NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Nitte University Journal of Health Science

Editorial Board Editor-in-Chief: K. R. Shetty, Editor: Arunachalam Kumar, Associate Editor: M. S. Ravi

Board of Advisors G Rajendra Prasad G C. S. Shastri G Fatima D'Silva G Md. Faisal G C. Vaman Rao G Sudhaker Nayak G Satheesh Kumar Bhandary G Vasudeva Kamath, USA G B. Sundar, Bengaluru, G Avinash Shetty, USA G Kapadia, Bahrain, G Anupam Agarwal, USA G Deepa Vinu, USA G M. Rajshekar

Editorial Office: Email: [email protected] / web: nitte.edu.in/journal Phone: 0824-2204300 Fax: 824-2204305 Address: Editor, Nitte University Journal of Health Science University Enclave, Health Science Complex, Deralakatte, Mangalore 575018,

The opinions and observations contained the journal are those of the authors/s and not of the NUJHS Editorial Board Subscription: Annual (4 issues) Rs. 1000 / Single copy: Rs. 300: For subscriptions or copies contact: [email protected]

INDEXED / CITED in Index Copernicus, Google Scholar, GFMER, Nursesmeet, HINARI, Mosbys, getCITED, EBSCOhost, Summon by Serial Solutions, SCOPUS, Genamics JournalSeek, EMBASE / Excerpta Medica, ProQuest, ProQuest Pharma Collection, WAME, ResearchGate, SciVerse, Biobase-CABS, Urlich's International Periodical Directory, Biblioteca Informa & Health Science Research Network.

The Nitte University Journal of Health Science (NUJHS) is a peer-reviewed indexed, open access, quarterly research publication. The annual subscription for NUJHS is Rs 1,000/- (4 issues). DDs / Checks payable to Nitte University Journal of Health Sciences, Syndicate Bank, ABSMIDS Branch, Deralakatte can be mailed to Dr. Arunachalam Kumar, Editor, NUJHS Journal Office, K. S. Hegde Medical Academy, Mangalore 585018, India. Single copies are available on payment of Rs. 300 each, by cash or check at the Journal Office. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Contents Page No Contents 2 Original Articles Development and Psychometric Evaluation of the Tool Aptitude Towards 3 - Maxie Andrade & Anice George Diagnostic Hysteroscopy in Abnormal Uterine Bleeding & It's Histopathologic Correlation: Our Experience 13 - Neetha Nandan, Lakshmi Manjeera, Supriya Rai & Mangala Gowri Nursing Informatics 18 - R. Ponchitra Trends of Poisoning Among Children at Kasturba Hospital, Manipal 25 - Pratik Vijay Tarvadi, Shankar M. Bakkannavar, Manjunath S., Vikram Palimar, G. Pradeep Kumar & Mahabalesh Shetty Comparison of Traditional Versus Video Based Teaching on Neurological Assessment Among Undergraduate Nursing Students 29 - Sushma Prabhu Food Adulteration and Family's Knowledge on Food Adulteration in Selected Village of Udupi Taluk, Karnataka. 33 - Abidfaheem T.K., Baby S. Nayak & Maxie Andrade Health Beliefs on Management of Diabetes Mellitus 38 - Jijomon P.P., Teena Sharon, Ruby Xavier & Malathi G. Nayak Validation Metrics of the Mastoid Triangle 44 - Bhagya B., Hema N. & Ramakrishna A. Knowledge Regarding RCH Services Among Health Workers, Pregnant Mothers and Adolescents in Rural Field Practice Area 46 - Anusha Rashmi, Rashmi & N. Udaya Kiran Butt and Hit - the Heart Kidney Saga: A Snap Shot and Long Term Perspectives 51 - Raghava Sharma & Shashank Shetty Thermoregulation in the Heart and the Biophysics of Coronary Arterial Flow 58 - Arunachalam Kumar Short Communications A Study on Father`s Knowledge and Attitude Towards Their Role in Child Care in Selected Areas of Mangalore with A View To Develop an Informational Booklet. 63 - Roshin M.S. & Sujatha R. Gender Differences in Childhood Poisoning 69 - Pratik Vijay Tarvadi, Shankar M. Bakkannavar, Vikram Palimar, G. Pradeep Kumar, Mahabalesh Shetty & Sanjeev Badiger Menopausal Transition Among Northern Indian Women 73 - Vijayalakshmi S., Ramesh Chandrababu & Eilean Victoria L. A Comparative Study on Coping Strategies and Sense of Coherence Among Caregivers of Mentally and Neurologically Ill Patients in Kasturba Hospital, Manipal, Karnataka. 80 - Rigi George, Asha Nayak & Anjalin D'Souza Nursing Aspects in Care of Patients With Dementia 86 - Linu Sara George & Asha K. Nayak Case Reports Fabrication of Single Piece Hollow Bulb Interim Obturator with Palatal Ramp for Treatment of Hemimaxillectomy and Hemimandibulectomy - A Case Report 91 - Anupama Prasad D., Krishna Prasad D. & Chethan Hegde Light Weight Hollow Denture - A Case Series 95 - Laxman Singh Kaira Cavity in The Lung: A Rare Case of Burkholderia Cepacia Infection 100 - Suresh G., Rama Prakasha S., Giridhar B.H. & Shama Prakash K. Chickenpox- Customs, Beliefs and Traditional Practices in Udupi District: A Case Study 102 - Asha K. Nayak & Shalini Review Article Enhancing Stability : A Review of Various Occlusal Schemes in Complete Denture Prosthesis 105 - Krishna Prasad D., B. Rajendra Prasad, Anshul Bardia & Anupama Prasad D. Biofilms Produced by Candida Yeasts and its Consequences: A Review 113 - Anupama Prasad D., B. Rajendra Prasad, Veena Shetty & C.S. Shastry Instructions to authors 122 Nujhs Declaration and Right Transfer Form 124

