21(56%) were from rural area. And most of (95%) time was noted in all .Different complications includ- patients were from Muslim community. ing carditis, acute renal failure, palatal palsy, mechan- ical obstruction, bronchopneumonia were noted. Ul- Total 60 (81.08%) were discharged successfully and timate outcome of all patients were noted. 14(18.9%) patients were expired. All the observation s were tabulated and analysed We observed maximum mortality in the patients who statistically. were totally unimmunised. Even patients who were partially immunised received only one dose of vac-

cine. Most of them had myocarditis and they came RESULTS very late to centre. The patients in which interventions were started within 72 hours of onset symp- Total 74 patients confirmed diphtheria positive pa- toms there was minimum morbidity and all were tients were included in study. 48(64.86%) were male successfully discharged. and 26 (35.13%) were female. After starting of treatment we have observed for

throat swab clearance Table 1: Distribution of diphtheria according to Almost 90% patients showed bacterial clearance age group (N=74) within 72 hours of starting treatment. The patients Age group (In Years) No. (%) who had persistent bacteria were all totally unim- 1-3 12 (16.2) munised and had bad outcome. 3-5 16 (21.62) 5-10 38 (51.35) We observed myocarditis was commonest complica- >10 8 (10.81) tion leading to mortality. More then one complications were present in many patients, still the reason for mortality was myocarditis.We have observed se- Table 2: Immunisation status of study partici- vere form of disease with many complications in pa- pants tients who were totally unimmunised. Vaccination status No (%) Fully immunised 6 (8.10) Partially immunised 26 (35.13) DISCUSSION Totally unimmunised 42 (56.75) Diphtheria epidemics are still persistent without much decline in many parts of India. Lots of out- Table 3: Outcome of study participants break studies of different districts like Assam 3, Hy- 4 5 9 Immunisation Discharged Expired Total derabad , Delhi and Maharashtra were done in status (%) (%) past decade. Still large no of the cases are not identi- Fully immunised 6 (100) 0 6 fied and even notified. Vaccine is still a gold standard Partially immunised 22(84.61) 4 (15.39) 26 of prevention of this disease 13, 14but still even after Totally unimmunised 32(76.19) 10 (23.81) 42 32 years of UIP, complete immunisation with all boosters is not reaching the targeted goals. Table 4: Throat swab clearance time In our study 51.3% of patients were from age group of 5-10 years. Before introduction of UIP diphtheria Throat swab clearance No (%) cases were maximum from <5 years of age group. In At 24 hrs 2(2.7) 48 hrs 30 (40.54) last decade change in age of presentation is observed 15 72 hrs 32 (46.0) in lots of studies even in developed world also .this >72 hrs 10 (10.81) is due to lack of booster immunisation and weaning of immunity of primary doses in later age. During 2015, about 86% (116 million) of infants worldwide Table 5: Complications and mortality received 3 doses of diphtheria-tetanus-pertusis Complications No (%) Mortality (%) (DTP3) vaccine, protecting them against diphtheria.. Myocarditis 26(35.0) 12(46.15) By 2015, 126 countries had reached at least 90% Palatal palsy 6(8.1) 0 coverage of DTP3 vaccine.12in India till 2014 DPT3 Laryngeal obstruction 8(10.81) 2(25.0) coverage was 74% as per NRHM data.12but again in Gujarat it is 56% till 2014.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 27 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 In our study almost 92% of cases were either unim- 3. Nath B, Mahanta TG. Investigation of an outbreak in Bor- munised or not immunised completely. Only borooah block of Dirbrugarh district, Assam. Indian J Community Med 2010;35:436-8. 6(8.10%) patients were fully immunised and they had very mild form of disease and all discharged success- 4. Bitragunta S, Murhekar MV, Hutin YJ, Penumur PP, Gupte fully. Complete immunisation including all boosters MD. Persistence of Diphtheria, Hyderabad, India, 2003– 2006. Emerg Infect Dis 2008;14:1144-6. is having a strong protective value for disease.12.13 To prevent outbreaks 90% of children less then 1 year 5. Sharma NC, Banavaliker JN, Ranjan R, Kumar R. Bacterio- logical and epidemiological characteristics of diphtheria cases should be immunised with DPT vaccine completely. in and around Delhi – A retrospective study. Indian J Med We have observed a grave outcome, with lots of Res 2007;126:545-52. complications and mortality with even delay in throat 6. Singhal T, Lodha R, Kapil A, Jain Y, Kabra SK. Diphtheria– swab clearance of bacilli in completely unimmunised Down but not out. Indian Pediatr. 2000;37:728-38. patients. 7. Ray SK, Gupta SD and Saha I. A report of Diphtheria sur- Most of the patients responded to standard treat- veillance from a rual Medical College, Hospital. Journal of ment showed clearance of bacilli within 72 hours of Indian Medical Association 1998 ; 96 (8) : 236-238. starting treatment .and 81.08% patients were dis- 8. Patel1 U, Patel1 B, Bhavsar B.A Retrospective Study of charged successfully. Patients who came late and Diphtheria Cases,Rajkot, Gujarat. Indian Journal of Com- who were totally unimmunised had complications munity Medicine Vol. XXIX, No. 4, October-December, like myocarditis expired.(case fatality rate 18.9%) 2004 Thus even in era of high no of resistant bacteria still 9. MN Dravid.M, Joshi S .Resurgence of diphtheria in Malega- C.Diphthrie is sensitive to standard antibiotics, pro- on & Dhule regions of north Maharashtra.Indian J Med Res. 2008 Jun;127(6):616-7. vided the treatment is started as early as possible. In Assam study done during outbreak 3 showed case fa- 10. WHO. Vaccine preventable disease monitoring system, global summary. Available at http://www.who.int/vaccine doc- tality rate only 3.33% while similar study done in Cali uments/Global summary/Global summary.pdf. Last ac- 16 showed 12.5% case fatality rate. cessed on 12th January, 2017 11. WHO vaccine-preventable diseases: monitoring system. 2016 global summary (india and world wide) CONCLUSION 12. Immunization. Available at: nrhm.gov.in/nrhm- Diphtheria is still prevalent in our area with the oc- components/rmnch.../immunization/background update currence of disease in older age groups. Complete 2016 Last accessed on 12th January, 2017 immunisation is gold standard for prevention and 13. Orenstein WA, Bernier RH, Dondero TJ, Hinman AR, better outcome of the disease. Early identification Marks JS,Bart KJ, et al. Field evaluation of vaccine effi cacy. and timely intervention is gold slandered for treat- Bull World Health Organ. 1985;63:1055–68. ment. 14. Bisgard KM, Rhodes P, Hardy IRB, Litkina IL, Filatov NN, Monisov AA, et al. Diphtheria toxoid vaccine effectiveness: a case-controlstudy in Russia. J Infect Dis. 2000;181(Suppl REFERENCE 1):S184–7. 15. Galazka Arthr, Robertson Susan. Diphtheria: Changing pat-

1. Manoj V Murhekar and Sailaja Bitraguntar. Persistence of terns in the developing world and the industrialized world. Diphtheria in India. Indian J Community Med 2011 Apr- European Journal of Epidemiology 1995; 11 (1): 107-117 Jun; 36(2): 164–165 16. Landazabal GN, Burgos Rodriguez MM, Pastor D; Diphthe-

2. K Park. Park’s Text Book of Preventive and Social Medicine, ria outbreak in Cali, Colombia, August-October 2000. Epi- th 16 Edition, Jabalpur: Bhanot Publishers, 2000; 125-128. demiological Bulletin 2001;22:3.

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ASSESSMENT OF QUALITY OF LIFE IN CHRONIC KIDNEY DISEASE PATIENTS IN A TERTIARY CARE HOSPITAL FROM SOUTH INDIA

Sasi Sekhar T.V.D1, Appala Naidu R.2, Vara Lakshmi R2, Ramya A2, Uma Devi U2

Author’s Affiliations: 1Professor & Head; 2Resident, Department of General Medicine, Dr Pinnamaneni Siddhartha In- stitute of Medical Sciences & Research Foundation, Chinoutpalli, Andhra Pradesh, India. Correspondence: Dr. Vara Lakshmi Rajanala Email: [email protected]

ABSTRACT

Introduction: The study was conducted to assess the physical and mental health dimensions of quality of life in the various stages of chronic kidney disease. Methodology: 100 patients in stages 1–5 of chronic kidney disease and 40 in hemodialysis were studied. Quality of life was rated by the Medical Outcomes Study Short Form 36- Item (SF-36) and functional status by the Karnofsky Performance Scale. Clinical, laboratory and sociodemographic variables were investigated. Results: Quality of life decreased in all stages of kidney disease. The dimensions showing lower values in stages 1 and 2 were emotional role functioning and general health; in stage 3, physical role functioning and vitality; and in stages 4 and 5 and hemodialysis, physical role functioning and general health. Conclusion: Quality of life is decreased in renal patients in the early stages of disease. No association was detected between the stages of the disease and the quality of life. It was possible to establish sociodemographic, clinical and laboratory risk factors for a worse quality of life in this population. It is a small study so cannot be applied in all aspects.

Keywords: Predialysis; Hemodialysis; SF-36; Chronic kidney insufficiency, Mental health, HRQoL.

INTRODUCTION HRQoL assessments can therefore identify possible problem areas related to health experiences. The The incidence and prevalence of patients with chron- concept of HRQoL builds on the subjective assess- ic kidney disease (CKD) is increasing worldwide.10% ment of the impact of disease and its treatment of the population worldwide is affected by chronic across the physical, psychological and social domains kidney disease (CKD), and millions die each year be- of functioning and well-being as is multidimension- cause they do not have access to affordable treat- al.4 ment.1 CKD 1–3 are not usually considered to impact on According the 2010 Global Burden of Disease study, the individual’s health experience, although some dis- chronic kidney disease was ranked 27th in the list of turbances may already have emerged. However, in causes of total number of deaths worldwide in 1990, CKD 4 the individual perceives an increasing but rose to 18th in 2010.2 amount of symptoms which may affect the The average incidence of chronic kidney disease HRQoL.6. Fatigue, muscle weakness, restless legs, Stage 5 (CKD5) in developing countries is 150 per cramps, itching, nausea and loss of appetite are fre- million, an incidence lower compared to the devel- quently reported symptoms.7 oped nations. In India, an estimated 100-220 per mil- Impaired HRQoL is well described among patients lion population reach CKD5 and approximately 10% on dialysis treatment.8 Low HRQoL scores in dialysis of these patients receive renal replacement therapy patients are further strong and independent predic- mainly due to socioeconomic limitations.3 tors of hospitalization and mortality.9 However, some When evaluating and improving health care in chron- studies have demonstrated deteriorated HRQoL also ic diseases, symptoms, function in daily life and well- in early stages of CKD, especially in physical health being are important patient outcomes . Health- but also in mental health.10 related quality of life (HRQoL) is a significant key Few studies have examined HRQoL patterns in dif- indicator of how a condition affects the patient’s life. ferent stages of CKD which indicate that more

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 29 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 knowledge is needed. The objective of this study was The procedure was repeated until the estimated therefore to evaluate HRQoL in patients with differ- number of participants was reached. The subjects ent stages of CKD up to initiation of dialysis treat- were interviewed prior to the medical visits or after ment and to explore possible correlating and influ- the hemodialysis session in a separate room by two encing factors and to signify need for multidiscipli- trained interviewers. nary approach All the subjects gave written informed consent to It was assumed that HRQoL would decline progres- participate in the study. To assess the QOL, we sively with impaired renal function but also that co- used the Medical Outcomes Study Short Form 36- morbidity, age, gender, inflammation, anemia, hyper- Item Health Survey (SF-36), a generic instrument tension and altered nutritional markers would impact translated and validated in Brazilian patients with negatively on HRQoL. ESRD and kornoffsky scale. SF-36 instrument is divided into 8 dimensions: physical functioning,

physical role functioning, pain, general health, vitali- METHODOLOGY ty, social role functioning, emotional role functioning, mental health. The results of each scale vary This was a cross-sectional study involving all the pa- from 0 to 100 (worse to best possible status). The tients with chronic kidney disease and who are on physical and mental components of the 8 scales hemodialysis from a tertiary care hospital , PSIMS were combined into a physical component summary &RF in chinoutpalli. . We excluded patients with re- (PCS) and a mental component summary (MCS). cent history of severe sepsis requiring hospitalization, severe trauma, recent fracture and malignancy. Ini- Chronic kidney disease (CKD) is defined as the pres- tially, a list of all patients with CKD (and another for ence of kidney damage or a glomerular filtration rate those on hemodialysis) was made, and a consecutive (GFR)<60 ml/min/1.73 m² for≥3 months . Stages number was given to each one. Then, a starting point of CKD and levels of renal function are described in was chosen at random and every fifth record (this Table 1. interval was prespecified) on the list was selected.

Table 1: Stages of chronic kidney disease (CKD) related to levels of kidney function, i.e., glomerular filtration rate (GFR) (National Kidney Foundation, 2002)5 CKD Stage Description GFR (ml/min/ 1.73 m2) 1 Kidney damage with normal or increased kidney function ≥ 90 2 Kidney damage with mildly diminished kidney function 60 – 89 3 Moderately reduced kidney Function 30 – 59 4 Severely decreased kidney function 15 – 29 5 Kidney failure <15

RESULTS Among the 140 patients in our study, 100 were ckd Table2: Characteristics of study participants pts and 40 were on hemo dialysis. Predialysispts are CKD Stage Cases devided into 5 stages and then grouped into 4 1&2 20 groups.The patients in the three groups of CKD 3 32 stage and those on hemodialysis were similar with 4&5 48 regard to their sociodemographic characteristics. Hemodialysis 40 With respect to laboratory variables, the groups dif- fered in some characteristics.

Table 3: Socio demographic profile Variable Stage1&2 Stage3Stage4&5 Hemodialysis Gender Male 11 19 28 22 Female 9 13 20 18 Mean Age (years) 52.8 ±10.5 58.3±16.9 58.1±16.5 52.5±15.9 Education Illiterate 4 4 6 5 School 8 17 25 25 College 8 11 17 10

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 30 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Table 4 : Risk factors Risk factors Stage 1&2 Stage3 Stage4&5 Hemodialysis Hypertension 4 6 13 9 Diabetes 5 7 13 13 Glomerulonephritis 2 2 4 2 idiopathic 9 17 18 16 Hemoglobin (g/dl) 14.6±1.9 13.0±1. 11.8±1.7 11.2±1.8

Table 5: Quality of life according to stage of chronic kidney disease: Variable Stage1&2 Mean ± SD Stage3 Mean ± SD Stage4&5 Mean ± SD Hemodialysis Mean ± SD Hb 13 ± 2 12 ± 2 11 ± 1 10 ± 2 PF 79 ± 9 74 ± 8 68 ± 8 61 ± 11 PRF 68.7 ± 15.8 64.1 ± 12.6 57.8 ± 17.2 48.8 ± 21.1 BP 65 ± 9 59 ± 6 61 ± 7 60 ± 5 GH 57 ± 19 60 ± 10 53 ± 8 53 ± 7 VT 61 ± 13 54 ± 10 58 ± 7 55 ± 7 SRF 76.9 ± 16.0 71.9 ± 11.4 73.4 ± 12.5 61.9 ± 15.7 MH 63 ± 11 60 ± 5 62 ± 6 61 ± 4 PSC 67.5 ± 7.4 63.9 ± 5.8 59.6 ± 5.4 55.3 ± 7.2 MCS 62.4 ± 8.9 63.2 ± 7.9 66.4 ± 6.3 59.4 ± 6.7 KS 80 ± 7 84 ± 9 77 ± 7 70 ± 12

Table 6: Mean and Standard Deviation for PSC, McS and KS Variable Stage1&2 Mean ± Stage3 Mean ± Stage4&5 Mean ± `Hemodialysis Mean ± Total Mean ± SD SD SD SD SD PSC 67.4 ± 7.4 63.9 ± 5.8 59.6 ± 5.4 55.3 ± 7.2 60.4 ± 7.6 McS 62.4 ± 8.9 63.2 ± 7.9 66.4 ± 6.3 59.4 ± 6.7 63.1 ± 7.7 KS 80.2 ± 6.9 83.7 ± 8.7 76.9 ± 6.9 70.1 ± 11.9 77.0 ± 10.3

There were total 20 patients of CKD stage 1 &2. Vitality, SF = Social functioning, RE = Role emo- Maximum number of patients were of CKD stage tional, MH = Mental health,PCS = Physical sum- 4&5. 40 patients were on Hemodialysis. mary scores, MCS = Mental summary scores Table 3 shows basic socio demographic profile of study participants. Mean age of all participants was around 56 years. 90 80 QOL, as evaluated by the means of SF-36 domains,decreased with respect to all doimains in all 70 stages and no much difference in between groups. 60 The dimensions, emotional role functioning and 50 general health showing lower values in stage 1 ans 40 2;physical role functioning and vitality in stage 3;physical role functioning and general health in 30 CKD1&2 CKD3 stage 4&5 and hemodialysis. No difference was ob- 20 served among the groups regarding the PCS, and the CKD4&5 DIALYSIS MCS and kps (Table 4) 10 0 Evaluating sociodemographic data, patients who had PF PRF BP GH VT SRF MH ERF PSC MCS KPS education performed better than the others in mean PCS. No significantly difference was found between Figure 1: HRQoL domains and summary scores (M) the mean PCS and MCS and kps when the patients in different stages of Chronic Kidney Disease (CKD) were divided by the etiology of CKD and the occurrence of hospitalization. From multivariate tests (MANOVA) for combined Figure 1 HRQoL domains and summary scores (M) variables p< 0.001 significant) of between subjects in different stages of Chronic Kidney Disease effect p< 0.001. With regards to age correlation sig- (CKD). PF = Physical functioning, RP = Role physi- nificant at 0.01 level (2 tailed) cal, BP = Bodily pain, GH = General health, VT =

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 31 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 DISCUSSION proffesionals improve the QOL .The health profes- sionals responsible for the care provided to this pop- Our study showed that low QOL scores in the early ulation should ideally be familiar with and trained in stages of CKD, although a significant decrease in the application of the QOL assessment tools, which QOL progressively in the different stages of renal may be valuable in the global assistance of these pa- disease was not demonstrated. Mean values of the tients, even in the earlier stages of disease, and allow physical components reduced as early as stages 1–3 timely health care interventions in the course of dis- of CKD and mental health also seemed to be com- ease. promised, based on the mean values of the SF-36 scores, which were below 70 in most dimensions. Normal healthy populations usually have scores REFERENCES above this level in most studies. Few studies have evaluated the QOL of patients in the early stages of 1. World Kidney Day: Chronic Kidney Disease. 2015; CKD. In these studies, a significant reduction in http://www.worldkidneyday.org/faqs/chronickidney- disease QOL was also not identified according to the progression of renal dysfunction. What is reported more 2. Garcia G, Iseki K, et al. Chronic kidney disease: global di- mension and perspectives. Lancet. J l 20 2013; 382(9888): frequently in the literature is a decrease in the physi- 260272 cal domains of QOL in the advanced stages of CKD, which was also identified in our study. 3. Veerappan, R. M. Arvind, V. Ilayabharthi. Predictors of quality of life of hemodialysis patients inIndia. Indian Jour- The subjective assessment of QOL is multifactorial, nal of Nephrology.Jan 2012, 221) and therefore the progression of renal dysfunction 4. Agneta A Pagels, Birgitta Klang Söderkvist, Charlotte Me- may not be the only determinant in its deterioration. din, Britta Hylander and Susanne Heiwe. Health-related In our study, more sociodemographic factors (age, quality of life in different stages of chronic kidney disease gender, professional activity, income) were associated and at initiation of dialysis treatment.Health and Quality of Life Outcomes 2012, 10:71 with decreased QOL than physical factors. Subjec- tive factors such as adaptation to disease and treat- 5. Harrisons principles of internal medicine , 18th edition, ment, satisfaction with the medical staff and social chronic kidney disease. chapter 200 support may interfere directly in the assessment of 6. NKF: KDOQI Clinical Practice Guidelines and Clinical QOL, but were not evaluated in this study. Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis 2006, 47(5 Suppl 3):S11 –S145 Some limitations of the present study are the relative- 7. Thong MS, Kaptein AA, Benyamini Y, Krediet RT, Boe- ly small sample size to detect significant differences schoten EW, Dekker FW: Association between a self-rated between the stages of CKD .The cross-sectional de- health question and mortality in young and old dialysis pa- sign of the study only permitted us to determine as- tients: a cohort study. Am J Kidney Dis 2008, 52(1):111 – sociations between variables and not causal relation- 117 ships. Thus, longitudinal studies that take into ac- 8. Chow FY, Briganti EM, Kerr PG, Chadban SJ, Zimmet PZ, count qualitative assessments should be conducted Atkins RC: Healthrelated quality of life in Australian adults with renal insufficiency: a population-based study. Am J to seek a better understanding of the influence of the Kidney Dis 2003, 41 (3):596–604 progression of CKD on QOL. 9. McHorney CA, Ware JE Jr, Raczek AE: The MOS 36-Item Short-Form Health Survey (SF36): II. Psychometric and clinical tests of validity in measuring physical and mental CONCLUSION health constructs. Med Care 1993, 31 (3):247–263 In this study, we observed decreased mental health 10. Bowling A: Measuring health: a review of quality of life of patients in the early stages of CKD. Early multi- measurement scales.3rd edition. Buckingham: Open Uni- disciplinary team effort,especially with mental health versity Pr; 2005

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THE INFLUENCE OF CENTRAL CORNEAL THICKNESS ON INTRAOCULAR PRESSURE, MEASURED BY DIFFERENT TONOMETERS: NONCONTACT AND GOLDMANN APPLANATION TONOMETERS

Punit Singh1, Raghunandan Kothari2, Himadri Patel3

Author’s Affiliations: 1Assistant Professor; 2Professor & Head; 3Resident, Department of Ophthalmology, Smt.B.K.Shah Medical Institute & Research Centre & Dhiraj Hospital, Wagodia, Gujarat Correspondence: Dr Punit Singh Email: [email protected]

ABSTRACT

Aim: The aim of this study is to determine if the central corneal thickness (CCT) influences the concordance of intraocular pressure (IOP) readings taken with a noncontact tonometer (NCT) and a Goldmann applanation tonometer (GAT). Methodology: 100 patients were enrolled in the present cross sectional comparative study. The difference in IOP readings between the 2 methods (NCT-GAT), were calculated and the relationship between the IOP readings, and CCT was analysed using a linear regression line. Results: IOP measured by both NCT and GAT was significantly correlated with CCT. NCT readings were significantly higher in the thicker group (CCT>or=530 micron) than in the thinner group (CCT<530 mi- crom). GAT readings had no difference between the thicker and thinner groups. An IOP value measured by NCT had a significant positive correlation with CCT .The value of IOP measured by NCT was significantly higher in the thicker group than in the thinner group. Conclusion: NCT can be more affected by CCT than GAT.Therefore CCT can influence the discordance of IOP readings taken with NCT significantly, whereas only minor influence is observed with GAT.

Keywords: Central corneal thickness, Intraocular pressure, Tonometers, Noncontact, Goldmann applanation tonometers

INTRODUCTION of applanation . The DCT uses the principle of contour matching. Glaucoma is the second leading cause of blindness worldwide.1 The only preventable risk factor for the GAT is the most commonly used device and is the development and progression of glaucoma is IOP. gold standard for measuring IOP.3 It calculates the Correctly measuring IOP is very important in diag- IOP by measuring the force needed to flatten a con- nosing glaucoma and conducting follow-ups. Medi- stant corneal area, of 3.06mm.4 cal, laser, or surgical treatments of glaucoma concen- The non-contact tonometer (NCT; Shin Nippon, trate on lowering IOP. Earlier studies have shown NCT 200, Japan), also called an airpuff tonometer. that every 1 mm Hg drop in IOP decreases visual The NCT uses a puff of air, at the cornea with an field damage by 10%.2 Therefore, precise measure- applanation area, similar to that of the GAT. The ments of IOP are very important. The various devic- force produced by the air puff is linearly increased es used for IOP measurement include the Schiotz over 8 ms and progressively flattens the cornea. tonometer, non-contact tonometer, Goldmann ap- When flat, the cornea reflects a light beam onto a planation tonometer, Dynamic contour tonometer sensor that triggers a reading. (DCT), Ocular blood flow tonograph, Ocular Re- sponse analyser. The ideal device must be easy to In this study, we aim to compare IOP measurements use, rapid, safe, and precise, irrespective of patient done with two different tonometers: the NCT and posture or age.3 The Schiotz tonometer works on the GAT (Appasamy Associates, TN, India) in individu- principle on indentation while the Goldmann appla- als having different Central Corneal thickness (CCT). nation tonometer (GAT), Tono-pen, Pneumatic tonometer, Perkins tonometer, work on the principle

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 33 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 METHODOLOGY Group A: Patients with low CCT (<530 µm) & Group B: Patients with high CCT (≥530 µm) This was a cross-sectional comparative study. A total of 100 eyes, randomly selected either eye of 100 patients in Dhiraj hospital from October 2014 to May RESULTS 2015 were included. Permission from institutional review board was obtained and all the participants The mean age of the patients included in the study were volunteers. was 59.94 years. The minimum being 35 years and the maximum 82 years. Of these there were 49 male All patients age of 18 years or more and of POAG, patients and 51 female patients. PACG, NTG, OHT, who are either newly diagnosed or on antiglaucoma drugs were included in the study. There were 53% patients between the age group of 60-80 years. Of them 27 were female and 26 were Patients with corneal surgery or any intra-ocular male patients. 33 had POAG, 16 with PACG, 2 of surgery done; patients with corneal edema, corneal NTG and 2 with OHT. Average CCT is 526.15μ and opacities & severe cases of corneal astigmatism or range from 445-560μ. The mean IOP of GAT was ocular surface disease and Patients with Neurological 23.69 mmHg and mean IOP by NCT was 24.48 cupping were excluded from the study. mmHg. All patients underwent a complete ophthalmic exam- 33% patients were between 50 to 60 years of age. Of ination including subjective and objective refraction, these 20 were male and 13 female patients.20 pa- best corrected visual acuity, slit lamp biomicroscopy, tients were of POAG and 13 were of PACG. The gonioscopy, dilated fundus evaluation with stereo- average CCT was 513μ. The IOP range for GAT was scopic biomicroscopic examination with a 90 D lens from 13 to 50 mmHg and for NCT was from 11 to . Automated visual field analysis and optic disc pho- 43.4 mmHg. tography were done in all patients to diagnose and assess the stage of glaucoma. There were 14 patients less than 50 years of age.9 were female and 5 were male patients. 9 with POAG, IOP of patients of POAG, PACG, NTG and OHT 4 with PACG and 1 of OHT. The mean CCT was with appropriately calibrated applanation tonometer 535.2μ. The GAT was from 14 to 34 mmHg and that and with NCT with 10-minute intervals. All meas- of NCT was from 17 to 40mmHg. urements were carried out between 10 am and 12 am. The NCT was used first to record three IOP The mean of Central Corneal thickness was 527.14 µ. readings. The device has a 5.7-inch color liquid crys- The maximum CCT was 565µ and the minimum was tal display and an auto puff control (APC), which 445 µ. provides a quieter and softer puff of air for the pa- IOP measured by NCT was from 11.00 mm of Hg tient’s comfort. If the first puff is too strong, the de- to 43.40 mm of Hg . The mean of NCT was 22.13 vice automatically uses a softer puff of air. The with a standard deviation of 8.103 for corneal thick- screen shows the results of three measurements, and ness<530 and the mean for corneal thickness ≥530 their average value was recorded for the study. was 27.54 with a standard deviation of 6.565. IOP The eyes were then anesthetized using Paracain measured by Goldmann applanation tonometer was drops and a fluorescein strip was applied to the infe- from 10.00 mm of Hg to 42.00 mm of Hg. The rior conjunctival fornix. GAT measurements using mean of GAT was 24.11 with a standard deviation of the cobalt blue filter of a biomicroscope were taken. 9.196 for corneal thickness<530 and the mean was 24.72 with standard deviation of 24.72 for corneal After this the central corneal thickness was measured thickness ≥530. using pachymtery. (mention here make of pacha) The measurements of IOP readings with GAT The patients were divided in two groups based on (F=0.964725, P=0.047) and NCT (F=2.682, corneal thickness P=0.105), followed a normal distribution (Levene’s test for equality of variances; P>0.05).

Table 1: Demography of subjects Variables Total (n=100) POAG(n=58) PACG(n=35) OHT (n=4) NTG (n=3) Age in years 59.94(35-82) 59.58(35-78) 58.93(40-77) 58.5(40-72) 77(73-82) Male 49 25 21 2 0 Female 51 30 12 2 3 GAT(mm Hg) 24.51(10-50) 25.65(10-50) 23.66(10-42) 22.75 (22-24) 14.6(10 to 20) NCT(mm Hg) 25.64(11 - 43.4) 26.80(11 - 42) 24.72(11 - 43.4) 25.25(25-26) 15.6(12-19) CCT (µ) 527.14(445 - 565) 529.1(470 - 565) 521.75(445- 560) 540(535 - 545) 527(512 - 535)

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 34 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 IOP measured by both GAT (r=0.049, P=0.625) and CCT is 520 μm, providing a “reference” value where NCT (r=0.325, P=0.001) was significantly correlated the applanating pressure equals the IOP.3 Thus the with CCT (as P<0.05 and r > 0.025 is significant cor- Imbert -Fick law stands when the ocular rigidity relation). The correlation between CCT and IOP ob- matches the surface tension. A cornea thinner than tained by GAT was significant but weak (r=0.049, 530µ may not have enough ocular rigidity. In this P=0.625). An IOP value of (NCT-GAT) (r=0.325, study, there were 36 subjects with less than 530µ P=0.001) (thinner group) and 64 subjects with 530µ and more (thicker group). We compared some factors between The samples were divided into 2 groups by CCT - both groups. Table 2 shows the results. Thicker group CCT ≥ 530 µ; Thinner group CCT<530 µ Silis and Hawlina9 concluded that in keratoconus patients, the IOP measured by NCT was significantly There were 64 patients in the study and 36 patients lower than GAT. Tonnu and associates10 found that in the thinner group. NCT significantly underestimated GAT measurements at lower IOP and overestimated at higher IOP in a study including 105 eyes with ocular hyperten- Table 2: Comparison of two groups sion or glaucoma. Sanchez-Tocino and co-workers11 Variables CCT(<530 µ) CCT (≥ 530) (n=64) determined a statistically significant difference (p < (n= 36) 0.001) between the measurements using NCT (15.6 Age in years 59.97(42-78) 59.93(35-82) ± 2.9 mmHg) and GAT (15.4 ± 2.7 mmHg). The Male 21 30 mean of the differences between the two tonometers Female 15 34 was 0.24 mmHg. GAT (mm HG) 24.11(12-50) 24.72(10-42) NCT 22.12(11-42) 27.54(11-43.4) The present results confirmed a significant correla- CCT (μ) 500.4(445-525) 540.95(530-565) tion between the IOP readings of NCT, GAT, and CCT. However, the coefficient of correlation be- DISCUSSION tween GAT and CCT was relatively low. This indicates that measurements with both NCT and GAT CCT affects the accuracy of IOP measurements by are affected by ocular rigidity. Ehlers concluded that applanation tonometer.6,7,8 Goldmann applanation GAT gives accurate IOP measurements only when tonometer (GAT) is the most commonly used device CCT was 520µ. Our data showed, in the normal IOP and is the gold standard for measuring IOP.3 It cal- range, the value of NCT is closely correlated with the culates the IOP by measuring the force needed to value of GAT, as NCT was calibrated on the basis of flatten a constant corneal area, measurements are not GAT.11 But for higher values of IOP, the NCT over- affected by scleral stiffness.4 A thicker cornea re- estimates while for lower values it underestimates. quires greater force to applanate, a thinner cornea is more easily flattened. A thin cornea is a significant However, NCT was not made on the basis of careful 11 risk factor for the development of glaucoma.5 considerations of the CCT. Thus value of NCT corresponds with the value of GAT in 530µ thick- Most published studies concerning the effect of CCT ness (near to 520). In a cornea that is thicker than on measured IOP relate to the Goldmann applana- 530µ, the IOP readings are overestimated by ocular tion tonometer (GAT). However, there is increasing rigidity. The present study showed that the readings evidence that other tonometers share this problem.5 taken with NCT were higher than GAT in corneas Thin shell theory was used by Orssengo and Pye to thicker than 530µ. demonstrate that corneal radius, thickness and material stiffness affect the applanation pressure for a giv- In NCT, fixed corneal area is applanated by a jet of en IOP. Reducing the applanation area reduces the air, which increases in force linearly. The GAT emits difference between the applanation pressure and a beam of light that is reflected from the corneal sur- IOP, because the corneal resistance for a smaller face with maximal intensity when a corneal area with 11 contact area is less.3 There may also be some reduced 3.60µ diameter is applanated. The time required to effects from surface tension. detect is directly related to IOP. The area applanated with NCT is larger than that with GAT, thus NCT The GAT is based on the Imbert-Fick law,3 which gives higher IOP readings. Schmidt12 showed that a assumes that the cornea has a dry surface, is infinitely change of internal pressure (when the cornea is ap- thin, and behaves as a “membrane” where the applanated) was so small that it could be negligible. planating pressure equals the IOP. In practice, a resistance force, by the corneal thickness, and a surface tension force, by the tear film, act upon the applana- CONCLUSION tor .Thus, this membrane assumption becomes in- correct. These forces balance each other for the The GAT readings had no significant difference be- GAT (applanation diameter of 3.06 mm) when the tween the 2 groups, but NCT was significantly higher

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 35 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 in the thicker than the thinner group. Thus NCT is 4. Ehlers N, Bramsen T, Sperling S. Applanation tonometry more affected by CCT (ocular rigidity) rather than and central corneal thickness.Acta Ophthalmol 1975;53:34. GAT. Previous reports support our results. 5. Gordon MO, Beiser JA, Brandt JD, et al. The ocular hypertension treatment study: baseline factors that predict the on- The IOP measurement with NCT is higher than set of primary open-angle glaucoma. Arch Ophthalmol 2002; GAT for thicker corneas, as the applanation area is 120:714–20. more and thicker corneas are more affected by ocular 6. Ehlers N, Bramsen T, Sperling S. Applanation tonometry rigidity (CCT) than the thinner corneas (CCT <530µ) and central corneal thickness. Acta Ophthalmol. 1975;53:34– 43. Therefore, the IOP measurements may be lower than the true IOP levels in a thinner cornea, and 7. Whitacre MM, Stein RA, Hassanein K. The effect of corneal thickness on applanation tonometry. Am J Ophthalmol. higher in a thicker cornea. 1993;115:592–596. Thus this article suggests that we should take the 8. Medeiros FA, Weinreb RN. Evaluation of the influence of characteristics of each tonometer into consideration corneal biomechanical properties on intraocular pressure when we evaluate the IOP. measurements using the ocular response analyzer. J Glauco- ma. 2006;15:364–370.

9. Goldmann H, Schmidt T. U¨ ber Applanation stonometrie. REFERENCE Ophthalmologica.1957;134:221–242. 1. Quigley HA. Number of people with glaucoma worldwide. 10. Goldmann H, Schmidt T. Weiterer Beitrag Zur Applanation Br J Ophthalmol. 1996;80(5):389–393. stonometrie. Ophthalmologica. 1961;141:441–456. 2. Goldberg I. Relationship between intraocular pressure and 11. Medeiros FA, Weinreb RN. Evaluation of the influence of preservation of visual field in glaucoma. Surv Ophthalmol. corneal biomechanical properties on intraocular pressure 2003;48(Suppl 1):S3–S7. measurements using the ocular response analyzer. J Glauco- ma. 2006;15:364–370. 3. Stamper RL. A history of intraocular pressure and its measurement. Optom Vis Sci. 2011;88(1):E16–E28. 12. Grolman B. A new tonometer system. Am J Optom Arch Am Acad Optom. 1972;49:646–660.

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A STUDY OF DIRECT AND CONCENTRATED SMEAR MICROSCOPY BY ZEIHL NEELSEN AND FLUORESCENT STAINING FOR DIAGNOSIS OF SUSPECTED TUBERCULOSIS IN TERTIARY CARE HOSPITAL

Rachana Patel1, Pragnesh Bhuva2, Mannu Jain3, Shashwati Bhuva4, Pinal Mangukiya5

Author’s Affiliations: 1Resident; 2Assi. Professor; 3Professor and Head; 4Tutor; 5Msc MLT student, Dept of Microbiol- ogy, SMIMER, Surat, Gujarat. Correspondence: Dr Rachana Dhirubhai Patel Email: [email protected]

ABSTRACT

Introduction: For early diagnosis of TB, it is essential to ensure proper identification. Smear microscopy is a simple, economical, less time-consuming technique is a good alternative. The stud was conducted to compare direct smear, concentrated smear and fluroscent microscopy of sputum of patient with tuberculosis; also to assess the sensitivity and specificity of direct and concentrated smear by ZN stain and fluorescent microscopy. Methodology: The 400 samples of suspected to be a case of pulmonary tuberculosis as per RNTCP guidelines are included. Direct smear and concentrated smear were made and stained by Carbolfuchsin methods which include the Ziehl-Neelsen (ZN) and Kenyon methods ( Light /bright field microscope) and Fluoro- chrome procedure using auramine-O or auramine-rhodamine dyes (Fluorescent microscope -FM). Result: On direct smear, out of 400 samples 138 samples were positive by ZN stain method and 150 samples were positive by FM stain method. While it was 154 samples and 156 sample by respective stains on concentrated smear. The sensitivity of direct and concentrated smear microscopy is comparable to FM stain and Zn stain. The difference between sensitivities (89.61 versus 96.15%.p<.01) obtained by the two methods was significant. The difference between sensitivities (92% versus 98.71%; p<.01) obtained by the two methods was significant. The specificity (100%) was similar for both techniques. Conclusion: The study showed that concentrated AFB microscopy is more efficient to detect M. tuberculosis in respiratory specimens than direct AFB microscopy. Fluorescent microscopy has higher sensitivity and comparable specificity which is further enhanced by concentration.

Key words: Direct and concentrated smear microscopy, Zeihl Neelsen and Fluorescent staining, Tuberculosis

INTRODUCTION sensitivity (10% higher) when compared with Z-N microscopy methods while speeding up the whole India is the country with the highest burden of TB.1 process to consume much lesser time. In this study Early diagnosis of TB is crucial both clinically and we wanted to compare the sensitivity and specificity epidemiologically. It is essential to ensure proper and obtained with smears for detection of AFB prepared early identification of cases and good treatment out- directly from respiratory specimens (direct AFB comes to be able to limit its transmission and obtain smears) to that obtained with the parallel smears successful TB control. Smear microscopy is a simple, prepared from concentrate of the specimens (con- economical, less time-consuming technique used for centrated AFB smears) and also to compare direct early detection, and it also has prognostic value.,This smear, concentrated smear and fluorescent and Zeihl method is specific, faster and cheaper for the detec- Neelsen microscopy of sputum of patient with tution of acid-fast bacilli (AFB) in sputum. It has sug- berculosis. gested that the performance of sputum smear microscopy can be significantly improved if sputum is liquefied with chemical reagents and then concen- METHODOLOGY trated by centrifugation or sedimentation prior to acid-fast staining. The newer alternative technique to The present study is hospital based cross sectional Z-N smear microscopy, FM is known to increase the observational study conducted over patients attend-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 37 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ing RNTCP in the SMIMER. Study was conducted field microscope) [2]Fluorochrome procedure using from 11th March 2016 to 31st May 2016. The study auramine-O or auramine-rhodamine dyes (Fluores- group consisted old and new cases of pulmonary tu- cent microscope). berculosis minimum total number of cases were 250. Statistical analysis was performed with IBM SPSS Sample size counted as per statistical formula. Statistics version 21 Software. Sensitivity and speci- A suspect was defined as an individual if he/she had ficity calculated.p-value less than or equal to 0.05 was persistent cough for more than three weeks, and/or considered as significance. evening rise of temperature for more than two weeks, and/or body mass index (BMI) less than 16. The sample of all adults of both the gender suspect- RESULTS ed to be a case of pulmonary tuberculosis as per In the present study, total 250 cases were taken. Out RNTCP guidelines are included. Samples other than of that 133(53 %) were new cases and 117(47%) sputum, samples macroscopically resembling saliva were already diagnosed cases. Out of total of 250 pa- are excluded. A total of 400 sputum specimens were tients, 162(64.8%) patients were male while rest aseptically collected and were transported in speci- 88(35.2%) patients were female. Majority of patients men transportation box (cool box) to the Tuberculo- (80) belong to in age group of 21-30 and minimum sis Laboratory at clinical laboratory for AFB micros- numbers of patients (5) in age group of greater then copy and culture. According to inclusion and exclu- 80 years. Maximum new cases (50) found in age sion criteria, 250 suspected/confirmed cases of pul- group of 21-30 years and maximum old cases (32) monary tuberculosis were taken. All they were sub- found in age group of 31-40years. jected to a thorough history, clinical examination and laboratory investigations. After sample collection In present study, we found that 16 cases were nega- homogenisation and decontamination was done by tive on direct smear came positive in concentration N-Acetyl L-Cysteine Sodium Hydroxide (NALC- method. Total out of 400, 138 sample were positive NaOH) method. In cases where there is no sponta- by direct smear method and 154 samples were posi- neous sputum production, a sample can be induced, tive for tuberculosis by concentration method. By usually by nebulized inhalation of a saline or saline FM stain 6 samples negative for tuberculosis by di- with bronchodilator solution. rect smear method came out to be positive by concentration method. Total out of 400, 150 samples Here two procedures used for acid-fast stain- were positive by direct smear method and 156 sam- ing:[1]Carbolfuchsin methods which include the ples were positive for tuberculosis by concentration Ziehl-Neelsen and Kenyon methods ( Light /bright method.

Table 1: Sputum result of study subjects 1 + 2 + 3 + SCANTY NEGATIVE TOTAL Direct ZN 76 28 11 23 262 400 Conc. ZN 39 63 37 15 246 400 Direct FM 54 58 17 21 250 400 Conc. FM 17 66 67 6 244 400

Zn Stain (Positive +1) FM Stain (Positive +1) Direct Smear Conc Smear

Figure 1: Stains

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 38 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 The sensitivity of direct and concentrated smear mi- The sensitivity of ZN stain and FM stain was differ- croscopy is comparable to FM stain and Zn stain. ent. The difference between sensitivities (92% versus The difference between sensitivities (89.61 versus 98.71%; p<.01) obtained by the two methods was 96.15%.p<.01) obtained by the two methods was found to be significant. These results showed that found to be significant. These results showed that FM stain increases the sensitivity of microscopy up concentrated technique increases the sensitivity of to 6.71% when performed with the same specimens. microscopy up to when performed with the same The specificity (100%) was similar for both tech- specimens. The specificity (100%) was similar for niques. both techniques.

DISCUSSION Table 2: Cross tabulation of Positive smear Early diagnosis of TB is crucial both clinically and grades by direct and concentration method by epidemiologically. It is essential to ensure proper and ZN stain early identification of cases, and good treatment out- Direct Negative Scanty 1+ 2+ 3+ Total comes to be able to limit its transmission and obtain smear successful TB control. AFB microscopy is believed results to be the most practical and fastest technique in es- Negative 246 14 2 0 0262 tablishing a diagnosis of pulmonary TB. Concentra- Scanty 0 1 21 1 023 tion method by NALC has been found to increase 1+ 0 0 16 54 676 the sensitivity of microscopy. The newer alternative 2+ 0 0 0 8 2028 3+ 0 0 0 0 1111 technique to ZN smear microscopy, FM is known to Total 246 12 39 63 37400 increase the sensitivity (10% higher) when compared with Z-N microscopy methods while speeding up the whole process to consume much lesser time. Table 3: Cross tabulation of Positive smear Fluorescent AFB can be seen at lower magnification grades by direct and concentration method by than ZN stained AFB. FM stain Comparison of direct and concentration method: Direct Negative Scanty 1+ 2+ 3+ Total In present study,we found that 16 cases were nega- smear tive on direct smear came positive in concentration results method. Total out of 400, 138 sample were positive Negative 244 6 0 0 0250 by direct smear method and 154 samples were posi- Scanty 0 0 17 4 021 1+ 0 0 0 48 654 tive for tuberculosis by concentration method. By 2+ 0 0 0 13 4558 FM stain 6 samples negative for tuberculosis by di- 3+ 0 0 0 0 1717 rect smear method came out to be positive by con- Total 244 6 17 66 67400 centration method. total out of 400, 150 sample were positive by direct smear method and 156 samples were positive for tuberculosis by concentration Table 4: Direct FL vs conc. ZN method. Direct FL Smear Conc. ZN Smear Total The sensitivity of direct and concentrated smear mi- Positive Negative croscopy comparing to FM stain and ZN stain, the Positive 150 0 150 Negative 4 246 250 difference between sensitivities (89.61 versus Total 154 246 400 96.15%.p<.01) obtained by the two methods was found to be significant. These results showed that concentrated technique increases the sensitivity of Table 5: Conc. FL vs Direct ZN microscopy up to when performed with the same Conc. FL Smear Direct ZN Smear Total specimens. The specificity (100%) was similar for Positive Negative both techniques. Positive 138 18 156 A study conducted by Barez et al. [2] showed that the Negative 0 244 244 sensitivity was almost similar in both methods as de- Total 138 262 400 scribed 81.6% for direct method and 82.7% for the concentrated method. In another study, Cattamanchi In present study, on direct smear, we found that out et al. [3] failed to find a difference in sensitivity be- of 400 samples 138 samples were positive by ZN tween direct and concentrated sputum smear micros- stain method and 150 samples were positive by FM copy, the calculated sensitivity of direct and concen- stain method. On concentrated smear, 154 samples trated smear microscopy was not significantly differ- were positive by ZN stain method and 156 samples ent (51% vs. 52%). were positive by FM stain method.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 39 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 In study of j.d.Harelimana [4] patients under 15 years found to be significant. These results showed that old, sputum concentration technique showed a dif- FM stain increases the sensitivity of microscopy up ference comparing to the direct smear microscopy to 6.71% when performed with the same specimens. (75% vs. 25%, C.I = 95%, P < 0.05). A study con- The specificity (100%) was similar for both tech- ducted by Apers et al.[5] showed that the sensitivity of niques. direct microscopy was 67.5% and the sensitivity of In a study of Zaib-un-Nisa, Javed H et al 2015 over- the concentration method 87.1%, an increase of all positivity increased by 2/9 (22.22%) by FL mi- 29%. croscopy over the conventional ZN method. The A study by Mindolli et al.,[6] showed that there was a difference in case detection was found to be statisti- significant increase in the sensitivity with the use of cally significant (p<0.00). FL technique has a better 5% NaOCl . The increase in the 23.14% smear posi- diagnostic value and is less time-consuming com- tivity with the use of 5% NaOCl with the centrifuga- pared to ZN in diagnosing tuberculosis in pediatric tion method was very encouraging as compared to patients. FL microscopy had more positive predictive that of the direct smears. value (PPV) than ZN microscopy. A study by Kaore et al.,[7] showed that there is rise of In a study of Roma Goyal et al[8] a total of 388 clini- 7.11% in sputum positivity over direct microscopy cally diagnosed pulmonary tuberculosis patients were by concentration method. A study by Ongkhzmmy included in the study Out of 388 sputum samples, et al., reported that the implementation of the bleach the smear positivity for AFB on the conventional method yields an overall increase in positivity of ZN method was 7.47% (29/388) while the positivity 33.5% . increased to 14.69% (57/388) on the modified fluorescent method. Comparison of ZN stain and FM stain: In present study, on direct smear ,we found that out of 400 In study of Saroj et al[9] direct fluorescent microscopy samples 138 samples were positive by ZN stain detected 9.29% paucibacillary sputum samples that method. And 150 samples were positive by FM stain were missed on ZN staining. On concentration, the method. On concentrated smear, 154 samples were sensitivity increased by 6.67% for ZN and 11.11% positive by ZN stain method and 156 samples were for AO. The sensitivity of AFB smear microscopy positive by FM stain method. increased by 27.41% and was statistically significant (p=<.001) when both methods were combined. The The sensitivity of ZN stain and FM stain was differ- specificity was 99.19% for both ZN and AO. ent. The difference between sensitivities (92% versus 98.71%; p<.01) obtained by the two methods was

Table 6: Comparison of slide positivity rate between ZN and FM in various studies Study Slide +ve rate by ZN Slide +ve rate by FM Sample size Prasanthi et al 10 50% 69% 38 Ulukanligil et al11 9.89% 12.47% 465 Golia S et al 12 10.41% 16.56% 634 Suria et al13 12.40% 19.10% 225 Jayachandra et a14 9.70% Not done 196 Our study 34.50% 37.50% 400

In present study, it was clearly evident that FM stain- The sensitivity of ZN stain and FM stain was differ- ing was more sensitive method than ZN staining in ent. The difference between sensitivities (92% versus both direct and concentrated technique. 98.71%; p<.01) obtained by the two methods was found to be significant. FM stain is more sensitive

then ZN stain.FM stain was 6.71% more sensitive CONCLUSION then ZN stain. It was observed that maximum number of pulmo- The study showed that concentrated AFB microsco- nary tuberculosis patients of our study group was in py is more efficient to detect M. tuberculosis in res- the 21-30 years age group. The sensitivity of direct piratory specimens than direct AFB microscopy. and concentrated smear microscopy comparing to Fluorescent microscopy has higher sensitivity and FM stain and zn stain. The difference between sensi- comparable specificity which is further enhanced by tivities (89.61 versus 96.15%.p<.01) obtained by the concentration. two methods was found to be significant. Concentra- Sputum examination for the tubercle bacilli is usually tion increases the sensitivity of test by 6.54%. conducted for patients clinically and/ radiologically suspected of pulmonary tuberculosis. However, the

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 40 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 standard method of sputum examination, that is, ZN cilli. The International Journal of Tuberculosis and Lung staining is not sensitive enough and a large number Disease. 2003;7(4):376-81. of the suspected cases miss diagnosis. Moreover 6. Mindolli,PB, Salmani MP, Parandekar PK. Improved many cases remain unsuspected and don’t seek DIANGNOSIS OF PULMONARY TUBERCULOSIS us- treatment. ing bleach microscopy method, Journal of clinical and diagnostic research: JCDR. 2013;7(7):1336. Fluorescent stain is a more efficient over ZN stain in 7. Kaore NM, Date KP, Thombare VR. Increased sensitivity of detecting Tubercle bacilli in sputum. Fluorescence sputum microscopy with sodium hypoclorite concentration has been found to be less time consuming compared technique: Apractical experience at RNTCPcenter. Lung In- to ZN method in the diagnosis of tuberculosis. dia: official organ of Indian Chest Society. 2011;28(1):17 8. Roma Goyal Anil Kumar,A Comparison of Ziehl-Neelsen Staining and Fluorescent Microscopy for Diagnosis of Pul- REFERENCE monary Tuberculosis OSR Journal of Dental and Medical Sciences (IOSR-JDMS)e-ISSN: 2279-0853, p-ISSN: 2279- 1. TB India. Available at: http://www.tbfacts.org/tb-statistics- 0861.Volume 8, Issue 5(Jul.-Aug. 2013). india/#sthash.MZULaYsQ.dpuf (assessed on 13th June

2016) 9. SarojHooja,Nita Pal, BhartiMalhotra, SumitGoyal,Vipin Kumarand LeelaVyas Comparison Of Ziehl Neelsen & Au- 2. Marie Yvette C, Barez MD, Myrna T, Mendoza MD, Regina ramine O Staining Methods On Directand Concentrated S, Celada RMT, Heidi R, Santos RMT. Accuracy of AFB in Smears In Clinical Specimens. Indian J Tuberc 2011; 58: 72- relation to TB culture in detection of pulmonary tuberculo- 76. sis. Phil J Microbiol Infect Dis. 1995;24(2):33–36. 10. Prasanthi K, Kumari AR. Efficacy of fluorochrome stain in 3. Cattamanchi A, Dowdy DW, Davis JL, Worodria W, Yoo S, the diagnosis of pulmonary tuberculosis co-infected with Joloba M, Matovu J, Hopewell PC, Huang L. Sensitivity of HIV. 2005. Indian J Med Microbiol 2005;23:179–81. direct versus concentrated sputum smear microscopy in

HIV-infected patients suspected of having pulmonary tuber- 11. Ulukanligil M, Aslan G, Tasci S. A comparative study on the culosis. BMC Infect Dis. 2009;9:53. doi: 10.1186/1471-2334- different staining methods and number of spec-imens for the 9-53. [PMC free article] [PubMed] [Cross Ref] detection of acid-fast bacilli. MemInstOswaldo Cruz. 2000;95:855-8. 4. J. D. Harelimana, J. Byiringiro, C. Mukaremera, G.

Ntamukunzi, A. Attahiru, C. M. Muvunyi, L. Mutesa Sputum 12. Global tuberculosis control 2012, WHO, Geneva, 2012 Concentration Improves Diagnosis Of Pulmonary Tubercu- 13. Suria K, ChandrasekarC, Rajasekaran S. Comparison of con- losis Cases In Children At A Tertiary Care Institution In ventional and fluorescent staining methods in diagnosis of Rwanda. RMJ 2013;.70(1). pulmonary tuberculosis among HIVseroposi-tive individuals. 5. Apers L, Mutsvangwa J, Magwenzi J, ChigaraN, Butterworth Jr of evolution of med and dental sci. 2012;1:463-66 A, Mason P, et al. Acomparison of direct microsco- 14. JayaChandra T, Selvaraj R, Sharma YV. Comparison of Vari- py,theconcentrationmethodandtheMycobacteria Growth In- ants of CarbolFuchsin and Phenol in ZiehlNeelsen Staining dicator Tube for the examination of sputum for acid-fast ba- to Detect AFB. J Mycobac Dis 2013;3:131.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 41 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

ETIOLOGICAL SPECTRUM OF CIRRHOSIS IN ANAND DISTRICT, GUJARAT, INDIA

Sulabhsinh G Solanki1, Nikhil D Patel2, Payal J Patel1

Author’s Affiliations: 1Assistant Professor, Dept. of M.L.T., Shri A. N. Patel PG Institute; 2Gastroentrologist, Jivan- deep Hospital, Anand, Gujarat Correspondence: Mr Sulabhsinh G Solanki Email: [email protected]

ABSTRACT

Introduction: Alcohol is considered to be a major etiological factor in western world, whereas viral etiology is considered to be predominant cause of cirrhosis in Indian subcontinent. Alcohol consumption and subsequent cirrhosis is increasingly seen in countries such as Japan and India. Early diagnosis and specific treatment for etiology can reverse the cirrhosis. Thus, we planned this study to define etiology for the development of cirrhosis. Methodology: All the consecutive patients with cirrhosis in last 4 years (February, 2012 to November, 2016) were analyzed for etiology. They underwent for the following investigations: liver function tests, complete blood count, alcohol and drug history, HBsAg, total anti HBc, anti HCV, Alpha Feto Protein, Ferritin, Ceru- loplasmin, eye check up for KF ring, α1-antitrypsin, autoimmune hepatitis profile, sonography and doppler of abdomen, 2-D echocardiography, endoscopy and liver biopsy. Results: A total of 304 cirrhotic patients (217 males, 87 female) were included and etiologies of cirrhosis were as follows [n (%)]:Alcohol in 105 (34.53%), Non Alcoholic Fatty Liver Disease (NAFLD) in 66 (21.71%), Cryptogenic-probable NAFLD in 50 (16.44%), Hepatitis B cirrhosis (HBV) in 35 (11.53%), Hepatitis C cirrhosis (HCV) in 16 (5.26%), Cryptogenic Cirrhosis in 16 (5.26%), Autoimmune liver disease in 7 (2.30%), Metabolic causes in 6 (2%) and Budd-chiari syndrome in 3 (0.98%). Conclusions: Alcohol remained the most common etiology of cirrhosis most commonly in males. NAFLD is also a major factor for cirrhosis, followed by HBV and HCV. Metabolic, autoimmune and vascular etiologies were seen in few patients. Most etiologies have peculiar age distribution. Key words: Cirrhosis, NAFLD, HBV

INTRODUCTION on liver transplantation program, as liver transplantation is the only available treatment that improves Cirrhosis has become a common disease due to survival and quality of life. heavy intake of alcohol in most countries, high prevalence of hepatitis B virus (HBV) and hepatitis C vi- Alcohol is considered to be a major etiological factor rus (HCV) infections; and new epidemic of non- for cirrhosis in western world and there is a rising alcoholic fatty liver disease (NAFLD).1There is a prevalence of alcoholism in young, women and af- trend towards increase in prevalence of cirrhosis and fluent class.1 Alcohol accounts for 80% of all liver subsequent morbidity and mortality worldwide.1,2 cirrhosis cases seen in district general hospitals in the UK. Alcohol consumption and subsequent cirrhosis According to recent WHO estimate, end-stage liver is increasingly seen in countries such as Japan and disease is responsible for one in forty deaths (2.5%) India which traditionally had a low prevalence of the throughout the World.3 As a cause of mortality, cir- disease.9, 25 HCV is steadily on rise in Europe, USA, rhosis ranks fifth most common in UK and ninth Egypt and Japan. HBV is highly prevalent in Asia most common in USA.1,4,5 A recent Scotland data and sub-Saharan Africa.1 With globalization, cheap suggests liver-related mortality has increased by dou- air travel and immigration, these viral infections are ble in males and by half in females.6 Increase in cir- spreading in variable frequency throughout the rhosis is getting translated in increasing prevalence of World.1 NAFLD has become commoner worldwide HCC worldwide, as 2-6% of all cirrhotics will devel- than before because of worldwide epidemic of obesi- op HCC every year.7,8,21 HCC is responsible for 0.5 ty and diabetes.1 Autoimmune, metabolic, toxic, vas- million deaths every year. Eventually increased cular and genetic disease represent minority of cases prevalence of cirrhosis will lead to increased burden

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 42 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 of cirrhosis. Of all chronic liver disease, 5-30% re- LKM-I, SLA/ LP, LC1, P-ANCA), sonography and mains cryptogenic despite multiple investigations, doppler of abdomen, 2-D echocardiography, endos- Burnt-out NAFLD, burnt-out autoimmune liver dis- copy and liver biopsy (as and when needed). This ease, occult viral infections and occult alcoholism study was approved by the Institutional Human Re- may be responsible for these cases. search Ethics Committee. The study patients were informed about the objective of the study. An in- Predicted burden of cirrhosis in India {general popu- formed consent was taken from all cirrhotic patients. lation (recent estimate: 1200 million)} is huge and varies according to different etiologies: Alcohol Statistical analysis: Data were statistically analysed (prevalence 5% and % expected to be cirrhotic 10%) using the SPSS statistical software (version 20 for 7.5 million, HBV (prevalence 3% and % expected to windows). Values of parameters were expressed as be cirrhotic 15%) 7.5 million, HCV (prevalence 1% Mean ± S.D. “p” values less than 0.05 (two-sided) and % expected to be cirrhotic 10%) 2.2 million and were considered to indicate statistically significant NAFLD (prevalence 10% and % expected to be cir- result. rhotic 5%) 7.5 million persons. Exact distribution of etiologies among cirrhotics is not well studied. It is commonly perceived that viral etiology especially RESULTS HBV is predominant cause of cirrhosis in Indian A total of 304 cirrhotic patients (mean age = 50 ± 16 subcontinent. Data regarding this matter is sparse. years) were included in the study. Among them, 217 According to WHO estimate, in India per capita al- were males (71.38%) and 87 were female (28.62%). cohol consumption is around 2 liters of alcohol and prevalence of alcoholism is 15-30% in males and 4- Etiology of cirrhosis: Etiologies of cirrhosis were 10% in females.9 Previous estimates have shown al- as follows: Alcohol in 105 (34.53%), NAFLD in 66 cohol to be caused of cirrhosis in 16% in biopsy (21.71%), Cryptogenic (probable NAFLD) in 50 proven cases.9 (16.44%), HBV in 35 (11.53%), HCV in 16 (5.26%), Cryptogenic cirrhosis [CC] in 16 (5.26%), Autoim- Early diagnosis and specific treatment for etiology mune liver disease in 7 (2.30%) [including autoim- can reverse the cirrhosis and thus prognosis and sur- mune hepatitis [AIH] in 5 (1.64%), AIH + PSC over- vival of these patients can be improved.11, 12 Hence lap in 1 (0.32%), autoimmune cholangitis in 1 the aim of this study was to find out various etiologi- (0.32%)], Metabolic causes in 6 (2.0%) [Including cal factors for the development of liver cirrhosis. Wilson’s disease [WD] in 4 (1.31%), Galactosemia in 1 (0.32%), Tyrosinemia in 1 (0.32%)], and Budd- chiari syndrome in 3 (0.98%). This is tabulated in ta- METHODOLOGY ble 1. This prospective observational study was carried out at Jivandeep Hospital and Shri A. N. Patel Post Graduate Institute, Anand, Gujarat, India from Feb- Table 1: Etiology of cirrhosis (n=304) ruary, 2012 to October, 2016. 304 consecutive pa- Etiology No. (%) tients of cirrhosis living in Anand city or nearby vil- Alcohol 105 (34.53) lages attending hospital were selected randomly for NAFLD 66 (21.71) the study. All those patients who were not confirmed Cryptogenic (Probable NAFLD) 50 (16.44) to be cirrhotic, excluded from this study. All the pa- HBV 35 (11.53) tients were carefully examined to determine the eti- Cryptogenic cirrhosis 16 (5.26) ology of the disease and related complication(s). Cir- HCV 16 (5.26) rhosis was diagnosed on the basis of presence of his- Autoimmune Hepatitis 5 (1.64) tory of decompensation, stigmata of the chronic liver Wilson’s Disease 4 (1.31) disease, portal hypertension on imaging, esophageal Budd-Chiari syndrome 3 (0.98) varices on endoscopy and/or cirrhosis on histolo- AIH+ PSC overlap 1 (0.32) 10 Galactosemia 1 (0.32) gy. Data were recorded on a proforma specially de- Tyrosinemia 1 (0.32) signed for this purpose. Autoimmune Cholangitis 1 (0.32) All the patients of cirrhosis underwent for the following investigations to define etiology: CBC (in- Relation of gender and etiology: Gender had sig- cludes Hb, platelet count and TC), liver function nificant relation with etiologies of cirrhosis: Alcohol tests (includes Bilirubin, SGPT, SGOT, SAP, GGTP, [105 (34.53%) vs. 0] was significantly common in Albumin, Globulin and PT), alcohol and drug histo- males, whereas Cryptogenic [39 (17.97%) vs. 27 ry, HBsAg, total anti HBc, anti HCV, Alpha Feto (31.03%)], AIH [3 (60%) vs. 2 (40%)], HBV [21 Protein, Ferritin, Ceruloplasmin, eye check up for (9.67%) vs. 14 (16.09%)] and HCV [7 (3.22%) vs. 9 KF ring, α1-antitrypsin, autoimmune hepatitis profile (10.34%)] were common in females. This is tabulated (gamma globulin, IgG, ANA, ASMA, AMA, anti in table 2.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 43 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Table 2: Relation of gender with etiology of cirrhosis among non alcoholic patient: Etiology Total (%) Male (%) Female p-value Cryptogenic 16 (5.26) 6 (2.76) 10 (11.49) 0.11 Cryptogenic (Probable NAFLD) 50 (16.44) 33 (15.2) 17 (19.54) 0.10 HBV 35 (11.47) 21 (9.67) 14 (16.09) 0.62 HCV 16 (5.24) 7 (3.22) 9 (10.34) 0.29 AIH 5 (1.96) 2 (0.92) 3 (3.4) 0.45 WD 4 (1.63) 3 (1.38) 1 (1.14) 0.44 BCS 3 (1.31) 1 (0.4) 2 (2.29) 0.41 AIH+PSC 1 (0.32) 1 (0.4) 0 - Galactosemia 1 (0.32) 0 1 (1.14) - Tyrosinemia 1 (0.32) 0 1 (1.14) - Autoimmune cholangitis 1 (0.32) 0 1 (1.14) - Total 304 (100) 112 (51.61) 87 (28.6) -

Table 3: Age wise distribution of etiological spectrum of cirrhosis: Age [year] <20 (%) 20-30 (%) 30-40 (%) 40-50 (%) 50-60 (%) >60 (%) Alcohol 0 6 (31.5) 29 (67.4) 40 (50.3) 24 (31.6) 6 (8.4) NAFLD 0 1 (5.2)0 5 (11.3) 28 (35.4) 32 (45.1) Cryptogenic (Probable NAFLD) 0 0 0 19 (24.1) 11 (13.9) 20 (28.1) Cryptogenic 4 (30.7) 4 (21) 7 (16.2) 1 (1.2) 0 0 HBV 0 5 (26.3) 4/43(9.3) 10 (12.6) 6 (7.5) 10 (14.1) HCV 0 0 0 3 (7.5) 8 (10.1) 5 (7.1) AIH 0 0 2 (4.6) 1 (1.2) 2 (2.5) 0 WD 2 (15.3) 2 (10.5) 0 0 0 0 BCS 2 (15.3) 0 1 (2.3) 0 0 0 AIH+ PSC 1 (7.6) 0000 0 Galactosemia 1 (7.6) 0 0 0 0 0 Tyrosinemia 1 (7.6) 00 0 0 0 Autoimmune Cholangitis 0 1 (5.2) 0 0 0 0

Relation of age and etiology: Age has significant etiologies of cirrhosis on the basis of maximum relation with following etiologies: alcohol, HBV, number of patients found in that particular age HCV, cryptogenic (probable NAFLD), CC, Wilson’s group. Alcohol and HBV was commoner after age of disease, AIH, Budd-Chiari syndrome: WD was 30 years, AIH in age range of 20-40 years; HCV and common before 30; Alcohol and HBV after 30; CC-NAFLD after age of 50 years and NAFLD after HCV after 50 and NAFLD after 60 years of age. Al- age of 60 years. This is shown in table 4. cohol: < 30 years: 6/105, > 30 years 99/ 105 patients; HBV: < 30 years: 5/35, > 30 years: 30/ 35 patients; HCV: < 50 years: 3/16, > 50 years: 13/ 16 DISCUSSION patients; NAFLD: < 60 years: 32/66, > 60 years: 34/ Various etiologies contribute to development of cir- 66 patients; WD: < 30 years: 4/4, > 30 years: 0/ 4 rhosis and later HCC, viral hepatitis and alcohol be- patients; Autoimmune liver disease: <20 years: 2/7, ing commonest. Epidemiology of liver cirrhosis is >20 years: 5/7; Cryptogenic (probable NAFLD): < different in parts of the world; with marked differ- 50 years: 19/50, > 50 years: 31/ 50 patients. HBV, ences between age, gender, ethnicity and geograph- HCV and NAFLD were not responsible for cirrhosis ical areas. Prevalence, nature and time of acquisition below the age of 20 yrs. This is tabulated in table 3. of the major risk factors for cirrhosis like HBV, HCV and alcohol may partially explain this.11 There Table 4: Significant cut off age for various etiol- are regional differences in relative contributions of ogies of cirrhosis these individual etiologies in development of cirrhosis.12-17 An understanding of these variations is very Etiology Cut off age (In years) important in developing public health and preventive Alcohol 30 Cryptogenic (Probable NAFLD) 50 strategies. Efforts at all levels of health care i.e. gov- HBV 30 ernment, health care agencies, health care profes- HCV 50 sionals and pharmaceutical agencies will be needed to NAFLD 60 curtail increasing burden of chronic liver disease and related mortality throughout the world.1,18 Significant cut off age for various etiologies of Contrary to global perception, alcohol is a predomi- cirrhosis: We suggested the cut off age for various nant etiology of cirrhosis in Western India. Alcohol

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 44 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 contributed to 34% of cirrhotics in our study, the (50 years). It is possible that environmental factors figure was even higher for males (48%). According may explain this finding, such as differential age at to previous study in 2000, alcohol was considered to exposure to HCV, but epidemiologic data supporting be responsible for 32% of all cirrhosis worldwide.19 this possibility are lacking. Recent increase in cirrhosis mortality in UK is In conclusion, NASH (proven & unproven) was the thought to be due to increased alcohol consumption most frequent etiologic factor for the development in last few decades, which might be reflection of easy of cirrhosis. This mostly develops in diabetes and availability of alcohol in market, relaxation in alcohol obese people. NASH can be prevented only with the policies and heavy effect of advertisements.1,20 In our control of CHO and Lipid content in their diet. study, alcohol is the most common etiology of cir- Even though, regular exercise may also help to rhosis even in the state where it is prohibited by law. workout in those patients who have their sedentary Globally, HBV contributed to 30% and HCV to life. The second most common etiological factor in 27% of cirrhosis, as per recent estimate in 2006.18 the development of liver cirrhosis was Alcohol in- Previous estimates have suggested 51% for HBV and take. Alcohol intake was seen mostly in men as com- 17% for HCV.18,21 Previous small-scale estimates pared to female. Patient may develop Hepatocellular from North India for relative contribution of viral Carcinoma in later stages. Therefore, awareness must etiology to cirrhosis suggested that HBV was respon- be created to avoid alcohol intake. It would be help- sible for 25-31%, HCV for 14-28% and combined ful in prevention of any type of liver disease includ- HBV-HCV 2-9% of cirrhosis.22,23 In a small study ing cirrhosis and HCC. Alcohol intake problem from western India, HBV contributed to cirrhosis in should be handled by the local health advisors and 16%, HCV in 11% and combined HBV- HCV in 2% religious leaders. Other minor etiological factor in- patients.24 Our study suggested around 11% for cludes HBV and HCV followed by Metabolic, auto- HBV and around 5% for HCV which was lower than immune and vascular etiologies in few patients. Most previous figures. etiologies have peculiar age distribution. The early diagnosis of above mentioned disease conditions NAFLD is the most common etiology for cirrhosis, may prevent the progression of disease severity and surpassing both HBV and HCV. Rising prevalence may also prevents the cirrhosis. of obesity and diabetes, adoption of western life styles, high calorie diet and sedentary habits are responsible for upcoming epidemic of NAFLD in our REFERENCE country.25 Prevalence of NAFLD in India is estimated around 5-28% of general population and 6-30% 1. Williams R. Global challenges in liver disease. Hepatology of all chronic liver disease in various series.26 In Ac- 2006; 44:521-526. cordance to previous series, most cases of CC were 2. Fleming KM, Aithal GP, Solaymani-Dodaran M, Card TR, due to burnt-out NAFLD. Metabolic, autoimmune West J. Incidence and prevalence of cirrhosis in the United Kingdom, 1992-2001: a general population-based study. J and vascular etiologies were seen in few patients. Hepatol 2008; 49:732-8. Preventable etiologies like alcohol, HBV and HCV 3. World Health Organization. The World health report 2003: were present in around 50%. Vaccination for HBV, shaping the future. Geneva: World Health Organization, safe blood, safe sex and safe injection practice, early 2003. treatment for these viral infections, awareness among 4. Harford TC, Brooks SD. Cirrhosis mortality and occupation. general population as well as medical-paramedical J Stud Alcohol 1992; 53:463-8 staff and widespread screening programmes can pre- 5. Bosetti C, Levi F, Lucchini F, Zatonski WA, Negri E, Vec- vent further spread of viral etiology of cirrhosis.18 chia C. Worldwide mortality from cirrhosis: an update to Awareness and education of life style, food, exercise 2002. J Hepatol 2007; 46:827-39. and activity might help in curtailing burden of alco- 6. Leon DA, McCambridge J. Liver cirrhosis mortality rates in holic as well as NAFLD as cause of cirrhosis. Britain, 1950 to 2002. Lancet 2006;367:645. Cirrhosis can occur at any age and often causes pro- 7. El-Serag HB. Hepatocellular carcinoma: an epidemiological longed morbidity. It is generally believed that cirrho- view. J Clin Gastroenterol 2002; 35:S72-S78. sis occur much less frequently in young adults than 8. Umemura T, Kiyosawa K. Epidemiology of hepatocellular in older patients. In our findings, the duration of al- carcinoma in Japan. Hepatol Res 2007; 37:S95-S100. cohol consumption was found to be significantly 9. Das SK, Balakrishnan V, Vasudevan DM. Alcohol: Its health higher in adult of age group of 30 years. Among old- and social impact in India. Natl Med J India 2006; 19:94-99. er patients, cryptogenic causes of cirrhosis were 10. Anthony PP, Ishak KG, Nayak NC, Poulsen HE, Soheuer greater as compared to younger patients. Genetic PJ, Sobin LH. The morphology of cirrhosis: definition, no- factors may likely to play a role in making patients menclature and classification. Bull World Health Organ more susceptible to NAFLD, and consequently cryp- 1977; 55:521-540. togenic/NAFLD/NASH cirrhosis.27 Cirrhosis 11. Mendez-Sanchez N, Villa AR, Chavez-Tapia NC, Ponciano- caused by HCV was also presented at an older age Rodriguez G, Almeda-Valdes P, Gonzalez D, et al. Trends in

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liver disease prevalence in Mexico from 2005 to 2050 tion and patterns of drinking to burden of disease: an over- through mortality data. Annals Hepatol 2005; 4:52-55. view. Addiction 2003; 98:1209-1228 12. Haukeland JW, Lorgen I, Schreimer LT, Frigstad SO, Brand- 20. Vass A. Rates of liver cirrhosis rise in England, fall in Eu- saeter B, Bjoro K, et al. Incidence rates and causes of cirrho- rope. BMJ 2001; 323:1388 sis in a Norwegian population. Scand J Gastroenterol 2007;

42:1501-8. 21. Kim WR. Global epidemiology and burden of hepatitis C. Microbes Infect 2002; 4:1219-1225 13. Stroroffolini T, Sagnelli E, Almasio P, Ferrigno L, Craxi A,

Mele A, et al. Characteristics of liver cirrhosis in Italy: results 22. Berry N, Chakravarti A, Kar P, Das BC, Santhanam, Mathur from a multicentre national study. Dig Liver Dis 2004; 36:56- MD. Association of hepatitis C virus & hepatitis B virus in 60. chronic liver disease. Indian J Med Res 1998; 108:255-299

14. Bayan K, Yilmaz S, Tuzun Y, Yildirim Y. Epidemiological 23. Agarwal N, Naik S, Aggarwal R, et al. Occult hepatitis B vi- and clinical aspects of liver cirrhosis in adult patients living in rus infection as a cause of cirrhosis of liver in a region with Southeastern Anatolia: leading role of HBV in 505 cases. intermediate endemicity. Indian J Gastroenterol 2003; Hepatogastroenterology 2007;54:2198-202. 22:127-131

15. De Bac C, Clementi C, Duca F, Livoli D, Poliandri G, Bozza 24. Sawant P, Rathi PM, Upadhyaya A. Hepatitis B subtypes and A, et al. Liver cirrhosis: epidemiological aspects in Italy. Res hepatitis C genotypes in cirrhosis in Western India: result of Virol 1997; 148:139-42. a pilot study. J Assoc Physicians India 1999; 47:580-583

16. Petersen J, Skinhoj P, Thorsen T. An epidemic of cirrhosis in 25. Amarapurkar DN. Approach to NAFLD in India. In Non- Danish women revisited. Scand J Soc Med 1986; 14:171-8. alcoholic fatty liver disease Ed. Khanna S. Elsevier, India 2010: 57-75. 17. Mendez- Sanchez N, Aguilar-Ramirez JR, Reyes A, Dehesa

M, Juarez A, Castaneda B, et al. Etiology of cirrhosis in Mex- 26. Amarapurkar DN, Hashimoto E, Lesmana LA, Sollano JD, ico. Annals Hepatol 20004; 3: 30-33. Chen PJ, Goh KL, et al. How common is non-alcoholic fatty liver disease in the Asia-Pacific region and are there local dif- 18. Perz JF, Amstrong GL, Farrington LA, Hutin YJF, Bell BP. ferences? J Gastroenterol Hepatol 2007; 22:788-93. The contributions of hepatitis B virus and hepatitis C virus

infections to cirrhosis and primary liver cancer worldwide. J 27. Puppala J, Siddapuram SP, Akka J, Munshi A. Genetics of Hepatol 2006; 45:529-38 Nonalcoholic fatty liver disease: an overview. J Genet Ge- nomics. 2013; 40:15–22. 19. Rehm J, Room R, Graham K, Monteiro M, Gmel G, Sempos CT. The relationship of average volume of alcohol consump-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 46 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

MORPHOMETRIC DIMENSIONS OF HUMAN EAR OSSICLES OF MALES

Shubhpreet Sodhi1, Zora Singh2, Jai Lal3

Author’s Affiliations: 1Senior Resident, Dept. of Anatomy, Dr.Y.S.Parmar Govt.Medical College, Nahan, Himachal Pradesh; 2Professor & Head, Dept. of Anatomy, Dasmesh Institute of Dental Sciences and Research, Faridkot; 3Professor & Head, Dept. of ENT, Guru Gobind Singh Medical College, Faridkot, Punjab Correspondence: Dr. Zora Sing Email: [email protected]

ABSTRACT

Introduction: The otologic surgeons need to be fully conversant with the anatomical details of middle ear and its bones so as to perform microsurgical maneuvers successfully. In India, data on normal anatomical parameters of the ossicles is limited. The present study attempts to provide the anatomical details of the three ossicles in North Indian Population in males and compare the parameters with those reported from different parts of the world. Methodology: The study was carried out on 100 sets of middle ear ossicles collected from adult male cadavers from the Department of Anatomy of various colleges of North India. The various measurements were taken with the help of digital verneir caliper Results: Our study reveals no significant difference between morphometric measurements of the bones of right and left side except Incus in males Conclusion: The precise measurements of the ossicles have been reported in the study in North Indian Pop- ulation (males), which would be very helpful in designing the prosthesis in ossicular chain pathology in North Indians.

Keywords: Otology, Ossicles, Measurements

INTRODUCTION achieve good postoperative results in patients who require middle ear surgery and to perform these mi- The tympanic cavity contains a chain of three mova- crosurgical maneuvers, the otologic surgeons need to ble auditory ossicles in humans – Malleus, Incus, be fully conversant with the anatomical details of the Stapes. These ossicles form a chain across the tym- ossicles of the middle ear. panic cavity from tympanic membrane to fenestra vestibule. These bones are bound together by articu- The present study was undertaken to provide the lations and have ligamentous connections with the valuable parameters of the three ossicles in North walls of middle ear cavity. These ossicles transmit the Indian Population for designing and constructing the sound waves smoothly from the tympanic membrane implants by using their precise measurements. and amplify them towards the surface of oval win- dow 1. Many congenital malformations of the middle ear ossicles have been reported to cause hearing METHODOLOGY problems 2,3,4. Globally, 250 million people are suf- The study has been carried out on 100 sets of middle fering from hearing loss, which is more than 4% of ear ossicles from adult male cadavers from the De- the world’s population; out of which 165 million partment of Anatomy of various colleges of North people live in developing countries. So, the develop- India. ing countries need more than 32 million hearing aids per year5. The calvaria was removed with the help of electric bone cutter and the brain was taken out to expose The ossicular chain reconstruction by the otolaryn- the petrous part of temporal bone. The duramater gologists can bring a significant improvement in was stripped off. The temporal bones were removed conductive hearing loses due to ossicular erosion6. en block with the help of hammer and chisel, a small The materials used in reconstruction of ossicular aperture was made by removing tegmen tympani to chain are autografts, homografts and allografts 7. To expose the roof of the middle ear. The rounded head

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 47 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 of the malleus articulating with the incus in epitym- panum were identified and were taken out with forceps after fine manipulations. Later to expose the stapes, a diagonal section of the temporal bone was taken through arcuate eminence. Then the stapes was removed with the help of fine forceps. This way, all the three ossicles were safely removed. These bones were cleaned (removal of any tissue attachment) and dried. The bones thus obtained were put into plastic satchel bags with zip locking mechanism. These pouches were assigned the serial number, side and gender. The following measurements were taken with the help of digital verneir caliper with the least count of 0.01 mm. Each bone was weighed on Metledo Figure 2: Shows various measurements of Incus weighing machine with least count of 0.01mg. 1) Measurements of Malleus (Fig1) 3) Measurements of Stapes (Fig 3) a) Total length: maximum distance between top of a) Total height: maximal distance between the top the head and the end of the manubrium (M1 in of the head and the foot plate (S1 in mm) mm) b) Length of foot plate: maximal length of the long b) Length of manubrium: distance from the end of axis of foot plate (S2 in mm) the lateral process to the end of manubrium (M2 c) Width of foot plate: maximal width of the foot in mm) plate (S3 in mm) c) Length of head and neck: maximal distance be- d) Index: Length of foot plate X 100/ total height tween the top of the head and the end of the lat- of stapes eral process (M3 in mm) e) Weight of Stapes( in mgs) d) Index: length of manubrium x 100/ total length e) Weight of Malleus(in mgs)

Figure 3: Shows various measurements of Stapes Figure 1: Shows various measurements of Malle- us The data has been statistically treated using SPSS software version 20.0 2) Measurements of Incus (Fig 2) a) Total length: maximal distance between the superior edge of the body and the end of the long RESULTS process (I1 in mm) All the parameters of the three bones of both sides b) Total width: maximal distance between the supe- (right and left) were analyzed statistically by applying rior edge of the body and the end of the short Independent Sample T test / Mann Whitney Test process (I2 in mm) (after the data analysis for assumption tests). All the c) Maximal distance between the tips of the pro- statistical calculations were performed using the cesses (I3 in mm) software SPSS version 20. The following parameters d) Index: Total width X 100/ total length of incus were recorded: e) Weight of Incus (in mgs)

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 48 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Table 1: Descriptive analysis of Malleus (n=50) Malleus Range Minimum Maximum Mean SD Right Left Right Left Right Left Right Left Right Left Total length (mm) 1.45 3.14 7.10 6.04 8.55 9.18 7.87 7.80 0.37 0.54 Length of Manubrium(mm) 2.14 1.78 3.23 3.52 5.37 5.30 4.47 4.42 0.41 0.42 Length of Head and Neck (mm) 2.43 2.31 3.30 3.53 5.73 5.84 4.70 4.68 0.43 0.41 Weight (mgm) 18.54 22.20 11.67 9.30 30.21 31.50 22.41 21.54 4.19 4.79 Index on right side was calculated to be 56.77% and on left side was 56.78%

Table 2: Descriptive analysis of Incus (n=50) Incus Range Minimum Maximum Mean SD Right Left Right Left Right Left Right Left Right Left Total length(mm) 1.43 2.01 5.56 5.32 6.99 7.33 6.465 6.48 0.36 0.42 Total Width(mm) 2.19 2.09 3.67 3.67 5.86 5.76 4.834 4.93 0.44 0.40 Two processes distance(mm) 1.86 1.87 4.32 4.42 6.18 6.29 5.396 5.23 0.40 0.44 Weight (mgm) 23.75 26.42 10.35 7.03 34.10 33.45 23.561 24.20 5.87 6.19 Index on the right side was calculated to be 74.87%and on left side was 76.04%

Table 3: Descriptive analysis of Stapes Stapes Range Minimum Maximum Mean SD Right Left Right Left Right Left Right Left Right Left Total height (mm) 1.31 1.16 2.59 2.91 3.90 4.07 3.38 3.39 0.25 0.26 Length of Footplate (mm) 0.82 0.962.53 2.17 3.35 3.13 2.82 2.79 0.19 0.19 Width of footplate (mm) 0.86 0.45 0.98 1.14 1.84 1.59 1.37 1.36 0.14 0.11 Weight (mgm) 2.93 3.05 0.89 0.98 3.82 4.03 2.51 2.60 0.65 0.68 Index on the right side was calculated to be 83.70% and on the left side was 82.74%

On comparison of right side of each parameter with incus and malleus in 1543 in his monumental work its left side of respective bone, no statistical signifi- “De Humani Corporis Fabrica” whereas Ingrassia cant difference was observed in case of malleus, in- and Eustachius9 were the first to describe Stapes in cus and stapes except in one of the parameters of in- 1546. cus i.e distance between long and short processes. According to Lempert and Wolff10, the ear ossicles Right side values were significantly at higher levels possess unique features in the form of : miniature than left side (p=0.047). The reason is difficult to size, adult state of which is attained during fetal life, comment at this point of time. However this has not isolated position in the middle ear, complete envel- been reported in literature earlier. opment of mucosa which is continuous with mucosa The correlation between the morphometric meas- of tympanic cavity and their constant involuntary ac- urements of the three bones were also studied using tivity. Pearson correlation test. A positive correlation was Though these bones attain full adult size during fetal found between total length of malleus with total life but continues to undergo changes throughout length of incus (p=0.005, r= 0.69) as well as with to- life, so the variations of the size and morphology of tal height of stapes,on left side(p=0.014, r=0.34). these bones are expected 11 Whereas, total length of incus showed positive correlation with total height of stapes on both sides (right Over the passage of time, very few studies are re- side p=0.024, r= 0.312), (left side p=0.004, r=0.39) . ported regarding the precise measurements of these miniature bones. The various parameters of the three Pearsons correlation test was also applied on the bones have been compared with those prescribed by weight of three bones and a positive correlation was other authors over the period of past 50 years as re- seen among the weights of all the three bone with ported from the different regions of the world.(table each other on both sides. 7,8,9)

When compared with the international studies, the DISCUSSION average dimensions of malleus were almost similar to South Africa subjects, but were on higher side to that The ear ossicles were first described in 16th century . of Turkey subjects and lower side to that of Colom- Hast and Garrisson 8 stated that Vesalius described bia and Isreal subjects. With in India, the dimensions

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 49 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 were at higher side to that of South population. But In case of Stapes, the values of the present study are when compared to regional areas, the values were at higher side to International studies (Turkey, Iran, similar to Gujrati population but were at little lower Switzerland, Israel). With in India, the dimensions level to Rajasthan, Rohtak and Uttar Pardesh popula- were again at higher side to that of South population tion and at higher side to Jaipur subjects. but at little higher level to regional studies of Patia- la,Jaipur and UP and at the lower level to studies In case of incus, the average dimensions are almost conducted in New Delhi. Values were very close to identical to Isreal and Turkey subjects. With in India, studies conducted at Jamnagar. the dimensions were again at higher side to that of South population (Mangalore, Mysore, Andhra Pra- Such a comparison of the observations on weight desh) and at lower level to regional studies (Raja- and dimensions of bones with those other workers sthan , Rohtak) and higher to that of Jaipur and Uttar confirm that the adult bones show marked morpho- Pradesh. metric variations.

Table 7: Comparison between morphometric data of Malleus with previous studies Author Population Sample Mean of Mean Of Length Mean of Weight Index Size Total Length Of Manubrium Head & Neck Harneja (1973)11 Jaipur 50 7.15 4.22 -- 23.65 -- Arrensburg (1981)13 Israel 31 7.8 4.4 -- -- 56.6 Oschman (1991)14 South Africa 90 7.84 4.39 -- .22gm -- Bhatnagar (2001)15 Punjab 60 8.36 4.65 -- 25.99 -- Unur (2002)16 Turkey 40 7.69 4.70 4.85 -- 60.97 Natekar (2010)17 Goa ------56.05 Jyoti (2011)18 Mysore 50 7.65 3.52 2.37 20.90 -- Kamal (2012)19 Rohtak 120 7.94 4.76 5.23 22.92 56.05 Gulrez (2013)20 Aligarh UP 30 8.00 4.58 ------Ramirez (2013)21 Colombia 23 8.53 4.91 ------Vinayachandra (2014)22 Mangalore 50 7.45 -- -- 18.26 -- Padmani (2014)23 AP 100 5.54 3.03 2.79 -- 54.73 Mogra (2014)24 Rajasthan 66 8.53 5.20 4.72 -- 61.01 Rathava (2015)25 Jamnagar 60 7.81 4.59 5.00 -- -- Present Study North India 100 7.83 4.44 4.68 21.97 56.77

Table 8: Comparison between morphometric data of Incus with previous studies Author Population Sample Mean of Mean of Mean Of Distance Weight Index size Total Length Total Width between two processes Haneja (1973)11 Jaipur 50 3.14 1.82 -- 25.06 -- Arrensburg (1981)13 Isreal 22 6.4 5.1 -- -- 80.1 Unur(2002)16 Turkey 40 6.47 4.88 6.12 -- 79.84 Natekar (2006)17 Goa 6.52 5.06 5.86 20.74 -- Jyothi (2011)18 Mysore 50 6.32 4.41 -- 23.82 -- Gulrez(2013)20 Aligarh 30 6.38 4.60 ------Padmini(2014)23 AP 100 5.13 3.47 4.5 -- 67.75 Mogra (2015)26 Rajasthan 66 7.26 5.95 6.80 -- 82.41 Kamal (2016)27 Rohtak 120 6.67 5.04 6.01 26.30 75.71 Present study North India 100 6.47 4.88 5.31 23.88 75.45

Table 9: Comparison between morphometric data of Stapes with previous studies Author Population Sample Mean of Mean of Length Mean of Weght Index Size Total Height of Footplate Width of Footplate Dass (1966)28 Patiala 165 3.29 2.79 1.43 3.02 -- Dass (1969)29 Patiala 100(fetal) 3.32 2.82 1.41 -- -- Harneja (1973)11 Jaipur 50 3.12 2.68 1.26 3.17 -- Arrensburg (1981)13 Isreal 3.2 2.8 1.3 -- 85.1 Awenger (1995)30 Switzerland 10 -- 2.48 ------Unur(2002)16 Turkey 40 3.22 2.57 1.29 -- 80.06 Wadwa (2005)31 New Delhi 17 3.41 2.97 0.38 -- -- Farahani (2008)32 Iran 12 3.28 2.99 1.43 -- -- Jyoti (2011)18 Mysore 50 3.11 3.12 1.51 2.23 -- Gulrez (2012)20 Aligarh 30 3.18 2.93 1.60 -- -- Padmini (2014)23 AP 100 2.71 2.36 -- -- 87.2 Rathava(2014)33 Jamnagar 60 3.33 2.78 1.34 -- -- Present study North India 100 3.38 2.80 1.36 2.55 83.22

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 50 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 CONCLUSION 13. Arrensburg B, Harell m, Nathan H. the human middle ear ossicles, morphometry and taxonomic implications. Journal The three ossicles are morphometrically similar in of human Evolution,1981;10:199-205. both the ears except Incus, which showed the signif- 14. Oschman Z, Meiring JH. A morphometric and comparative icant difference in left and right side. A positive cor- study of the malleus. Acta Anat,1991; 142:60-61. relation was found between the weights of three 15. Bhatnagar DP, Singal P, Thapar SP. Anatomy of malleus – A bones in right as well as left side and also between human ear ossicle; Anthropologists, 2001; 3(2): 139-141. total length of malleus with total length of incus and 16. Unur E, Ulger H, Ekinci N. Morphometrical and morpho- total length of malleus with total height of stapes on logical variations of middle ear ossicles in the new born. left side. Total length of incus was positively corre- Erciyes Medical Journal, 2002; 24(2):57-63. lated with total height of stapes on both sides. 17. Natekar P, De Souza M. Indices of malleus in reconstructive surgery. Indian journal of Otology, 2010; 16: 36-40. The precise measurements of the ossicles have been 18. Jyoti KC, Shama SN. A study of morphological and mor- reported in the study in North Indian Population phometrical analysis of human incus. Int J of Current Re- (males), which would be very helpful in designing the search,2015; 7(5): 16102-104. prosthesis in ossicular chain pathology in North In- 19. Singh K, Chhabra S, Sirohiwal BL et al. Morphometry of dians. The variations seen in the dimensions of the malleus, a possible tool in Sex Determination. J Forensic ossicles with other studies confirms that the adult Res, 2012; 3(6): 152-154. bones show marked morphometric variations or it 20. Gulrez N. Can fetal ossicles be used as prosthesis in adults? may be due to racial differences or regional popula- A morphometric study. International Journal of Experi- mental and Clinical Anatomy, 2013; 6-7: 52-57. tion difference. This variability should be a strong reminder, that sculpting an ossicle for ossiculoplasty 21. Ramirez LM, Ballesteres LE. Anthropometry of Malleus in Humans: a direct anatomical study. International Journal of or reconstruction,must be customized to a particular Morphology, 2013;31(1): 177-183. ear. Even the implantable hearing aids may yield bet- 22. Vinayachandra PH, Viveka S, Sudha MJ. Morphometry and ter performance if they are customized to variations variations of malleus with clinica correlations. Int J of Anat in ossicle masses and linear dimensions. Res, 2014; 2(1):191-94. 23. Padmani MP,Rao NB. Morphometry of human fetal ear ossicles: a human cadaveric study. British journal of Medicine REFERENCE and Medical Research, 2014; 4(9): 1873-1882. 1. Standring, Gray’s Anatomy, 40th Ed; Elsevier Churchill Liv- 24. Mogra K,Gupta S, Chauhan S. Morphological and mor- ingston; 2005: 627-630. phometrical variations of malleus in human cadavers. Inter- 2. Werhs F. Congenital absence of long process of Incus. The national Journal of Healthcare and Biomedical Research, Laryngoscope, vol 109(2):192-197. 2014; 2 (3):186-192. 3. Evcimik MF, Ozkurt FE, Ahmet K. the morphological find- 25. Rathava J, Trivedi P, Kukadiya U. Morphometric study of ings of malleus and incus in a case of Marfan’s syndrome. malleus in gujrati population. International journal of Ad- The laryngoscope,2012; 122: 389-392. vanced Research, 2015; 3(3): 306- 310. 4. Bruintje TD. The auditory ossicles in human skeletal remains 26. Mogra k, Panwar L, Shekhawat S. Morphological and mor- from a leper cementry in Chichester, England. Journal of phometrical variations of Incus in human cadavers. Interna- Arch Sci, 1990;17(6):627-633. tional Journal of Medical Research prof, 2015; 1(2): 11-13. 5. Kumar S. WHO tackles hearing disabilities in developing 27. Singh K,Rohilla A,Jyoti. Incus morphometry : a possible tool world. Lancet,2001;3, 58:219 in sex determination. Journal of Forensic Research, 2016; 7: 320. 6. Prendergast PJ, Ferris P, Ric HJ. Vibroacoustic modeling of the outer and middle ear using the nite element method. Au- 28. Dass R, Grewal B.S,Thapar S.P. Human stapes and its varia- diology and Neuro-otology,1999; 4:185-191. tions I General Features. Journal of Laryngology and Otolo- gy,1966; 80(1): 11-25. 7. Zenev I, Zenev E, Sopundzhiev N. Scanning electron microscopy of auditory ossicles. Journal of otology,2006; 3:112- 29. Dass R, Thapar S.P, Makhni S.S. Feotal stapes I General fea- 116. tures. Journal of Laryngology and Otology1969; :101-117. 8. Hast MH, Garrison DH. Vesalius on the variability of hu- 30. Awenger D.F. Measurements of the stapes superstructure. man skull: Book I chap V of De Humani Corporis Fabrica. Ann Otol Rhinol Laryngol, 1995;104: 311-316. Clin Anat, 2000;13(5): 311-320. 31. Wadhwa S, Kaul JM, Agarwal AK. Morphometric study of 9. Francesco C, Aldo G, Giovanni Z. Giovanni Filippo In- stapes and its clinical implications. Journal of Anatomical So- grassia: a Five Hundred Year Long Lesson. Clinical Anato- ciety of India, 2005; 54(2):1-9. my, 2010; 23: 743-749. 32. Farahani RM, Nooranipur M. Anatomy and Anthropometry 10. Lempert J, Wolff D. histopathology of incus and head of of human stapes. American journal of otolaryngology- Head malleus in cases of stapedial ankylosis. Arch Otolaryng, 1945; & Neck Medicine and Surgery, 2008;29: 42-47. 42: 333-367. 33. Rathava JK, Gohil DV, SataparaVK. Osteometric dimen- 11. Harneja NK, Chaturvedi RP. A study of human ear ossicles. sions of stapes. Journal of Res Med Den Scien, 2014; 2(2): Indian journal of otology,1973;25: 154-160. 30-33. 12. Harada O, Ishii H. The condition of auditory ossicles in mi- 34. Natekar PE, De Souza FM. A morphometric study of malle- crotia: findings in 57 middle ear operations. Plastic recon- us and incus and its clinical implications. Indian J Otol,2006; struction surgery, 1972; 50: 48-53. 12: 6-9.

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VACUUM ASSISTED PLASTINATION USING MELAMYNE

Aarushi Jain1, Sandhya Mehra2, Kalpana Makhija1, Shweta Asthana2

Author’s Affiliations: 1Assistant Professor; 2Senior demonstrator, Anatomy, Govt. medical college, Kota, Rajasthan Correspondence: Dr Aarushi Jain Email: [email protected]

ABSTRACT

Introduction: This study is an attempt to perform plastination using indigenous method which is cheap, executable and does not require extremes of cold temperature and technical instruments. The effectiveness of the procedure was judged by calculating shrinkage post plastination, external appearance, polymer cost and consumption, extra equipment cost, and student’s feedback post teaching with plastinates. Methodology: The present study was conducted from June 2016 to December 2016 in Department of anatomy, GMC Kota Rajasthan. The cadaveric specimens procured were fixed in 10% formalin. The measurements were taken by scale and digital vernier caliper. The steps of plastination were same as the original technique i.e. Fixation, Dehydration, Degreasing, Forced Impregnation in vacuum and Curing (hardening). Simple technique using indeginous instruments were used to apply the vacuum fitted with the timer for 20 minutes Final measurements were taken of all the specimens and then ANOVA between the groups in medcalc software was used to compare the shrinkage. Results: Dry, odourless, portable and aesthetically pleasing plastinates were obtained. The dimensions were much reduced after each step except after vacuum assisted impregnation there was slight increase in the dimensions though it did not reach the initial value. Conclusion: Feedback from students regarding plastinates revealed that they were easy to handle but less flexible and difficulty in visualizing deeper structures but good for cross-sectional anatomy as the tissue got fixed and displacement of structures was minimal. These plastinates are excellent adjunct for teaching as they have nullified exposure to the toxic fumes of formalin.

Keywords: Plastination, intermittent vacuum assisted impregnation, melamyne, acetonometers

INTRODUCTION ternal appearance, polymer cost and consumption, extra equipment cost and student’s feedback post Plastination is the process of permanently preserving teaching with plastinates. tissue in a natural state by replacing the body fluids (i.e. fat and water) with synthetic materials. The S 10 technique is the standard technique in plastination METHODOLOGY which gives opaque, more or less flexible, and natural looking specimens.1 But the standard technique is The present study was conducted from June 2016 to quite costly as it requires extremes of temperature December 2016 in Department of anatomy, GMC and technical instruments. Thus cost effective and Kota Rajasthan. The cadaveric specimens procured feasible plastination technique is an ongoing chal- were fixed in 10% formalin. The measurements were lenging aspect for anatomist all over medical colleges taken by scale and digital vernier caliper. Prosection in India due to lack of funds and limited infrastruc- of arm, forearm, neck at C6, brain with internal cap- ture. In 1998, Daniel Corcoran, Dow Corning Cor- sule ,paranasal sinuses coronal section and floor of poration, proposed a different silicone impregnation fourth ventricle and lateral ventricle were used. Con- mixture, and the room temperature plastination sumables—Acetone, xylene, hardener, paint brush, technique was developed 2,3,4,5,6. This study is an at- acetone, glass jars , vacuum chamber, acetonometer tempt to perform plastination using indigenous /alcoholmeters, mortuary chamber. method which is cheap, executable and does not re- Dehydration—The specimens were then transferred quire extremes of cold temperature and technical in- to acetone specific gravity -0.8 which was measured struments. The effectiveness of the procedure was by acetonometer /alcoholmeters (fig no. 1). Speci- judged by calculating shrinkage post plastination, ex- mens were subjected to 3 changes of acetone. Each

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 52 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 change comprised of 7days treatment. Last change wiped off from extra polymer. Again all the meas- was reused for other specimen till the specific gravity urements were taken. decreased to 0.6. Measurements were taken after last Curing and hardening –Specimens were shifted change. into a sealed chamber with diluted sulfuric acid in a Degreasing: Dehydrated specimens were then sub- beaker and calcium chloride as hygroscopic element jected to 3 changes of xylene, each change of 7 days. in other beaker. The whole chamber was then trans- Xylene acts as the volatile intermediary with the acid ferred into freezer (mortuary chamber) with tem- curing polymer and also a degreasing agent for lipid perature of 10°C for 1 month. After drying the rich specimens.10 Measurements were taken after last whole chamber was kept in UV light at room tem- change. perature. Final measurements were taken of all the specimens and then ANOVA in medcalc software Impregnation—A intermittent vacuum assisted im- was used to compare the shrinkage. Shrinkage was pregnation was done for the specimen which com- calculated as Final reading(of each step)/ Initial prised of solution of melamyne and xylene mixed in Reading X100. proportion 1:1 (Fig 2) A vacuum of 7 mm of Hg was applied till the bubbling ceased ( as average of 10 days for the specimen.) Timer was set for twenty RESULTS minutes with a pause of five minutes. The specimens Dry, odourless, aesthetically pleasing plastinates were were taken out of vacuum chamber and they were obtained which were lighter (Fig 3-8)

Table 1: Comparision of specimens using ANOVA within subjects Specimens Sum of Squares DF Mean Square F P PNS 2.342 4 0.586 2.83 0.052 4th Ventricle 0.782 4 0.195 24.82 0.004 Internal Capsule 4.686 4 1.172 7.95 0.035 Lateral Ventricle 3.16 4 0.8 8.2 0.035 Anterior horn of Lateral Ventricle 3.181 4 0.795 8.05 0.034 Root of Neck 1.063 4 0.266 5.51 0.02 T.S. of Hand (Wrist) 0.808 4 0.202 1.67 0.316 T.S. of Proximal Forearm 1.09 4 0.273 1.29 0.405 T.S. of Distal Forearm 0.947 4 0.237 2.46 0.202 DF – degrees of freedom, PNS- paranasal sinuses T.S- transverse section

Table 2: Specimens showing shrinkage in Percentage Specimens Initial After Dehydration After Degreasing After Impregnation After Plastination PNS 100 93.02±5.2291.83±4.74 96.23±10.60 86.55±7.67 4th Ventricle 100 91.19±3.34 85.77±5.93 87.52±4.85 85.50±9.26 Internal Capsule 100 90.64±5.94 86.60±2.50 89.54±2.38 87.42±3.70 Lateral Ventricle 100 90.67±1.18 84.16±7.22 90.93±3.51 88.14±4.21 Anterior Horn 100 91.56±1.58 88.44±2.80 89.65±1.85 81.33±9.31 Root Of Neck 100 94.67±3.09 93.03±3.09 95.35±4.09 92.10±2.63 Wrist 100 95.88±3.5390.89±5.06 97.52±9.84 90.41±0.33 Proximal Forearm 100 91.33±1.69 89.88±1.63 100.45±7.14 90.02±13.40 Distal Forearm 100 89.27±0.54 87.48±0.63 94.28±7.85 83.73±12.66

Table 3: External appearance of specimens after each step Specimens Formalin fixed Post dehydra Post degrea Post impreg- Final specimens tion sing nation plastinates PNS Brown Dark brown Black Brown Light brown 4th Ventricle Grey Dark brown Black brown white Internal Capsule Grey Dark brown Black brown white Lateral Ventricle Grey Dark brown Black brown white Anterior Horn of Lateral Ventricle Grey Dark brown Black brown white Root of Neck Brown Dark brown Dark brown Brown Light Brown T.S. of Hand(Wrist) Brown Dark brown Dark brown Brown Light Brown T.S. of Proximal Forearm Brown Dark brown Dark brown Brown Light Brown T.S. of Distal Forearm Brown Dark brown Dark brown Brown Light Brown PNS- Paranasal sinuses, T.S.- Transverse section

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Figure no.1 Alcoholmeters /Acetonometer

Fig 4 Transverse section of neck at C6 level

Figure 2 Vacuum chamber with timer

Fig 5.Specimen of proximal section of forearm

Figure .3 Transverse section of brain showing inter- Fig. 6 Specimen showing lateral ventricle of brain nal capsule and basal ganglia

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 54 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 12. Also it can be recycled especially of last change which can be used as first change for new specimen till its specific gravity reaches 0.6.Dehydration was carried out at room temperature in the department .Next step was clearing or degreasing for which xylene was used which dissolves all the fat. Incomplete impregnation have been tried earlier by diluting the polymer with the xylene to enhance the pliability of the specimen as proportionately less polymer is drawn by the specimen.13 The major shortcoming of this step was remarkable color change of the specimen specially of brain due to which we had to dis- card a specimen of cerebellum as the nuclei could not be differentiated after this degreasing. This is a ground breaking trial of preserving specimen by use of inexpensive and indigenous chemicals like, acetone, xylene and melamyne. A few anato- mists have earlier tried at room temperature11 . We prompted the use of melamyne for plastination as its curing temperature is below 100°C which made this Figure 7: Specimen of paranasal sinus step of impregnation feasible at room temperature and also catalyst or gas curing agents were not required. 14 Melamyne is readily soluble in xylene so the The dimensions were much reduced after each step mixture obtained had the desirable viscosity and 13 except after vacuum assisted impregnation there was transparency required for plastination. Xylene acts slight increase in the dimensions though it did not as intermediary volatile solvent. reach the initial value. Shrinkage though was present The vacuum impregnation was done till bubbling but was not so remarkable as it varied from 10%- ceased. It was fitted with timer for 20 minutes for 17%(fig. no. 3-7). The change was significant applying intermittent impregnation. This reduced amongst the specimens except in the case of trans- shrinkage as clearly depicted by the dimensions taken verse sections of extremities as depicted by p value in after each step as the polymer replaced acetone table no.1. Decolourisation was maximal in case of which preserved life like state. Intermittent vacuum brain prosections as compared to extremities. (Table assisted impregnation was applied instead of contin- no.3). uous sudden and rapid impregnation as it avoids compression of specimen. Curing is often done by gas, heat or light. In this step we utilized H2SO4 solu- DISCUSSION tion and for drying and hardening CaCl2 as its highly Preserving prosections has been a persistent aspira- hygroscopic and the whole procedure was further tion for anatomist all over India. The standard plas- speeded up by cold temperature of 10 degrees centi- tination process consists of four sequential steps viz. grade which was achieved by using mortuary cham- Fixation, Dehydration, Forced Impregnation in vac- ber. uum and curing (hardening). 7, 8, 9. The steps of plas- The major shortcoming of our procedure is the time tination were same as the original technique i.e. fixa- required which is 1968 hours as compared to stand- tion, dehydration, impregnation and curing. This ard procedure which is 101.7 hrs16 but it is cost effec- study instigated possibility of plastination partially at tive. room temperature, which was also tried as pink city technique10.The modification was introduction of Alsopercentage shrinkage coincided with that of oth- intermittent vacuum which reduced the shrinkage of er room temperature technique which was 10-17% in specimens to a greater extent and also drying in a the present study as compared to 12-16% and much cold environment of 10 °C which was achieved by lower than standard procedure which is about 20- 16 keeping the specimen in a mortuary chamber with 30%. Decolourisation of the specimen was also 17 calcium chloride . The introduction of cold tempera- minimal as compared to that of ameko et al. ture and calcium chloride (since it is hygroscopic) speeded up the drying process and reduced the shrinkage. CONCLUSION Dehydration was achieved by using acetone as it can Specimens obtained were durable and portable .In be used as dehydration as well as intermediary agent short specimens more as a model with real look was

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 55 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 obtained. Feedback from students regarding plasti- 6. Latorre R; Vaquez JM; Gil F; Ramirez G; Lopez-Alhors O; nates revealed that they were easy to handle but less Orenes M; Martinez-Gomariz F; Arencibia A;: Teaching anatomy of the distal equine thoracic limb with plastinated flexible and difficulty in visualizing deeper structures slices. J Int Soc Plastination 2001:16:23-30. but good for cross-sectional anatomy as the tissue got fixed and displacement of structures was absent . 7. VonHagens ,G; Tiedemann K; Kriz W.:The current potential of plastination. Anat. Embryol. 1987; 175(4):411-421. Further the cost of plastination due to use of melamyne is nominal and also vacuum was applied by us- 8. Bickley HC. Plastination: A new technique for anatomic pathology and forensic science. Pathol. Update Series, 1984; ing locally assorted instruments which did not re- 2(16):2-8. quired any expertise to handle. This procedure minimized dependence of cadavers for teaching anato- 9. Srisuwatanasagul K, Srisuwatanasagul S, Adirekthaworn A, Darawiroj D. Comparative Study between Using Acetone my. These plastinates are excellent adjunct for teach- and Absolute Alcohol for Dehydration in Plastination Pro- ing as they have nullified exposure to the toxic fumes cedure. Thai J. Vet. Med.2010; 40(4):437-440. of formalin. 10. Chandel CS, Jain A, Chouhan S, Hada R, Jain R. Plastina- tion by an Acid Curing Polymer at Room Temperature: A Pink City Technique. Int. J. Pure Appl. Sci. Technol., 2013; ACKNOWLEDGEMENT 16(2):39-45. We would like to thank PHOD Anatomy and Dr 11. Mehra S, Choudhary R, Tuli A. Dry Preservation of Cadav- eric Hearts: An Innovative Trial. Journal of the Internation- C.S. Chandel and Dr. Ritesh Jain Consultant Plastic al Society for Plastination, 2003; 18:34-36. Surgery. 12. Suganthy j ,Francis DV;Plastinaion using standard S10 technique our experience in Christian Medical college,vellore j. Anat. Soc. India :2012 61(1)44-47.

13. Henry.RW and Nel, P.P.C. Forced impregnation for the REFERENCE standard S10 method, J. Int. Soc. Plastination, 7(1993), 27-31. 1. Pashaei, S: A brief review on the history, methods and ap- 14. Holmberg K., Low temperature acid catalyzed curing of plications of plastination. Int. J. Morphology. 2010; melamine resin systems, Polymer Bulletin, 11(1) (Jan) (1984), 28(4):1075-1079. 81-84. 2. Glover RA; Henry RW; Wade, RS.: Polymer preservation 15. Bickley, HC; Von Hagens ,G;. and Townsend, F.M.; An technology: Poly-Cur. A next generation process for biolog- improved method for preservation of teaching specimens, ical specimen preservation. J lnt Soc Plastination Arch Pathol Lab Med., 105(1981), 674-6. 1998;3(2):39 16. Starchik ,D.; Henry ,RW.;Comparison of Cold and Room 3. Glover ,R.;. Silicone plastination, room temperature meth- Temperature Silicone Plastination Techniques Using Tissue odology: Basic techniques, applications and benefits for the Core Samples and a Variety of Plastinates . The Journal of interested user. J lnt Soc Plastination 2004; 19:7. Plastination 27(2):13-19(2015). 4. Henry ,RW;: Silicone Plastination of Biological Tissue: 17. Ameko,E; Milla-Amekor,E; Achio, S;Alhassan,S; and Ep- Room-temperature Technique North Carolina Technique ke,J; Suitability of a Modified Adapted Standard (S10) and Products. J Int Soc Plastination 2007b :22:26-30 Method for Plastinating Three Species of Fishes(Tilapia, African catfish and African Bonytongue) :Int. J. Pure Appl. 5. Henry RW; Reed RB; Henry CL; "Classic" silicone pro- Sci. Technol., 2013: 16(2):63-74. cessed specimens vs "New formula" silicone plastinated specimens:A two year study. J Int Soc Plastination2001: 16:33.

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WOMEN UNDER DURESS: A CROSS-SECTIONAL STUDY ON VIOLENCE AGAINST WOMEN IN DISTRICT DEHRADUN

Vidisha Vallabh1, Ashok K Srivastava2, Ruchi Juyal2, Jayanti Semwal3

Author’s Affiliations: 1Resident, 2Professor, 3Professor & Head, Department of Community Medicine, Himalayan Insti- tute of Medical Sciences, Dehradun, Uttarakhand Correspondence: Dr Ashok K. Srivastava Email: [email protected]

ABSTRACT

Introduction: Violence against women is a significant public health problem, as well as a fundamental viola- tion of women’s human rights. It is one of the most common forms of violence globally and includes physical, sexual, emotional and economic violence. Aims and Objectives: 1.To study the prevalence of Violence against Women (VAW) amongst ever-married women of reproductive age group in district Dehradun.2. To study their awareness regarding protection from such violence. Methodology: The community-based, cross-sectional study was conducted using multistage random sampling method, amongst 880 ever married women aged 15-49 years, in the rural & urban areas of district Deh- radun. Results: Out of the surveyed sample of 880 women, receiving obscene phone calls was reported by 11.8 %; eve teasing by 9.4 %; being followed home by 5.7% and unsolicited advances by 3.9%. About 1.0% women reported being forced into unsolicited sexual activity by a person other than a spouse. Overall only 19.2% women had any knowledge about protection laws and agencies for victims of VAW. Conclusion: Nearly 37% women in our study reported suffering from any harassing activity ever in life, it was disheartening to see that only one-fifth had knowledge regarding protection laws. Primary prevention in this scenario becomes very important to disjoin VAW from cultural acceptance.

Keywords: Violence against women, harassment, eve teasing, gender-based violence, perception of safety

INTRODUCTION Violence against Women (VAW) is defined as "vio- AIMS AND OBJECTIVES lence that is directed against a woman because she is 1. To study the prevalence of Violence against a woman or violence that affects women dispropor- Women (VAW) amongst ever-married women of re- tionately. It includes acts that inflict physical, mental productive age group in district Dehradun. or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty”.1 It is a con- 2. To study their awareness regarding protection temptible fact that around the world at least one from such violence. woman in every three has been beaten, coerced into sex, or otherwise abused in her lifetime.2 METHODOLOGY Ensconcing women to their rightful position requires a deep insight into the dynamics of gender-based A community based, cross sectional study was con- oppression and violence but unfortunately, most ducted under the department of Community Medi- studies conducted on GBV are set in nations in high- cine, Himalayan Institute of Medical Sciences income group. The dearth of studies in middle and (HIMS), Dehradun amongst ever married women low-income group poses an obstacle in ascertaining aged 15-49 years, in the rural & urban areas of dis- the problem statement for the world as well as indi- trict Dehradun from 1st May 2015 to 30th April 2016. vidual nations. In India, only a few community-based The study was approved by Ethical Committee, micro level studies are available. There is also very SRHU. Based on the prevalence of GBV of 33.5 % limited empirical evidence of its various determi- according to National Family Health Survey-III find- nants, outcome, and their relationships.3 ings, the sample size calculated by using the follow-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 57 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ing formula: n=4pq/l2 [ l= relative allowable error Table 1: Age wise distribution of respondents (10 % of prevalence)] was 794.4 Assuming 10% for Age group Rural (%) Urban (%) Total non-responses, the sample size was equated to 873. in years (n=440) (n=440) (n=880) A sample of 880 was equally allocated to rural and 15-19 1 (0.2) 15 (3.4) 16 (1.8) urban areas i.e. 440 subjects in each area. Multistage 20-29 185 (42.0) 197 (44.8) 383 (43.4) random sampling method was adopted. The rural 30-39 183 (41.6) 141 (32.0) 324 (36.8) area of Dehradun district has 6 community devel- 40-49 71 (16.1) 87 (19.8) 158 (18.0) opment blocks, out of which one block (10%), Doi- wala was selected by simple random sampling. Table 2: Bio-social profile of the respondents Doiwala block has five Nyay Panchayats out of which 10% i.e. one Nyay Panchayat (Markham Variables Rural (%) Urban (%) Total Grant) was chosen by simple random sampling. In (n=440) (n=440) (n=880) Markham Grant Nyay Panchayat there are 38 villag- Religion es, out of which 10% i.e. four villages were selected Hindu 252 (57.3) 425 (96.6) 677 (76.7) by simple random sampling. In the urban area out of Muslim 82 (18.6) 14 (3.2) 96 (10.9) 4 municipalities 10% i.e. one municipality Sikh 106 (24.1) 1 (0.2) 107 (12.2) Family type (Rishikesh) was selected randomly that has a total of Nuclear 305 (69.3) 300 (68.2) 605 (68.8) 20 wards, out of which 10% wards were randomly Joint 135 (30.7) 140 (31.8) 275 (31.2) selected for the study. Study houses were selected by Socioeconomic class systematic random sampling. Sampling interval (k) I 15 (3.4) 0 (0.0) 15 (1.7) was calculated as - total number of households in II 47 (10.7) 74 (16.8) 121 (13.8) rural / urban area divided by sample size. Thus study III 91 (20.7) 112 (25.5) 203 (23.1) houses were selected by visiting every “kth” house IV 145 (33.05) 251 (57.0) 396 (45) (rural area-every 4th house; urban area- every 3rd V 142 (32.3) 3 (0.9) 145 (16.5) house). Literacy status Illiterate 92 (20.9) 108 (24.5) 200 (22.7) Adult and adolescent ever married females aged 15- Primary education 64 (14.5) 66 (35.9) 130 (14.8) 49 years who were ready to give written consent for Junior high school 85 (19.3) 73 (16.6) 158 (18.0) the study and were permanent residents of district High school 92 (20.9) 64 (14.5) 156 (17.7) Dehradun for past 12 months were included in the Intermediate/ 47 (10.7) 46(10.5) 93 (10.6) study. In every selected household, one ever married diploma female fulfilling the inclusion criteria was interviewed Graduate &above 60 (13.6) 83 (18.9) 143 (16.2) Occupation after taking informed written consent. A pre- Housewife 357 (81.1) 381 (86.6) 738 (83.9) designed, semi-structured questionnaire [modified Unskilled worker 31 (7.0) 20 (4.5) 51 (5.8) version of questionnaire from the United States Skilled and Semi- 26 (5.9) 26 (5.9) 52 (5.9) Agency for International Development (USAID)] skilled worker was used to carry out the survey.5 The participants Sales/clerical/ Self 19 (4.3) 6 (1.4) 25 (2.8) were interviewed face-to-face in their homes in pri- employed/ business vate space using the pre-tested and predesigned da- Semi-professional 7 (1.6) 7 (1.6) 14 (1.6) ta collection tool. Confidentiality of participants’ data and above was maintained at all levels of the study and was strictly anonymised. A database was constituted us- Table 2 shows the bio-social profile distribution of ing SPSS Version 20.0 and MS Excel to store and the surveyed population. Religion: Out of the 880 manage the collected data. Percentages and propor- respondents surveyed, around three-fourth (76.9%) tion were calculated for all the variables, while Chi- were Hindus, followed by Sikhs (12.2%) and Mus- square test was applied for testing significance of lims (10.9%). Family Type: Most of the surveyed association between two variables. Statistically signif- women belonged to nuclear family (Nuclear – 68.8%, icant level was assumed at p<0.05. Joint 31.2%). Socio-economic status: Lower middle class dominated the study population with maximum respondents (45%) followed by the middle RESULTS class (23.1%) and lower (16.5%). The trend was same Table 1 shows the age-wise distribution of respond- in the rural and urban settings. Literacy Status: ents in age groups of 15-19, 20-29, 30-39 and 40-49 More than three-fourths (77.3%) of the surveyed years. Majority of the women in the study were in women were literate with 16.2% women acquiring a their early adulthood i.e. 20-29 years (43.4%).The degree of graduate and above. Only 22.7% women mean age of the respondents was 32.5 years ±7.16 were illiterate in the surveyed population and this dif- years. ference was found to be statistically significant (χ2 – 24.485, df – 2, p - 0.000). Occupational status: Ma- jority of the women (83.9%) were not employed in

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 58 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 the formal or informal sector but restricted them- spouse. Of the 9 women who reported the occur- selves to household work. In the case of employed rence of an unsolicited sexual activity, perpetration women, the unskilled (5.9%) and skilled workers of crime was 66% (6 cases) by relatives, 24% (2 cas- (5.8%) were nearly equally distributed. Only 2.8% es) by neighbours and 12% (1 case) by a stranger. women were engaged in clerical work/business/ self- Women belonging to rural areas were more forth- employment. Even in this era of technology, only coming in acknowledging suffering from harassing 1.6% of women were involved in professional and activities than women of urban setting. semi-professional work. Table 5 depicts the distribution of interviewed wom- Table 3 shows the perception of safety after dark in en according to their awareness regarding protection various situations by the studied subjects. Half of the agencies against such violence. Only 19.2% of stud- women felt unsafe using public transport after dark ied women had any knowledge about protection laws (53.4%). They also felt their safety was compromised and agencies for victims of VAW. It was more while walking alone (20.1%) after dark or walking amongst the urban women (21.4%) than rural wom- past teenage boys/men (21.9%). en (17.8%). Table 4 shows the harassing activities suffered by About 8.3% women knew of a public figure/leader women in the course of their life. Out of the sur- in their area that assisted the victims of GBV, fol- veyed sample of 880 women, receiving obscene lowed by the women’s helpline (4.7%). The rural phone calls was reported by 11.8 %; eve teasing by women were more aware of NGO /Mahila Mangal 9.4 %; being followed home by 5.7% and unsolicited Dal for victims of VAW (5.0%), after the public fig- advances by 3.9%.With India being labelled as a very ure/leader (8.9%). Amongst the urban women too, unsafe nation for women, it was very unusual that public leaders too were most commonly known only 1.0% women reported being forced into unso- agency (7.7%) for protection against VAW followed licited sexual activity by a person other than a by Women’s helpline (5.5%).

Table 3 - Respondents by Perception of Safety in their Residential Area after Dark (N=880) Feel unsafe after dark while Rural (%) (n=440) Urban (%) (n=440) Total p-Value Using public transport 263 (59.8) 207 (47.0) 470 (53.4) 0.001 Walking alone 70 (15.9) 107 (24.3) 177 (20.1) 0.000 Walking past teenage boys, men 35 (8.0) 158 (35.9) 193 (21.9) 0.000

Table 4 - Respondents by Types of Harassment Activities Ever in Life (N=880) Harassment activity Rural (%) (n=440) Urban (%) (n=440) Total Obscene phone calls 54 (12.3) 50 (11.4) 104 (11.8) Eve teasing 48 (10.9) 35 (8) 83 (9.4) Been followed home 25 (5.7) 25 (5.7) 50 (5.7) Unsolicited advances * 22 (5.0) 12 (2.7) 34 (3.9) Forced into unsolicited sexual activity ** 7 (1.6) 2 (0.5) 9 (1.0) Multiple responses*Man got too close, touched in a sexual way (touching, grabbing, fondling, and kissing); ** As a child or adult, by person other than husband, forced to perform sexual intercourse/sexual acts

Table 5-Respondents by Awareness Regarding Protection from VAW (N=880) (Multiple response) Knowledge About Rural (%) Urban (%) Total (n=440) (n=440) NGO /Mahila Mangal Dal for victims of GBV 22 (5.0) 0 (2.3) 32 (3.6) Public figure/leader 39 (8.9) 34 (7.7) 73 (8.3) Women’s helpline 17 (3.9) 24 (5.5) 41 (4.7) Women’s commission/ shelter 12 (2.75) 8 (1.8) 20 (2.3)

DISCUSSION prise for nearly two-third of the total crime targeting women .7 The NCRB figures for Uttarakhand reveal that the crime rate against women was only 8.8% in 2001 (a The present study involving 880 women in age group year after the state was formed), which has gone up 15-49 years in rural and urban areas of Dehradun, to 27.4% in 2014, showing a jump of over 200%. 6 Uttarakhand were interviewed for the experience of Haridwar, Dehradun and Udham Singh Nagar com- VAW ever in life.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 59 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Majority of women in our study felt unsafe using 151 rape cases have been registered by police in the public transport after dark (53.4%). This is similar to first six months of 2016, a rise from 131 such cases the findings from a baseline survey conducted by reported in 2015. A quarter of rape cases this year JAGORI foundation in Thiruvananthapuram and have been filed in Dehradun and Haridwar alone .15 Delhi (2010) where 54% of women felt unsafe in Our study results are also lower than findings from a public transport .8 In our study women felt that their urban baseline survey by JAGORI (2010) where the safety was compromised while walking alone (20.1%) prevalence was 3.8% for rape.8 Our results are com- after dark or walking past teenage boys/men parable to sexual abuse statistics stated in a multi- (21.9%). These figures are lower than reported by nation study (2011) by Abramsky where the preva- women in a baseline survey conducted by JAGORI lence was 0.4% in rural Bangladesh and 2% each in foundation in Thiruvananthapuram and Delhi (2010) urban Serbia and rural Thailand, yet highly con- where 39.9% avoided going out alone after dark.8 trasting with Peru (11%). 16 Figures for sexual abuse Gallup’s annual Crime Survey (2014) on safety after by a person other than the husband in our study are dark revealed that 45% of women do not feel safe much lower than the estimated 7 % of women who walking alone at night which are much higher than have experienced sexual violence perpetrated by findings from our study.9 Women’s fear of rape fur- someone other than an intimate partner in their life- ther circumscribes their use of public space and pub- time according to World’s Women Report (2015) by lic transport. UN .17 This may not only be due to the reason that the sample covered by this study was small but also Although eve teasing is cognitive, it has always been that the nature of the question being sensitive, there- considered as a minor nuisance, a jocular practice fore many women might not have felt comfortable in validated both culturally and sub-culturally across disclosing the information. India. 10 In our study, receiving obscene phone calls were reported by 11.8 %; followed by reports of eve All 13 districts in the state have a dedicated Mahila teasing (9.4 %); being followed home (5.7%) and un- Helpline and a Mahila desk to look into such matters. solicited advances by (3.9%). Our figures are on the 7 Still, overall only 19.2% of 880 women had any lower side when compared to a Tamil Nadu-based knowledge about protection laws and agencies for study by Jaishankar and Kosalai (2007) where being victims of GBV in our study, the urban women followed and obscene phone calls were experienced (21.4%) being overall more knowledgeable than rural by 55.3% and 30.7% urban women .11 In a Lucknow- women (17.8%). This is in contrast with a Lucknow- based urban study by Singh and Singh (2010), 5.79% based urban study by Singh and Singh (2010) where women reported receiving obscene calls which are 45% women had some knowledge about protection lower than our findings of 11.4%.12 When compared laws and agencies for victims of VAW.12 A report to a study by Reen and Kaur (2013) done in Chandi- published in 2009 by Executive Council Office – garh, 65% women had experienced eve teasing, 33% Women’s Issues Branch, Government of Canada had been followed which is higher as compared to showed that 31 % women were aware of health and our figures.13 Our figures are very low when com- social services as a source of assistance and infor- pared to the multi-nation study in 2016 by ActionAid mation to women and women with children who are on street harassment in a number of countries. They abused which is higher than our findings. When found 79% of women living in cities in India, 86% in women were specifically asked if they knew where to Thailand, and 89% in Brazil and 75% of women in turn to if they were ever victimised, the police (39%) London, the United Kingdom have been subjected were most widely cited.18 to harassment or violence in public.14

In a Lucknow-based urban study by Singh and Singh CONCLUSION (2010), 22.6% women reported unsolicited advances as which is considerably higher than our findings of It can be concluded from our study that though 2.7%.12 This may be due to reluctance in reporting Dehradun is a small and peaceful city, the prevalence due to shame and social acceptance of eve-teasing in of VAW amongst women of district Dehradun is on day to day life. This also may be the cause why only the rise. Therefore it is only judicious that effective 1.0% (rural-1.6%; urban – 0.5%) women in our study strategies are employed to combat the medusa that is reported being forced into unsolicited sexual activity VAW. The multi-faceted nature of the factors that by a person other than a spouse, although according influence VAW highlight the need for a multi- to NCRB data for Uttarakhand, there has been a sectoral response that combines development activi- sharp increase in the rate of crime against women in ties, including improved access to secondary educa- the state over the past few years. While 119 rape cas- tion for girls and boys, with initiatives to transform es were reported in various districts of the state in gender norms and attitudes. the first ten months of 2012, the figure went up to

181 in the corresponding period of 2013. In 2014, the number of rape cases reported was 205.7 Over RECOMMENDATIONS

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 60 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 The importance of primary prevention of violence by 6. Pant N. Uttarakhand: In 15 years, over 200% rise in crimes intimate partners cannot be denied. Schools are also against women. Hindustan Times.2015. [online] Available at: http://www.hindustantimes.com/dehradun/uttara- an important setting for primary prevention activi- khand-in-15-years-over-200-rise-in-crimes-against-women ties, with the potential to address issues of relation- /story-RVYZNWQCgtFc0Un1dBIh0L.html. Accessed ships, gender roles, power and coercion within exist- March 1st, 2017. ing youth violence and bullying programmes. 7. Crime against women on rise in state, Haridwar tops chart. Strengthening informal sources of support can help The Times of India. 2014. [online] Available at: lower the consequences of VAW as according to our http://timesofindia.indiatimes.com/city/dehradun/Crime- study many women are not aware of assistance from against-women-on-rise-in-state-Haridwar-tops-chart/article st the official services or systems that are available to show/45377593.cms. Accessed March 1 2017. them. Governments and other donors should be en- 8. JAGORI. Report on the Baseline Survey. New Delhi,India: couraged to invest much more in research on vio- UN Women; 2010. lence by intimate partners over the next decade. 9. Crabtree S, Nsubuga F. Women Feel Less Safe Than Men in Many Developed Countries. Washington DC, USA: Gallup; 2012. Available at: http://www.gallup.com/ poll/155402/women-feel-less-safe-men-developed- LIMITATION countries.aspx There are limitations in this study, as usual to this 10. Bhattacharyya R. Understanding the spatialities of sexual type of research topic. The topic of the interview is assault against Indian women in India. Gender, Place & very sensitive and participants may not express their Culture.2014; 22(9):1340-56. views openly, as they think that their responses may 11. Jaishankar K, Kosalai P. Victims of stalking in India: A damage the reputation of themselves and their fami- study of girl college students in Tirunelveli City. lies. Sometimes in this type of research, participants Temida.2007; 10(4):13-21. may also report the behaviour that is believed to be 12. Singh A, Singh K. A Study on the Problem of Eve Teasing consistent with their culture, rather than the actual in India. International Research Journal of Social circumstances. Sciences.2010; 3(2):205-229. 13. Reen M, Kaur J. Extent of Eve Teasing and Sexual Abuse Obviously, the cross-sectional nature of this study Experienced by College Going Girls in Chandigarh. Indian limits the extent to which we can draw conclusions Journal of Health and Wellbeing.2013; 4(2):208-9. regarding temporality or the causal nature of ob- 14. Statistics – The Prevalence of Street Harassment. Available served associations. Also as the sample size is lim- from: http://www.stopstreetharassment.org/resources/ ited, the generalisation of results is not advisable. statistics/statistics-academic-studies/. Accessed August 18th ,2016.

15. Saxena S,Budhwar Y. Crimes against women on rise, Doon REFERENCE no longer a safe zone.The Times of India. 2016.[online] Available at: http://timesofindia.indiatimes.com/city/ 1. United Nations Women. Handbook for National Action dehradun/Crimes-against-women-on-rise-Doon-no-longer- Plans on Violence Against Women. New York : UN a-safe-zone/articleshow/53344400.cms. Accessed March 1st Women;2012.p11. Available at: http://www.un.org/ , 2017. womenwatch/daw/vaw/handbook-for-nap-on-vaw.pdf 16. Abramsky T, Watts C, Garcia-Moreno C, Devries K, Kiss 2. Facts and figures: Ending violence against women. L, Ellsberg M, et al. What factors are associated with recent Available at : http://www.unwomen.org/en/what-we- intimate partner violence? findings from the WHO multi- do/ending-violence-against-women/facts-and-figures. country study on women’s health and domestic violence. Accessed March 28th, 2017. BMC Public Health. 2011;11(109). 3. Mahapatro M, Gupta R, Gupta V. Risk factor for domestic 17. Violence against women:Intimate partner and sexual violence in India. Indian J Community Med. violence against women:Fact sheet. Available at: 2012;37(3):153-7. http://www.who.int/mediacentre/factsheets/fs239/en/. 4. International Institute for Population Sciences (IIPS) and Accessed March 28th, 2017. Macro International. 2008. National Family Health Survey 18. Province of New Brunswick,Executive Council (NFHS-3), India, 2005-06: Uttarakhand. Mumbai: Office,Women’s Issues Branch. Attitudinal Survey on IIPS;2008. p25. Violence Against Women. Canada:Harris/ Decima; July 5. Statistics Canada. The Violence against Women Survey. 2009.p 32. Ottawa: Statistics Canada;1993.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 61 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 ORIGINAL ARTICLE

EXTRAPANCREATIC INFECTIONS IN ACUTE PANCREATITIS AND ITS INFLUENCE ON DISEASE OUTCOME

Majid Abbas Khawaja1, Reyaz Ahmed Para2, Mushtaq Ahmad Khan3, Adnan Firdous Raina1, Sumera Saba1

Author’s Affiliations: 1Resident, Dept. of Internal Medicine; 2Senior Resident, Dept. of Emergency Medicine; 3Professor, Dept. of Gastroenterology, SKIMS, Srinagar, J & K Correspondence: Dr Reyaz Ahmed Para Email: [email protected]

ABSTRACT

Introduction: Limited data is available on prevalence of extrapancreatic infection, its influence on outcome of pancreatitis. Objectives: To assess the prevalence of extra-pancreatic infections in acute pancreatitis, identify risk factors for development of such infections and influence of extrapancreatic infections on outcome of pancreatitis. Methodology: Patients of acute pancreatitis admitted from June 2013 to July 2015 were recruited in the study. The patients who developed extra-pancreatic infection formed the study group while patients who didn’t develop infections were included in the control group. Both groups were followed and their final outcome was compared. Results: A total of 350 patients comprising of 158 cases and 192 controls were studied. Prevalence of extra pancreatic infections was found in 41.5% with Urinary tract infections (UTI)(14.4 followed by Biliary (10.0%), pulmonary (8.4%), Pulmonary and UTI (3.7%),Injection site infections (2.1%). Predisposing factors for development of extra pancreatic infections and subsequent outcome of acute pancreatitis was found to be influ- enced by duration of hospital stay (p<0.001), etiology of acute pancreatitis and comorbidities especially Dia- beties mellitus (p<0.001). Conclusions: Early detection and proper treatment of infections will definitely improve outcome of acute pancreatitis with infections.

Keywords: Acute pancreatitis, Extrapancreatic infections

INTRODUCTION ventions. They often have extrapancreatic infections which may also influence the outcome.12 We con- Sepsis as a complication is an important cause of ducted this study to evaluate the prevalence and char- morbidity and mortality in acute pancreatitis.1-3 Oc- acteristics of extrapancreatic infections in patients currence of infection characterizes the more severe with acute pancreatitis and to determine their effect forms of the disease, especially when it is associated on patient outcome. with secondary organ failure.4 There mechanisms by which bacteria may enter pancreatic and peripancreatic necrosis are the haematogenous route via the circu- METHODOLOGY lation.5,6, transmural migration through the colonic bowel wall either to the pancreas (translocation), via The study was conducted in department of Gastro- ascites to the pancreas, or via the lymphatics to the entrology, Sheri Kashmir Institute of Medical Sci- circulation; via the biliary duct system; from the duo- ences (SKIMS) Srinagar, Kashmir. A total of 350 Pa- denum via the main pancreatic duct.7-10 Various ex- tients of acute pancreatitis who were admitted in the trapancreatic infections that are seen associated with hospital from August 2013 to May 2015 were en- acute pancreatitis are, Respiratory tract, Genitouri- rolled in the study. 158 patients who developed ex- nary tract, Peritoneal fluid Infections , Biliary tract trapancreatic infection constituted the case group like acute cholangitis, skin, and Intra venous site in- while 192 patients who didn’t develop any infection fections.10,11 Patients with severe pancreatitis often were placed in the control group.Patients who either require prolonged hospitalization and multiple inter- presented with acute attack of chronic pancreatitis or

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 62 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 developed pancreatic infection or had acute recurrent fection were excluded from the study, consisting of pancreatitis were excluded from the study. These pa- 158 cases and 192 controls which were followed till tients were followed upto final outcome. The study their final outcome. was approved by the ethical committee of Sheri The mean age was 49.9 years in the case group and Kashmir institute of medical science.Patients were 46.6 years in the control group. There was no signifi- diagnosed acute pancreatitis if they present with two cant difference in number of cases as per gender, of the following three features: Typical Pancreatic with overall female preponderance in both cases and Type of Pain; i.e. Persistent epigastric pain radiating controls. Gall stone was the commonest etiology to back which may be associated with nausea and (67.7%) followed by Ascariasis (15.1%), Alcohol vomiting. Serum amylase/Lipase > 3 times of upper (1.3%), Hypercalcemia (1.9%), Hypertriglyceridemia limit (normal value 30 to 110 u/l ).Imaging evidence (1.3%), while in 30 (19%) cases Etiology could not of pancreatitis; USG features of acute pancreatitis- be ascertained. The average Hospital stay was 12.01 Bulky pancreas /Peripancreatic fat stranding with or days in cases and 4.97 days in controls .There was without collection. Typical CT findings include focal prolonged hospital stay in patients with extra pancre- or diffuse parenchymal enlargement, changes in den- atic infections in comparable disease severity groups sity because of oedema, indistinct pancreatic margins (p<0.005) (Table 1). owing to inflammation surrounding retroperitoneal fat stranding liquefactive necrosis of pancreatic pa- renchyma, lack of parenchymal enhancement, pres- Table 3: Baseline Characteristics and etiology ence of gas is helpful, FNA helpful, little or no ne- crotic tissues (thus distinguishing it from infected ne- Variables Cases (%) Controls (%) p Value crosis), haemorrhage, high-attenuation fluid in the Total Patients 158 192 retroperitoneum or peripancreatic tissues. Patients in Age in years* 49.9±16.59 46.6±16.54 >0.05 both groups were followed till final outcome. De- Males 55 (34.8) 58 (30.2) 0.346 tailed physical examination and investigation accord- Females 103 (65.2) 134 (69.8) Duration of 12.01±5.96 4.97±1.61 <0.001 ing to a well defined protocol which included Gen- hospitalization* eral physical examination and relevant systemic ex- Etiology amination, Base line investigations like CBC, Liver Gall Stone Induced 107 (67.7) 51 (26.6) <0.003 function test(LFT),Kidney function test (KFT) , Se- Worm Induced 29(15.1) 14 (7.3) rum Amylase, Serum calcium, Lipid profile, CRP, Hypercalcaemia 3(1.9) 2 (1) Imaging – Chest x ray USG Abdomen and CECT Hypertriglyceridemia 2 (1.3) 0 (0) Abdomen as needed. Those who developed fever Unknown Etiology 30 (19.0) 109 (56.8) during the first week were regarded as having SIRS Alcohol Use 2 (1.3) 1 (0.5) unless they have features suggestive of infection. * Values are in Mean ±SD Those who persisted with fever for more than a week or developed fever after a week were regarded as having infecion and were screened for the focus Table 2: Comparison of Co morbidities between of infection according to a well defined protocol. cases and controls Contrast enhanced CT scan (CECT) Abdomen and Comorbidity Cases (%) Controls (%) p- MRCP as per need. (n=158) (n=192) Value Statistical software SPSS (version 20.0) and Mi- Hypertension 71 (44.9) 68 (35.4) 0.071 crosoft Excel were used to carry out the statistical Diabetes 29 (18.4) 12 (6.3) <0.001 analysis of data. Data was analysed by means of de- Hypothyroid 2 (1.3) 6 (3.1) 0.247 scriptive statistics viz, means, standard deviations COPD 7 (4.4) 4 (2.1) 0.345 and percentages and presented by means of Bar and Obesity 3 (1.9) 1 (0.5) 0.242 Pie diagrams. For parametric data, Student’s inde- CKD 0 1 (0.5) 0.549 pendent t-test was employed. Chi-square test or CAD 23 (14.6) 18 (9.4) 0.134 Fisher’s exact test, whichever appropriate, was used for non-parametric data. A P-value of less than 0.05 Table 3: Extrapancreatic infections was considered statistically significant. Extrapancreatic infection No. (%) Treated empirically due to persistent SIRS 11 (2.9) RESULTS Pulmonary 32 (8.4) Injection site infections 8 (2.1) This study was conducted in the Department of Gas- Bilary/Liver 38 (10.0) troenterology Sheri Kashmir Instititute of Medical UTI 55 (14.4) Sciences Srinagar Kashmir, from August 2013 to Pulmonary+ UTI 14 (3.7) May 2015. A total of 158 patients of acute pancreati- Overall 158 (41.5) tis were admitted, patients developing pancreatic in-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 63 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Among comorbidities Diabetes was significantly as- cases and bacteraemia in 8.4%. Willdison et al18, in sociated with the development of extrapancreatic in- 1993 showed a higher incidence of bacteraemia in fections (p<0.001)(Table 2). patients with pancreatic infections. The source of bacteraemia was respiratory in 17% cases, genitouri- Extra pancreatic infections was found in 41.5 %, nary in 17%, biliary in 3%, skin in 3% and the intra- most commonly urinary tract infections 14.4 % fol- venous site in 3% .Acute cholangitis occurred in 6 lowed by liver and biliary infections 10 %, pulmonary patients, intravenous site infection in 5 patients, and 8.4 %,both pulmonary and UTI in 3.7%, injection urine and peritoneal fluid infection occurred in 3 pa- site infections 2.1 % and 2.9 % of patients were tients each. The most common organisms isolated treated empirically in view of persistent SIRS (Table were Escherichia coli in 25% of the cultures and 3). Pseudomonas aeruginosa in 23%of the cultures.19

DISCUSSION CONCLUSION Extra-pancreatic infectious complication (EIC) in Extrapancreatic Infection influences the outcome of patients with Acute Pancreatitis has been shown to pancreatitis. It increases the morbidity and mortality. influence morbidity and mortality.13 We enrolled 350 Early Detection and Proper treatment of infection by in our study with 67.71% females and 32.28% males appropriate antibiotics depending on culture sensitiv- having a female to male ratio of 2.09, while studies ity, site of infection and antibiogram will definitely conducted by Bessel ink et al, Garg et al., and De- reduce the influence of infection on the outcome of linger et al 4,14,15 have male predominance. The female disease. Diabetic patients should be monitored for predominance in our study may be related to the eti- the development of infection especially.Patients ology of pancreatitis. Gall stones and worm induced should be discharged as soon as possible. pancreatitis accounting for 86%, Gall stones and As- cariasis are found more in female as compared to males.Mean age of cases was 49.9 years and that of REFERENCE controls was 46.6 years. Hypertension was the commonest co morbidity in all patients however it had 1. Isenmann R, Rau B, Beger HG. Bacterial infection and ex- no impact on disease outcome. Diabetes was the tent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis. Br J Surg. 1999; 86:1020– second commonest co-morbidity seen in 29 (18.4%) 1024. of cases compared to 12 (6.3 %) controls and contributed to occurrence of extra pancreatic infections. 2. Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007; 132:2022–2044. Extrapancreatic infection affects the course of pan- 3. Uomo G, Pezzilli R, Gabbrielli A, et al. Diagnostic assess- creatitis and influences the outcome of disease. It in- ment and outcome of acute pancreatitis in Italy: results of a creases the mobidity which is reflected by prolonged prospective multicentre study. ProInf- AISP: Progetto in- hospital stay.Mean hospital stay in case-group was formatizzato pancreatite acuta, Associazione Italiana Studio Pancreas, phase II. Dig Liver Dis. 2007; 39:829–837. 12.01 days with range of 4 to 37 days against the mean hospital stay of 4.97 days with range of 3 to 13 4. Dellinger EP, Forsmark CE, Layer P . Determinant-based days in control group. This finding is in accordance classification of acute pancreatitis severity. An international multidisciplinary consultation. Ann Surg 2012; 256: 875-880. with the national and international studies.16,17 Extra pancreatic infection was seen in 41.5 % of patients 5. Lange JF, van Gool J, Tytgat GN. The protective eVect of a reduction in intestinal flora on mortality of acute haemor- ,with urinary tract infections UTI being commonest rhagic pancreatitis in the rat. Hepatogastroenterology 14.4 % followed by liver and biliary tract infections 1987;34:28–30. 10 %, pulmonary 8.4 %,both pulmonary and UTI in 6. Webster MW, Pasculle AW, Myerowitz RL, et al. Postinduc- 3.7 % ,Injection site infections 2.1 % and 2.9% pa- tion bacteremia in experimental acute pancreatitis. Am J Surg tients treated empirically with antibiotics. Urine cul- 1979;138:418–20. ture was positive only in 5 (3.16%) patients with 7. Widdison AL, Karanjia ND, Reber HA. Routes of spread of E.coli grown in 3 (1.89%) cases sensitive to Amika- pathogens into the pancreas in a feline model of acute pan- cin, Imepenam and Enterococcus Feacalis in 2 creatitis. Gut 1994;35:1306–10. (1.26%) sensitive to Imepenam. Blood culture was 8. Tarpila E, Nystrom PO, Franzen L, et al. Bacterial transloca- positive only in 2 patients with growth of E.coli sen- tion during acute pancreatitis in rats. Eur J Surg 1993; sitive to Imepenam, Linezolid, resistant to Piperacil- 159:109–13. lin Tazobactum culture positivity was low as majority 9. Marotta F, Geng TC, Wu CC, et al. Bacterial translocation in of patients had taken antibiotics prior to septic the course of acute pancreatitis: beneficial role of nonab- screen. This is comparable with various other studies sorbable antibiotics and lactitol enemas. Digestion like, Brown LA et al 13. In 2014 conducted studies in 1996;57:446–52. 1741 patients with extra pancreatic infectious com- 10. Runkel NS, Moody FG, Smith GS, et al. The role of the gut plications and found respiratory infection in 9.2% in the development of sepsis in acute pancreatitis. J Surg Res 1991;51:18–23.

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11. Schwarz M, Thomsen J, Meyer H, Büchler MW, Beger HG. pact of infections in acute pancreatitis. Br J Surg Frequency and time course of pancreatic and extrapancreatic 2009;96:267-73. bacterial infection in experimental acute pancreatitis in rats.

Surgery 2000; 127:427-32. 16. Rao C, Bhasin DK, Rana SS, Gupta R, Gautam V, Singh K. Implications of culture positivity in acute pancreatitis: does 12. Noor MT, Radhakrishna Y, Kochhar R, Ray P, Wig JD, Sin- the source matter? J Gastroenterol Hepatol. 2013; 28: 887- ha SK, Singh K. Bacteriology of infection in severe acute 92. pancreatitis;2011 Jan 5;12(1):19-25. 17. Dellinger EP, Tellado JM, Soto NE, Ashley SW, Bade PS, 13. Brown L, Hore T, Phillips W, Windsor J ,Petrov M:A sys- Dygernier T, et al. Early antibiotic treatment for severe acute tematic review of the extra-pancreatic infectious complica- necrotizing pancreatins. A Randomized, double-blind, place- tions in acute pancreatitis, Pancreatology 14 (2014) S1-S129. bo-controlled study. Annal Surg 2007;245(5):674-83. 14. Garg PK, Khanna S, Bohidar NP, Kapil A, Tandon RK. 18. Willdison AL, Karanjia ND. Pancreatic infection complicat- Incidence, spectrum and antibiotic sensitivity pattern of bac- ing acute pancreatitis. Br J Surg 1993; 80:148-54. terial infections among patients with acute pancreatitis. J

Gastroenterol Hepatol 2001; 16:1055-9. 19. Besselink MG, van Santvoort HC, Boermeester MA et al. Timing and impact of infections in acute pancreatitis. Br J 15. Besselink MG, Santvoort HCv, Boermeester MA, Nieu- Surg 2009; 9: 267-73. wenhuijs VB, Goor Hv, Dejong CHC, et al. Timing and im-

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PROPOFOL OR SEVOFLURANE – WHICH IS BETTER WITH RESPECT TO PREVENTING NAUSEA, VOMITING AND PAIN POSTOPERATIVELY?

Purvi Mehta1, Shishir Mehta2, Deepak Mistry3

Author’s Affiliations: 1Assistant Professor; 2Senior Resident; 3Professor, Dept. of Anesthesis, Muljibhai Patel Urological Hospital, Nadiad, Gujarat Correspondence: Dr Purvi Mehta Email: [email protected]

ABSTRACT

Introduction: Anesthetic agents today have been designed and marketed to meet specific niche criteria for ambulatory anesthesia. Propofol, Sevoflurane, etc. have significantly increased the ability of the anesthesiologist to provide a successful ambulatory surgical experience for the patient. This study was aimed at assessing the effect of Propofol and Sevoflurane in preventing postoperative nausea, vomiting and pain after laproscopic surgery among the patients of ASA 1 and 2. Methodology: All patients having ASA 1 and ASA 2 physical status scheduled for laparoscopic surgery in the age group 20 to 70 years not having clinically significant cardiovascular, respiratory, hepatic, renal, neurologic, psychiatric or metabolic disease; non-pregnant; not having morbid obesity; not having history of alcohol and drug abuse and willing to give informed consent were included in the study. Patients were randomly divided into two groups, of which one were administered Propofol and two were administered Sevoflurane to maintain anesthesia. Results: There were total 60 patients scheduled for laparoscopic surgery. Out of these 60 patients, 30 were administered Propofol and 30 were administered Sevoflurane as maintenance drug. Maximum number of nausea and vomiting were with Sevoflurane. Total 13 (43.3%) patients were having 4 times Nausea/Vomiting in first four hours postoperatively. Among patients to whom Propofol was administered, 17 (56.7%) not experienced any spell of nausea/vomiting in first 4 hours. Remaining patients also experienced only one spell of nausea/vomiting. post operative mild pain is seen in both group of patient. But moderate to severe pain is seen in Sevoflurane group. Least pain is seen in Propofol group. This suggestive that analgesic property of Propofol is greater than Sevoflurane.

Keywords: Post operative Nausea & Vomiting, Post operative pain, Laparoscopic surgery

INTRODUCTION ence for the patient.3 Because of the rapid onset and termination of effect of these agents, longer cases The history of ambulatory anesthesia is as old as the can be performed on an ambulatory basis. Patients history of anesthesia itself. At its very inception anes- recover much more quickly and can be discharged thesia was provided for ambulatory surgery. in the home more safely. Side effects such as the ‘‘hango- 1840s the first uses of anesthesia by Crawford Long, ver’’ effect have also been minimized. Horace Wells, and William Morton occurred in office settings. By the turn of the last century, ambula- Hemodynamic monitoring should be continued in tory anesthesia had been documented in the litera- the PACU. Hemodynamic changes induced by the ture. James Nicoll documented the successful admin- pneumoperitoneum, and more particularly the in- istration of 8988 ambulatory anesthetics in England creased systemic vascular resistance, outlast the re- in a 10-year period from 1899 to 1908.1 Ralph Waters lease of the pneumoperitoneum. The hyperdynamic opened an outpatient facility in 1918 in Sioux City, state developing after laparoscopy could conceivably Iowa, and described it in his seminal article.2 lead to a precarious hemodynamic situation in patients with cardiac disease. Despite the reduction in Anesthetic agents today have been designed and postoperative pulmonary dysfunction, PaO2 still de- marketed to meet specific niche criteria for ambula- creases after laparoscopic surgeries.4 tory anesthesia. Propofol, Sevoflurane, etc. have significantly increased the ability of the anesthesiologist Increased oxygen demand is observed after laparos- to provide a successful ambulatory surgical experi- copy. Although laparoscopy tends to be considered a

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 66 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 minor surgical procedure, oxygen should be adminis- ten consent of all patients were taken after explaining tered postoperatively, even to healthy patients. Final- nature of the study. Patients not willing to take part ly, prevention and treatment of nausea, vomiting, in the study were given anesthesia as per standard and pain are important, particularly after outpatient protocol of the hospital without affecting course of laparoscopic procedures. treatment. Strict confidentiality was maintained during all parts of study. This study was aimed to assess the effect of Propofol and Sevoflurane in preventing postoperative nausea, In all patients spells of Nausea and Vomiting were vomiting and pain after laproscopic surgery among recorded for 24 hrs postoperatively in separate data the patients of ASA 1 and 2. recording sheet. Data was entered and analysed using Microsoft excel.

METHODOLOGY RESULTS This study was done among the patients of ASA 1 and 2 physical status scheduled for laparoscopic sur- There were total 60 patients scheduled for laparo- gery in Sterling Hospital, Ahmedabad. scopic surgery. Out of these 60 patients, 30 were administered Propofol and 30 were administered All patients having ASA 1 and ASA 2 physical status Sevoflurane as maintenance drug. scheduled for laparoscopic surgery in the age group 20 to 70 years not having clinically significant cardio- Table 1 shows number of events of Nausea/ vomit- vascular, respiratory, hepatic, renal, neurologic, psy- ing during first 4 hour postoperatively. Maximum chiatric or metabolic disease; non-pregnant; not hav- numbers of events were with Sevoflurane. Total 13 ing morbid obesity; not having history of alcohol and (43.3%) patients were having 4 times Nau- drug abuse and willing to give informed consent sea/Vomiting in first four hours postoperatively. were included in the study.

There were total 60 patients eligible for the study Table 1: Comparison of postoperative events of during the study period. All patients were randomly nausea/vomiting (0-4hours) divided in two groups by chit method. Patients were asked to draw any one chit from total 60 chits which No. of events of Nausea/ Propofol Sevoflurane includes 30 chits written group 1 and 30 chits written vomiting during 0-4hr (%) (%) group 2. This result was not revealed to study partic- 0 17 (56.7) 0 ipants and observer. Patients having group 1 chit 1 12 (40.0) 0 were administered Propofol and Patients having 2 1 (3.3) 2 (6.7) 3 0 5 (16.7) group 2 chit were administered Sevoflurane to main- 4 0 13 (43.3) tain anesthesia. These drugs were given to drug ad- 5 0 8 (26.7) ministrator in closed envelope after confirming drug 6 0 2 (6.7) and removing labels. Total 30 (100) 30 (100) General anesthesia was induced with IV Midazolam 0.03mg/kg, Propofol 1.5-2.5mg/kg, Fentanyl 2μg/kg Table 2: Comparison of postoperative events of and Ondansetron 4mg. Laryngoscopy and tracheal nausea/vomiting (4-24hours) intubation was facilitated with Rocuronium 0.09mg/kg. Anesthesia was maintained initially with No. of events of Nausea/ Propofol Sevoflurane either Propofol 100 μg/kg/min (group 1) or vomiting during 4-24hr (%) (%) 0 30 (100) 6 (20.0) Sevoflurane 1- 2%(group 2) in combination with 1 0 9 (30.0) N2O 60% in O2.Concentration of maintenance an- 2 0 12 (40.0) esthetic varied to maintain hemodynamic variables 3 0 3 (10.0) within 15% of pre induction values i.e., Sevoflurane Total 30 (100) 30 (100) 0.6-1.75% and Propofol 50-150 μg/kg/min. All patients were mechanically ventilated to maintain end tidal CO2 within 27-32 mm of mercury. In all cases, Table 3: Post operative pain assessment by VAS Propofol and Sevoflurane was discontinued when Pain VAS Propofol (%) Sevoflurane (%) the laparoscope was removed. The N2O was contin- Mild pain 18 (60.0) 19 (63.3) ued till the last suture. To minimize the risk of resid- Moderate pain 1 (3.3) 7 (23.3) ual neuromuscular blockade after surgery, reversal of No pain 11 (36.7) 4 (13.3) neuromuscular blockade was provided by neostig- Total 30 (100) 30 (100) mine 50µg/kg and glycopyrrolate 8µg/kg. Permission was obtained from the ethical committee Among patients to whom Propofol was adminis- of the institute to conduct the study. Informed writ- tered, 17 (56.7%) not experienced any spell of nau-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 67 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 sea/vomiting in first 4 hours. Remaining patients al- rane group. There was no significant differences so experienced only one spell of nausea/vomiting. were observed in orientation, sitting and walking times (delayed recovery) and PONV amongst the Both groups were compared for post operative nau- groups. They concluded early recovery time was sea /vomiting. The incidences of nausea/vomiting shortest in Desflurane group while delayed recovery were least seen with Propofol group as compare to time and PONV had no differences.5 Sevoflurane group of patient. Anil Gupta, MD6et al in a systematic review com- Table3 suggests that post operative mild pain is seen pared on postoperative recovery and complications in both group of patient. But moderate to severe using four different anesthetic techniques with pain is seen in Sevoflurane group. Least pain is seen Propofol, Isoflurane, Sevoflurane, and Desflurane. in Propofol group. This suggestive that analgesic The database MEDLINE was searched via PubMed property of Propofol is greater than Sevoflurane. (1966 to June 2002) using the search words “anesthesia” and with ambulatory surgical procedures limited to randomized controlled trials in adults (19 yr), DISCUSSION in the English language, and in humans. A second Laparoscopy is frequently associated with minor search strategy was used combining two of the words postoperative sequelae that can persist more than 48 Propofol, Sevoflurane, or Desflurane. They found hours and that can significantly delay discharge of that early recovery was faster with Desflurane when outpatients. Postoperative pain of various types, one compared with Propofol-Isoflurane and with of the main complaints is postoperative nausea and Sevoflurane when compared with Isoflurane. They vomiting (PONV) (40% to 75% of patients). Where- concluded that the differences in early recovery times as perioperative opioids increase the incidence of among the different anesthetics were small and in PONV, Propofol anesthesia can markedly reduce the favor of the inhaled anesthetics. The incidence of high incidence of these side effects. The effect of side effects, specifically postoperative nausea and N2O on the incidence of nausea is still controversial. vomiting, was less frequent with Propofol. Intraoperative drainage of gastric contents also re- Post operative pain assess by visual analogue scale duces PONV. Intraoperative administration of (VAS). In our study post operative pain was least droperidol and 5- hydroxytryptamine type 3 antago- seen with Propofol. Mild pain is seen in Propofol nists appears to be helpful in the prevention and group while mild to moderate pain seen in Sevoflu- treatment of these side effects. Transdermal scopol- rane group patients. amine reduces nausea and vomiting after outpatient laparoscopy. Perioperative liberal intravenous fluid Thus, from this study it is concluded that Propofol is therapy can contribute to decreasing these symptoms having beneficial effect of low incidence of postop- and to improve postoperative recovery. erative nausea, vomiting and pain with compare to Sevoflurane. Because of antiemetic property of Propofol incidence of post operative nausea/vomiting are seen lees with Propofol as compared to Sevoflurane. REFERENCE Propofol inhibit serotonin in area postrema of brain. Incidence of post operative nausea vomiting for 1. Nicoll JH. The surgery of infancy. Br Med J 1909;18:753– 4. Sevoflurane and Propofol were 4.1+/-0.9 and 0.5+/- 2. Waters RM. The down-town anesthesia clinic. Am J Surg 0.4 respectively (p=0.001). 1919;39(Suppl):71– 3. Thus, Propofol has provided the added benefit of 3. Pandit SK. Ambulatory anesthesia and surgery in America: a reducing PONV and pain relief, the biggest is ad- historical background and recent innovations. J Perianesthia Nursing 1999;14(5):270– 4. vantage in outpatient practice, the biggest side effect is delayed recovery. Muscle relaxant development has 4. Miller RD,Anesthesia for laparoscopic surgery. Millers Anes- also benefited ambulatory surgery. There are several thesia, 7th editon. Churchill Livingstone; 2010;P 2185–2196. intermediate nondepolarizing neuromuscular block- 5. Gulcan Erk, Gulay Erdogan, Fazilet Sahin, Vildan Taspinar, ers that are perfectly suited for the majority of ambu- Bayazit Dikmen: Which One Is Better Anesthetic For Lapa- roscopic Cholecystectomy: Desflurane, Sevoflurane or latory surgical procedures that require relaxation. Propofol?. The Internet Journal of Anesthesiology. Gulcan Erk, Gulay Erdogan, Fazilet Sahin, Vildan 2006;10(2):210-218 Taspinar, Bayazit Dikmen compared the effects of 6. Anil Gupta, MD, FRCA, PhD, Tracey Stierer, MD, Rhonda Desflurane, Sevoflurane and Propofol on recovery Zuckerman, MD, Neal Sakima, MD,Stephen D. Parker, MD, and Lee A. Fleisher, MD.Comparison of Recovery Profile characteristics and PONV in laparoscopic surgeries. After Ambulatory Anesthesia with Propofol, Isoflurane, They found that extubation and eye opening times Sevoflurane and Desflurane:A Systematic Review. Anesth (early recovery) were meaningfully lower in Desflu- Analg 2004;98:632–41.

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DIFFERENTIAL DIAGNOSIS OF HIV POSITIVE PATIENTS WITH NEUROLOGICAL MANIFESTATIONS

Ankur S Patel1, HemantKumar M Shah1, Ashok K Gagia2, Dipika A Patel1, Vinod A Dandge1, Komal V Gamit3, Nirmal K Patel3

Author’s Affiliations: 1Assistant Professor; 2Associate Professor; 3Resident, Dept. of Medicine, SMIMER, Surat. Correspondence: Dr. HemantKumar Mishrilal Shah Email: [email protected]

ABSTRACT

Introduction: The nervous system is among the most frequent and serious target of HIV infection and is most frequently occur in patient with profound immunosuppression. 40 to 70 percent persons with HIV have neurological disorder. In 10 to 20 percent it is AIDS defining illness. It has higher mortality than other infections. Considering these facts the current study was designed to check the differential diagnosis of various neurological manifestations in HIV patients. Methodology: All HIV positive patients above 18 years presenting with neurological manifestations and ready to give informed written consent to participate in the study were included in the study. Detailed clinical history with special emphasis on consciousness, convulsions and headache was taken. Thorough clinical examination included mental status examination including MMSE, sensory, motor and cranial nerves examination. Results: The present study comprises 50 HIV infected patients with neurological manifestation presenting at the hospital. There were total 15 (30%) patients diagnosed with primary neurological illness. Most of the patients were having DSPN as primary neurological illness. ADC is one of the common neurological manifestations. 4% of our patients had ADC which is diagnosed by MMSE (mini mental status examination) score. Out of total 50 patients, 35 (60%) patients were diagnosed as Secondary Neurological Illness. Out of these, TBM was the most common illness, Other common secondary illnesses were Cryptococcal Meningitis (16%), Tox- oplasmosis (10%) and PML (8%). Conclusion: Tubercular Meningitis and Distal sensory polyneuropathy were the most common cause of neurological manifestation among HIV positive patients.

Keywords: HIV, Distal sensory polyneuropathy, TB Meningitis, AIDS dementia complex, Cryptococcal Meningitis

INTRODUCTION problems that occur in HIV infected individual may be either primary to pathological process of HIV in- Acquired immunodeficiency Syndrome (AIDS) is fection or secondary to opportunistic infections or caused by Human Immunodeficiency virus (HIV). It neoplasms.1 It may be inflammatory, demyelinating is a serious disorder of immune system in which or degenerative in nature. normal defense of body breaks against infection leading to life threatening conditions. Since the first In assessment of neurological symptoms, it should detection of acquired immunodeficiency syndrome be kept in mind that multiple HIV associated disor- (AIDS) cases in summer of 1981 among Homosexu- ders may coexists in a patient simultaneously.2 even als in USA, the number of Human Immunodeficien- in absences of specific complains careful neurological cy Virus (HIV) positive individuals and AIDS cases examination frequently reveals evidence of CNS or has increased explosively.1 PNS dysfunction. Although extensive studies on HIV and AIDS have been done in west, there is The nervous system is among the most frequent and pressing need for elaborate studies in India owing to serious target of HIV infection and is most frequent- the differences in social economic, cultural and edu- ly occur in patient with profound immunosuppres- cation background. sion.1 40 to 70 percent persons with HIV have neurological disorder. In 10 to 20 percent it is AIDS de- Considering these facts the current study was defining illness.2 It has higher mortality than other in- signed to check the differential diagnosis of various fections. It has also higher morbidity. Neurological neurological manifestations in HIV patients.

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 69 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 METHODOLOGY Maximum number of patients (79%) were from age group of 21 to 40 years. 8 (16%) patients were above This was a cross sectional study among HIV patients the age of 41 years. Among study subjects, 37 (74%) attending medicine OPD and admitted patients in were male and 13 (26%) were female. SMIMER, a tertiary care hospital in Surat, Gujarat. There were total 15 (30%) patients diagnosed with All HIV positive patients above 18 years presenting primary neurological illness. Most of the patients with neurological manifestations and ready to give were having DSPN as primary neurological illness. informed written consent to participate in the study ADC is one of the common neurological manifesta- were included in the study. tions. 4% of our patients had ADC which is diag- Permission of Institutional Ethical Committee was nosed by MMSE (mini mental status examination) obtained before conducting study. There were total score which included questions for assessment of 50 HIV infected patients showing clinical evidence orientation, memory, attention and concentration of nervous system involvement were ready to con- ability, recall, language, etc. sent and included in the study. Out of total 50 patients, 35 (60%) patients were di- Detailed clinical history with special emphasis on agnosed as Secondary Neurological Illness. Out of consciousness, convulsions and headache was taken. these, TBM was the most common illness, Other Thorough clinical examination included mental sta- common secondary illnesses were Cryptococcal tus examination including MMSE, sensory, motor Meningitis (16%), Toxoplasmosis (10%) and PML and cranial nerves examination. (8%). Apart from routine investigations, CD4 count was measured using standard flow cytometry. Diagnostic DISCUSSION investigations like MRI brain with contrast, cerebro- spinal fluid (CSF) examination and electromyogra- HIV-infected individuals can experience a variety of phy-nerve conduction study (EMG-NCS) were done neurological abnormalities due either to opportunis- as and when required. tic infections and neoplasm or to direct effects of HIV or its products. With regard to the latter, HIV

has been demonstrated in the brain and CSF of in- RESULTS fected individuals with and without neuropsychiatry abnormalities. The main cell types that are infected in The present study comprises 50 HIV infected pa- the brain in vivo are those of the mono- tients with neurological manifestation presenting at cyte/macrophage lineage, including monocytes that the hospital. Following observations were noted dur- have migrated to the brain from the peripheral blood ing this study. as well as resident microglial cells. HIV entry into brain is felt to be due, at least in part, to the ability of Table 1: Age distribution of study subjects virus infected and immuneactivated macrophages to (n=50) induce adhesion molecules such as Eselectin and vascular cell adhesion molecule-1 (VCAM-1) on Age (in Years) No. (%) brain endothelium. 18-20 3 (6) 21-40 39 (78) HIV-infected individuals may manifest white matter >41 8 (16) lesions as well as neuronal loss. Given the relative absence of evidence of HIV infection of neurons either in vivo or in vitro, it is unlikely that direct infec- Table 2: Primary neurological illness (n=50) tion of these cells accounts for their loss. Rather, the Primary neurological illness No. (%) HIV-mediated effects on brain tissue are thought to DSPN (Distal sensory polyneuropathy) 11 (22) be due to a combination of direct effects, either toxic ADC (AIDS dementia complex) 2 (4) or function-inhibitory of gp120 on neuronal cells and AIDP (acute inflammatory demyelinating 2(4) effects of a variety of neurotoxins released from infil- polyneuropathy) trating monocytes, resident microglial cells, and as- trocytes. In this regard, it has been demonstrated that Table 3: Secondary neurological illness (n=50) both HIV-1 NEF and Tat can induce chemotaxis of leukocytes, including monocytes, into the CNS. Neu- Secondary Neurological Illness No. (%) rotoxins can be released from monocytes as a conse- TBM (TB meningitis) 18 (36) quence of infection and/or immune activation. Cryptococcal Meningitis 8 (16) Monocyte-derived neurotoxic factors have been re- Toxoplasmosis 5 (10) ported to kill neurons via the N-methyl-D-aspartate PML (Progressive Multifocal Leuko- 4 (8) encephalopathy) (NMDA) receptor. In addition, HIV gp120 shed by virus-infected monocytes could cause neurotoxicity

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 70 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 by antagonizing the function of vasoactive intestinal probably because of high risk sexual behavior than peptide (VIP), by elevating intracellular calcium lev- female. els, and by decreasing nerve growth factor levels in DSPN was most common primary neurological ill- the cerebral cortex. ness. DSPN was found in 22% cases accounting Clinical disease of the nervous system accounts for a most common primary HIV illness. ADC was found significant degree of morbidity in a high percentage in 4% of cases and AIDP in 4% of cases. Our results of patients with HIV infection. The neurologic prob- are comparable with results of NIMS study.5 lems that occur in HIV-infected individuals may be In our study Tuberculous meningitis was found in either primary to the pathogenic processes of HIV 36% of cases while in AKD study56 it was 10%. infection or secondary to opportunistic infections or Cryptococcal meningitis found in 16% in our study neoplasms.1 The likelihood that HIV or its products while in AKD study it was 21% which is comparable. are involved in neuropathogenesis is supported by TBM is most common secondary neurological ill- the observation that neuropsychiatric abnormalities ness. Overall TBM is most common neurological ill- may undergo remarkable and rapid improvement ness. upon the initiation of antiretroviral therapy, particularly in HIV-infected children.1 In our study the incidence of neurological involve- REFERENCE ment was found maximum (78%) in age group 21-40 1. Anthony s. Fauci, H.Clifford Lane. Ch.189: HIV Disease; years. This is closely related with A.R Sircar study3 in AIDS and Related disorders. In: Harrisons principles of in- which maximum incidence (77.9%) was found in age ternal medicine, Mc-Graw Hill, 18th Editon; 1506-87. group 21-40 years. This is the sexually active age 2. HIV sentinel surveillance and HIV estimation in India 2007: group and hence increased prevalence of HIV and its a technical brief. Available on http://www.nacoonline.org neurological manifestation were found in this age /upload/Publication/M&E Surveillance Research/HIV Sen- group. This is a social danger as this is the most pro- tinel Surveillance and HIV Estimations 2007A Technical ductive group of society so it is going to affect Brief.pdf (Last accessed on 18/03/16) growth of nation and next generations also. So it is 3. Sircar AR, Tripathi AK, Choudhary SK, Misra R. Clinical an issue of major concern for further prevention of profile of AIDS: a study at a referral hospital. J Assoc Physi- cians India 1998 Sep; 46(9): 775-8. disease. 4. Levy RM, Bredesen DE, Rosenblum ML. Neurological man- There were 37 males (74%) and 13 female (26%) are ifestations of the acquired immunodeficiency syndrome affected in our study and Male: Female ratio was (AIDS): experience at UCSF and review of the literature. J. 2.9:1 comparable to study done by A.R. Sircar3 and neurosurg. 1985 Apr; 62(4): 475-95. AKD Study4 in which male: female ratio was 3.1:1 5. Wadia RS, Pujari SN, Kothari S, Udhar M, Kulkarni S, Bha- and 3:1 respectively. Male have high chances for gat S, et al. Neurological manifestations of HIV DISEASE. HIV infection and its neurological manifestation JAPI. 2001 Mar; 49:343-8.

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A STUDY ON COMPARISON OF DERMOSCOPIC PATTERNS ASSOCIATED WITH PLAQUE PSORIASIS AND PITYRIASIS ROSEA IN A TERTIARY CARE HOSPITAL OF PUNE CITY

Riddhi C Chauhan1, Kedar N Dash2

Author’s Affiliations: 1Junior Resident, Dept. of Dermatology Dr.D Y Patil Medical College, Pune; 2Consultant, Kanungo Institute of Diabetes Specialities, Bhubaneswar Correspondence: Dr Riddhi C Chauhan Email: [email protected]

ABSTRACT

Introduction: Plaque psoriasis (PP) and pityriasis rosea (PR) are common inflammatory skin diseases. Their characteristic appearance allows a clinical diagnosis in a high proportion of patients. This present study was conducted with an objective to determine and compare the dermoscopic patterns associated with PP, and PR to explore the utility of dermoscopy in the examination and diagnosis of these diseases. Methodology: The present study was a descriptive study conducted in the Department of Skin & V.D. where all PP and PR patients were subjected to general physical examination, cutaneous examination including nail, hair, genitalia, mucosae and dermoscopic examination to note down associated diseases and HIV. Findings were documented in the proforma. Results: There was female preponderance (58%) while male patients constituted 42%. Dotted vessels in PP were most commonly arranged in a regular distribution (44/50; 88%) and PR (8/12; 66.7%). In PP (29/50; 58%) vessels were associated with dull red background whereas in PR dotted vessels were mostly associated with a yellowish background colour (13/20; 65%). Conclusion: Plaque psoriasis (PP) and Pityriasis Rosea (PR) reveal specific dermoscopic patterns that may aid the clinical diagnosis. Besides its diagnostic purposes, dermoscopy might provide a useful tool for the evaluation of treatment outcome in patients with PP such as early detection of treatment response.

Keywords: Plaque Psoriasis, Pityriasis Rosea, Dermoscopic pattern

INTRODUCTION Dermoscopy is continually gaining appreciation in the field of general dermatology, while recent data The papulosquamous skin disorders are a heteroge- indicate that it might also be profitable in assessing neous group of disorders comprising the largest the outcome and adverse effects of various treat- group of diseases seen by a dermatologist. The no- ments.3-6 By revealing morphologic structures invisi- sology of these disorders is based on a descriptive ble to the unaided eye, dermoscopy improves cuta- morphology of clinical lesions that is characterized neous clinical examination. The expansion of der- by scaly papules and plaques.1 There is an overlap in moscopy has been facilitated by the development of morphology and distribution of lesions that leads to hand-held dermatoscopes using polarized light, difficulty in diagnosis. The papulosquamous disor- which are highly portable, do not require skin con- ders are complex to diagnose, because of the difficul- tact or immersion fluid, and allow a fast screening of ty in identification and may resemble a similar disor- numerous lesions.4 der of the group. Hence these lesions are commonly misdiagnosed.2 This present study was conducted to determine and compare the dermoscopic patterns associated with Plaque psoriasis (PP) and pityriasis rosea (PR) are PP, and PR to explore the utility of dermoscopy in common inflammatory skin diseases. Their charac- the examination and diagnosis of these diseases. teristic appearance allows a clinical diagnosis in a high proportion of patients.3–6 However, unusual presentations at times do exist and may cause diffi- METHODOLOGY culties in the differentiation among this entities.3–6 In those cases, histopathology contributes significantly The present study was a descriptive study conducted to the accurate diagnosis.7 in the Department of Skin & V.D. of Padmashree

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 72 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Dr. D.Y. Patil Medical College and Hospital and Re- light red, i.e. fading red colour, yellowish) and scale search Centre, Pimpri, Pune. A total of 100 patients colour (white, yellow, white + yellow). In PP (29/50; were included in the study from July 2014 to Sep- 58%) vessels were associated with dull red back- tember 2016. ground whereas in PR dotted vessels were mostly associated with a yellowish background colour This study was conducted after obtaining Institute (13/20; 65%). Ethics Committee Clearance. A written and informed consent was taken from all individuals selected for the study. The questionnaires were completed Table 1: Distribution of patients according to anonymously, after assuring the responders about the their age and gender confidentiality of the data and explaining the objectives of the research. Those cases who were recently Variable Cases (%)(N=62) developed lesion of PP and PR were consecutively Age group (in years) enrolled in the study. Those cases who had all other 21-30 7 (11.3) skin lesions and diseases with similar clinical features 31-40 8 (12.9) like Lupus Erythematosus, dry forms of Eczema, 41-50 11 (17.7) 51-60 12 (19.4) Seborrheic dermatitis, Syphilis and some superficial 61-70 14 (22.6) types of fungal infections are to be excluded from >70 10 (16.1) the study. All patients were subjected to general Gender physical examination, cutaneous examination includ- Male 26 (41.9) ing nail, hair, genitalia, mucosae and systemic exami- Female 36 (58.1) nation to note down associated diseases and HIV. Findings were documented in the proforma. Table 2: Distribution of Vascular morphology The new version of dermoscope which polarizes and arrangement light and does not require a contact medium and direct physical contact between the optical lens and Variable Plaque Psoriasis Pityriasis Rosea (%) (n=50) (%) (n=12) skin is used for dermoscopic examination. The re- Vascular morphology sults of the study were tabulated, analyzed and dis- Dotted 50 (100) 12 (100) cussed. Simple proportions and percentages for Linear 0 0 comparing different variables like age, sex etc was Dotted + Linear 0 0 used. Final outcome was expressed as the percentage Vascular arrangement of papulosquamous disorders among the study group Regular 44 (88) 3 (25) as a whole and as the percentage of individual papu- In clusters 1 (2) 1 (8.3) losquamous disorders. Patchy 1 (2) 8 (66.7) Peripheral 0 0 In rings 4 (8) 0 RESULTS A hospital based study was conducted among 100 Table 3: Distribution of background and scale patients to further our information about various colour dermoscopic patterns characteristic of papulo- Variable Plaque Psoriasis Pityriasis Rosea squamous skin disorders. As shown in the table, ma- (%) (n=50) (%) (n=12) jority of the patients (22%) were in the age group of Background colour 61-70 years followed by 19% in the age group of 51- Dull red 29 (58) 3 (25) 60 years. There was female preponderance (58%) Light red 20 (40) 1 (8.3) while male patients constituted 42% of the study Yellowish 1 (2) 8 (66.7) group. The M:F ratio was 1:1.38. It was seen that Scale colour White 36 (72) 10 (83.4) On the basis of vascular morphology (dotted, linear, Yellow 0 1 (8.3) dotted+linear), Dotted vessels were seen in all cases White+Yellow 2 (4) 1 (8.3) of PP and PR. On the basis of vascular arrangement (regular, in clusters, patchy, peripheral, in rings), Table 4: Scale distribution among the papulo- Dotted vessels in PP were most commonly arranged squamous diseases in a regular distribution (44/50; 88%) and PR (8/12; 66.7%), vessels were mostly associated in peripheral Scale Plaque Psoriasis Pityriasis Rosea arrangement of scales and patchy distribution respec- Distribution (%)(n=50) (%) (n=12) tively. Patchy 7 (14) 0 Peripheral 2 (4) 8 (66.6) Dermoscopic evaluation was done on the basis of Diffuse Central 23 (46) 2 (16.7) background colour (dull red, i.e. intense red colour, Central 6 (12) 2 (16.7) Wickham Striae 0 0

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 73 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 On the basis scale colour, Dotted vessels in PP cant differences with respect to the distribution of (29/50; 58%) and PR (10/12; 83.3%) were mostly vessels or additional criteria among PP and PR. In associated with white scales. detail, the combination of regularly distributed dotted vessels over a light red background associated On the basis of scale distribution (patchy, peripheral, with diffuse white scales was highly predictive of PP. diffuse and central), Vessels in PP (23/50; 46%) ap- On the other hand, although red globular rings (i.e. peared more commonly in diffuse distribution. In PR red globules arranged in irregular circles or rings) as (8/12; 66.7%) vessels appeared more commonly in described previously by Vázquez López et al9 repre- patchy and peripheral distribution respectively. sented a highly specific feature for PP. In our study, this pattern was seen in only a minority of cases (8%) in our series. Therefore, the value of this pattern in DISCUSSION the diagnosis of PP remains to be elucidated further. The papulosquamous skin disorders are a heteroge- Our study furthermore confirms preliminary obser- neous group of disorders comprising the largest vations on the dermoscopic patterns of PR.9,12 As group of diseases seen by a dermatologist. The no- such, PR was typified by peripheral scaling (so called sology of these disorders is based on a descriptive collarette scales) around a diffuse and structureless morphology of clinical lesions that is characterized yellowish centre, although dotted vessels were seen by scaly papules and plaques.1 There is an overlap in in all our cases of PR, they were generally much less morphology and distribution of lesions that leads to evident and fewer in number compared with PP or difficulty in diagnosis. The papulosquamous disor- dermatitis. ders are complex to diagnose, because of the difficulty in identification and may resemble a similar disor- It still remains to be determined how much dermos- der of the group. Hence these lesions are commonly copy may aid the differential diagnosis of tumours misdiagnosed.2 from PP this question seems particularly important when facing patients with diffuse PP, who received Distinct histopathological features and clinical corre- past psoralen plus ultraviolet A therapy and are at lation gives a conclusive diagnosis. Specific histo- increased risk for nonmelanoma skin cancer.13 With pathological diagnosis is important to distinguish regard to this Pan et al14 introduced a dermoscopic these lesions as the treatment and prognosis varies diagnostic model for differentiating solitary psoriatic significantly. Given that PP and other inflammatory plaques from intraepidermal carcinoma (IEC) and skin diseases may sometimes be difficult to differen- superficial basal cell carcinoma (sBCC). They con- tiate clinically, a more detailed determination of spe- cluded that red dots, homogeneous vascular pattern cific dermoscopic patterns of inflammatory skin dis- and light red background were significant dermo- eases could be a valuable addition for the clinical as- scopic features for psoriasis, yielding a diagnostic sessment. The present study was undertaken to fur- probability of 99% if all three features were present. ther our knowledge about various dermo-scopic pat- In contrast, clustered vessels, glomerular vessels and terns characteristic of papulo-squamous skin disor- hyperkeratosis yield a 98% probability for the diag- ders. nosis of IEC, whereas four of six described criteria In the present study, dotted vessels were seen in all (i.e. scattered vascular pattern, arborizing mi- cases of PP and PR. Dotted vessels in PP were most crovessels, telangiectatic or atypical vessels, milky commonly arranged in a regular distribution (44/50; pink background, and brown dots/globules) 88%) and PR (8/12; 66.7%), vessels were mostly as- achieved a diagnostic probability of 99% for sBCC. sociated in peripheral arrangement of scales and patchy distribution respectively. Dermoscopic patterns of red dots or globules arranged in a homoge- CONCLUSION neous, regular or ring like fashion have been de- Plaque psoriasis (PP) and Pityriasis Rosea (PR) reveal scribed as common findings in PP.7-9 However, our specific dermoscopic patterns that may aid the clini- and previous studies showed that dotted vessels are cal diagnosis. Certain combinations of dermoscopic not limited to PP but occur at variable frequency in features can reliably predict the diagnosis of PP. Be- several other inflammatory and neoplastic le- sides its diagnostic purposes, dermoscopy might sions.4,10,11 Accordingly, dotted vessels as the only provide a useful tool for the evaluation of treatment dermoscopic criterion are insufficient to distinguish outcome in patients with PP such as early detection between these different entities accurately. of treatment response. The feasibility of our observa- Besides the vascular morphology, the vascular ar- tions in clinical practice, as well as in studying the rangement and specific dermoscopic clues have been course of PP, warrants, however, further clinical judged to be of equal importance in the differential studies. diagnosis of non-pigmented skin lesions.8 This is fur-

ther supported by our study, which revealed signifi-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 74 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 REFERENCE 9. Va´zquez-Lo´pez F, Zaballos P, Fueyo-Casado A, Sa´nchez- Martı´n J. A dermoscopy subpattern of plaque-type psoriasis: 1. Fox BJ, Odom RB; Papulosquamous diseases: a review. J red globular rings. Arch Dermatol 2007; 143:1612. Am Acad Dermatol., 1985; 12(4): 597- 624. 10. Va´zquez-Lo´pez F, Kreusch J, Marghoob AA. Dermoscopic 2. Norman RA, Blanco PM; Papulosquamous diseases in the semiology: further insights into vascular features by screen- elderly. Dermatol Ther., 2003; 16(3): 231-242. ing a large spectrum of nontumoral skin lesions. Br J Derma- 3. Zalaudek I, Lallas A, Moscarella E, et al. The dermatologist's tol 2004; 150:226– 31. stethoscope-traditional and new applications of dermoscopy. 11. Argenziano G, Zalaudek I, Corona R et al. Vascular struc- Dermatol Pract Concept 2013;3:67–71. tures in skin tumors: a dermoscopy study. Arch Dermatol 4. Zalaudek I, Argenziano G, Di Stefani A, et al. Dermoscopy 2004;140:1485–9. in General Dermatology. Dermatology 2006;212:7–18. 12. Chabbert P. Pierre Borel (1620?-1671). En: Centre Interna- st 5. Lallas A, Argenziano G, Zendri E, et al. Update on non- tional de synthèse, editor. 1 ed. Revue d‘histoire des scienc- melanoma skin cancer and the value of dermoscopy in its di- es et de leur application, 1968;303-343. agnosis and treatment monitoring. Expert Rev Anticancer 13. Lim JL, Stern RS. High levels of ultraviolet B exposure in- Ther 2013;13:541–58. crease the risk of nonmelanoma skin cancer in psoralen and 6. Vázquez-López F, Marghoob AA. Dermoscopic assessment ultraviolet Atreated patients. J Invest Dermatol 2005; of long-term topical therapies with potent steroids in chronic 124:505–13. psoriasis. J Am Acad Dermatol 2004;51:811–3. 14. Pan Y, Chamberlain AJ, Bailey M et al. Dermatoscopy aids in 7. Vázquez-López F, Manjón-Haces JA, maldonado-Seral C, et the diagnosis of the solitary red scaly patch or plaque – fea- al. Dermoscopic features of plaque psoriasis and lichen tures distinguishing superficial basal cell carcinoma, intraepi- planus: new observations. Dermatology 2003;207:151–6. dermal carcinoma and psoriasis. J Am Acad Dermatol 2008; 59:268–74. 8. Zalaudek I, Argenziano G. Dermoscopy subpatterns of inflammatory skin disorders. Arch Dermatol 2006; 142:808.

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A STUDY ON PREVALENCE OF DIFFERENT TYPES OF DERMATOSIS IN PEDIATRIC AGE GROUP IN SEMIURBAN POPULATION OF PUNE CITY

Bhuvnesh G Shah1, Sweta P Patel2, Rachna V Patel3, Jigar J Patel3, Keya Shah4

Author’s Affiliations: 1Assistant Professor; 2Senior Resident; 3Junior Resident, Dept. of Skin and VD, GMERS Medical College, Valsad; 4Consultant, Surat, Gujarat Correspondence: Dr Bhuvnesh G Shah Email: [email protected]

ABSTRACT

Introduction: Dermatological problems constitute at least 30% of all outpatient visits to pediatricians and 30% of all visits to a dermatologist involve children. The present study was undertaken to determine the pattern of common dermatosis in children between 1-12 years in a semi-urban population in industrial areas of Pimpri-Chinchwad suburbs of Pune. Methodology: This was the cross-sectional study conducted on 1-12 years children in the Department of Dermatology. We have taken detailed history and clinical findings were noted and recorded in the predesigned proforma. Results: Most common group of dermatosis seen in this study was infectious diseases including bacterial 31 (25.80%), parasitic infestations 32 (26.4%), eczematous conditions 12 (10%) and viral infections 8 (6.6%). In 21 (17.5%) and primary bacterial infection occurred in 10 (8.32%) consisting of impetigo in 8 (6.66%) cases followed bullous impetigo in 2 (1.66) cases. Vitiligo and urticaria seen in 4 (3.33%) cases, Molluscum contagiosum in 5 (4.16%) cases, Sabies in 18 (15%) cases followed by pediculosis in 14 (11.66%) cases. Conclusion: We conclude that Infections and infestations were common while secondary bacterial infections were more common that the primary ones. Scabies was seen more commonly than pediculosis and Viral and fungal infections occurred in a small number of cases. Eczema dermatitis group was the second in prevalence among the various groups of dermatoses.

Keywords: dermatosis, pediatric age, infection, Semiurban population

INTRODUCTION drome, molluscum contagiosum, human papilloma virus infection, pediculosis, scabies, urticaria, sclere- Dermatological problems constitute at least 30% of ma neonatorum, lichen planus, vitiligo, alopecia ar- all outpatient visits to Pediatricians and 30% of all eata, atopic dermatitis, pityriasis alba, pityriasis rosea, visits to a dermatologist involve children.1 The preva- keloid and hypertrophic scar etc. A prevalence of lence of skin disease amongst children in various 68.8% has been reported for these physiological parts of India has ranged from 8.7% to 35% in changes, while pathological changes are seen 41.2% school- based surveys. School from rural areas of cases.3 Some of the pathological conditions can be showed relatively higher prevalence of skin diseases. treated and some others prevented by maintaining All the children in a school survey of a high altitude hygiene and care. However some are difficult to tribal area of Himachal Pradesh were found to have treat. The present study was undertaken to determine one or more type of skin diseases.2 the pattern of common dermatosis in children be- A Significant proportion of the skin conditions oc- tween 1-12 years in a semi-urban population in in- curring in children can be physiological such as seba- dustrial areas of Pimpri-Chinchwad suburbs of Pune. ceous hyperplasia, milia, Mongolian spot, cutis mar-

morata, harlequin colour changes, erythema toxicum neonatorum, pigmentary changes, hemangioma or METHODOLOGY pathological such as diaper dermatitis, acrodermatitis The present study was conducted in the Department enteropathica, phrynoderma, impetigo, staphylococ- of Dermatology and Department of Pediatrics of cal scalded skim syndrome, ecthyma gangrenosum, Dr.D.Y.Patil Medical College Hospital for period of neonatal herpes simplex, congenital varicella syn- 2 years from August 2009 to July 2011. Pediatric pa-

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 76 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 tients of age between 1 to 12 years attending outdoor Table 4: Distribution of bacterial and viral infec- and indoor department in Dr.D.Y.Patil Medical Col- tions lege Hospital’s were selected. Those cases having age Pathogens Male Female Total between 1-12 years, willing to provide detailed histo- Bacterial ry and willing to conduct necessary investigations if Secondary infected pyoderma 10 11 21 required are included in the study. A total of 120 pa- Impetigo 6 2 8 tients were included. A predesigned structure ques- Bullous impetigo 0 2 2 tionnaire was prepared which included the infor- Viral mation regarding gender, ecematous condition, bac- Molluscumcontagiosum 4 1 5 terial infection, pigmentary disorder, urticaria, viral Viral exanthema 2 0 2 conditions, dermatophytic conditions, parasitic infes- Verruca vulgaris 1 0 1 tations and other dermatological conditions. Detailed Parasitic infestation history and clinical findings were noted and recorded Scabies 12 6 18 Pediculosis 6 8 14 in the designed proforma. Data analysis was carried out by using Microsoft office Excel. The study was approved by the Institutional Ethics committee. The Table 5: Distribution of pigmentary disorders participants were enrolled in the study after obtaining Disorders Male Female Total written informed assent from their parents. Pigmentary disorders Vitiligo 2 2 4 PIH 1 1 2 RESULTS Mongolian spot 1 1 2 As tabulated and depicted below (table 1), males 72 Urticaria Urticaria 3 1 4 constituted 60% and the females constituted 40% of Dermatophytes total number of patients. T.capitis 0 2 2 T.corporis 2 0 2 T.cruris 2 0 2 Table 1: Age and Gender wise distribution of cases Table 6: Distribution of other dermatological Age Group Male (%) Female (%) Total (%) conditions (in years) 1-4 26 (36.1) 17 (35.4) 43 (35.8) Other conditions Male Female Total 5-8 24 (33.3) 12 (25.0) 36 (30.0) Keloid 1 0 1 9-12 22 (30.6) 19 (39.6) 41 (34.2) Bed sore 1 0 1 Total 72 (100) 48 (100) 120 (100) Hemangioma 2 0 2 Lichen striatus 1 0 1 Miliaria 1 0 1 Table 2: Distribution of Pediatric Dermatosis Pityriasis rosea 1 1 2 Xerosis 2 1 3 Conditions Males Females Total Pityriasis alba 1 0 1 Infestation 18 (25.0) 14 (29.2 ) 32 (26.7) Bacterial 16 (22.2) 15 (31.3) 31 (25.8) Eczema 7 (9.7) 5 (10.4) 12 (10.0) As depicted in (table 2) the most common group of Pigmentary disorders 4 (5.6) 4 (8.3) 8 (6.7) dermatosis seen in this study was infectious diseases Viral 7 (9.7) 1 (2.1) 8 (6.7) including bacterial 31 (25.8), parasitic infestations 32 Insect bite 3 (4.2) 4 (8.3) 7 (5.8) (26.7), eczematous conditions 12 (10), viral infections Dermatophytes 4 (5.6) 2 (4.2) 6 (5.0) Urticaria 3 (4.2) 1 (2.1) 4 (3.3) 8 (6.6) and other conditions. Other 10 (13.9) 2 (4.2) 12 (10.0) Diaper dermatitis and seborrheic dermatitis were Figures in parathesis indicate percentage commonest type of eczemas, each occurring in 3 (2.5), atopic eczema, nummular eczema and contact dermatitis each were seen in 2 (1.6) patients as tabu- Table 3: Proportion of Various Eczematous lated (table 3). Conditions Commonest bacterial infections found were second- Eczema condition Male Female Total ary infected lesion of pyoderma. In 21 (17.5) and Seborrheic dermatitis 1 2 3 primary bacterial infection occurred in 10 (8.3) con- Diaper dermatitis 1 2 3 Atopic eczema 2 0 2 sisting of impetigo in 8 (6.7) cases followed bullous Nummular eczema 1 1 2 impetigo in 2 (1.7) cases as tabulated table 4. Contact dermatitis 2 0 2 Molluscum contagiosum is the most common viral infection occurring in 5 (4.2%) of our cases as shown

NJMR│Volume 7│Issue 1│Jan – Mar 2017 Page 77 NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 in table 4. Sabies, the commonest parasitic infection Comparison of various viral infection revealed total in our study was seen in 18 (15) cases followed by incidence (6.59%) in our study to be higher than that pediculosis in 14 (11.7) cases, as shown in table 4. (3.60% in the other indian study by Thappa et al5. However the highest (10.90%) incidence was that in Vitiligo seen in 4 (3.4) cases was the commonest dis- the Turkish study by Tamer et al4. Out of the three order found in this group. Prevalence of urticaria was viral conditions, molluscum condition was the com- seen in 4 (3.4) cases. Among other dermatosis, xero- monest among the our study as well as by Thappa et sis was seen in 3 (2.5) cases. Hemangioma and pytri- al5. Comparison of various dermatophyte condition asis rosea occurred in 2 (1.6) cases each. One case reveled total incidence (4.80%) slightly higher than (0.8) each of keloid, malaria, pityriasis alba and lichen (3.10%) in other indian study by Thappa et al5, and striatus were seen. much higher than that (1.30%) Turkish study by Tamer et al4. DISCUSSION Our Study found prevalence of xerosis of 2.5%. Study done by Tamer et al4 showed incidence of xe- In our study, eczemas of all types was found in 10 % rosis to be 2.6%. Prevalence of miliaria was found to patients, approximately similar was the proportion of be 0.83%. Tamer et al4 showed incidence of miliaria the eczemas in the two other Indian studies while the in their study to be 0.8%. Incidence of keloid was study by Tamer et al4 from turkey showed the highest found to be 0.83% while study done by Tamer et al4 prevalence of 18.9 %. The incidence of atopic ecze- showed incidence of keloid to be 0.4%. In our study ma was low in our study (1.60%) and much lower Pityriasis Rosea was found to be 1.6% prevalent. (0.01%) in the study by Thappa et al5 . However, it Study done by Tamer et al4 showed incidence of pit- had a high incidence of 11.80% in the Turkish study yriasis rosea to be 1.2%. Incidence of hemangioma by Tamer et al4. Incidence of contact dermatitis is and pityriasis alba were found to be 1.6% and 0.83% much lower (1.60%) in our studies than that of respectively. While in the study by Tamer et al4 inci- 11.30% in the Turkish study by Tamer et al4. Inci- dence of hemangioma and pityriasis alba to be 0.3% dence of seborrheic dermatitis is also lower (2.5%) in & 1.6% respectively. the present study as compared to that (4.30%) in the Turkish4 study. Incidence of a diaper dermatitis (2.50%) and nummular eczema (1.60%), however, is REFERENCE much higher in the present study than that of 0.90% of diaper dermatitis and 0.40% of nummular eczema 1. Bhatia V. Extent and pattern of pediatric dermatosis in rural in the Turkish4 study. Incidence of secondary bacte- areas of central India. IJDVL 1997; 63 (1): 22-25. rial infections (17.50%) in our study approximates 2. NL Sharma, RC Sharma Prevalance of Dermatologic diseas- that seen in the two other Indian studies by Thappa es in school children of a high altitude tribal area of Hima- et al5 (17.90%) and Negi et al6 (15.60%). chal Pradesh. IJDVL 1990; 56:375-376. 3. Baruah CM, Bhat V, Bhargava R, Garg RB, Ku. Prevalence Incidence of impetigo in our study (6.66%) was of dermatoses in the neonates in Pondichery. Indian J Der- higher than those seen in the other two studies by matol Venerol Leprol. 1991; 57: 25-8. 5 4 Thappa et al (5.80%) and Tamer et al (4.10%). 4. Tamer E, Ilhan MN, Polat M, Lenk N, Alli N. Prevalence of Bullous impetigo was found in 1.66% of our cases, it skin diseases among pediatric patients in Turkey. J Dermatol. incidence being slightly higher in the study of Thap- 2008 Jul;35(7):413-8. 5 pa et al who found it in 1.9% of their cases. Our 5. Thappa DM. Skin diseases ("Dermatology") in India - Histo- study showed a higher prevalence of 3.33% of vitili- ry and Evolution: Amiya Kumar Mukhopadhyay. Indian J go as compared to that of 2.9% of in the study by Dermatol Venereol Leprol 2011;77:629. 6 4 Negi et al and 1.40% by Tamer et al . 6. K.S.Negi, S.D.Kandpal, D.Prasad, Pattern of skin disease in children in Garhwal region of Uttar Pradesh, Indian Paediat- rics 2001; 38:77-80.

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