2 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article DEVELOPMENT AND PSYCHOMETRIC EVALUATION OF THE TOOL APTITUDE TOWARDS NURSING Maxie Andrade1 & Anice George2 1 Asst. , 2 Dean, Manipal College of Nursing, Manipal University, Manipal, Correspondence: Maxie Andrade Asst. professor, Manipal College of Nursing, Manipal University, Manipal. E-mail : [email protected] Abstract : Nursing is an attribute expected of every living being and every living being is capable of providing care to another in need. Few occasions especially the sickness, unawareness or disability call for special skills of nursing to substitute or supplement to the acute or chronic need of a living being. These skills can be acquired only through special training through a well planned curriculum. Hence in modern medicine, a group of health care providers called nurses are trained to care for the sick and the needy. Nursing profession has been the attraction for many young adults, however, this attraction has become the passion for some, while for few others, it is still an occupation. The transformation into an effective nurse demands special psychomotor abilities. The transformation is easier and can happen at a faster pace if one possesses an aptitude towards nursing. This assumption led the researcher to develop a tool to identify such able candidates for the profession of nursing. This article explores researcher's two attempts in developing the tool, which were though not fruitful, they certainly have given an impression on the complexity of the measurement of the construct of nursing and caring. Keywords : Aptitude towards nursing, caring, tool development

Introduction : knowledge, skill or composite of knowledge, Education is a human right and is open for every desiring understanding and skill. The chief value of aptitude testing citizen. It is the foundation for national growth. Diversity in is in fact that it enables us to pick out from those who do medical education has opened newer courses and not yet have the ability to perform certain skills; those who professional groups in health sector. Indian universities with a reasonable amount of training will be most likely to admit good number of medical and paramedical students acquire the skills in question and acquire them to a to various courses, producing a large number of graduates. desirable level of a proficiency. Testing aptitude of students There are many who choose a profession out of their own during admission to a professional course has been a far interest, whereas some desire to explore a particular field thought of the educational administrators, who strongly and quit, thinking, that is not what they are good at. There believe that aptitude of the students can be measured and are a few who leave their decisions on their loved ones and moreover it is useful for the students to succeed in their take up the profession but remain totally dissatisfied to career. Standardized Aptitude tests for several occupations continue in the same profession or struggle to exist in the are available and are in use; however nursing is in the look same. out of the same. 1, 2, 3. Access this article online Aptitude is a condition, a Nursing is a practice oriented profession and the core of Quick Response Code quality or a set of qualities nursing is care. Nursing is both an art and a science and the in an individual which is nursing education includes the knowledge and skills from indicative of the probable the basic, behavioural and applied sciences. There is extent to which one will be remarkable progress in health sector and health care able to acquire under knowledge. Nurses remain with clients round the clock in suitable training some the in-patient setting and are required to exhibit

Keywords: Aptitude towards nursing, caring, tool development 3 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science competent care. Nurses have to rationalize actions and act, the most suitable candidates and predict their stay in the because they are accountable and responsible for each profession. 2 action. Thus nursing is challenging and to face the A number of attempts have been made to develop tools to challenges, one has to have a favourable attitude and assess nursing aptitude. However the review reveals that aptitude towards nursing.4 these attempts are either to assess the specific ability such High Power Committee on nursing and nursing profession, as math or science aptitude or for selecting students to the appointed by Government of India, Ministry of Health and upper nursing division Aptitude continues to be predictive Family Welfare, in its report in 1990 stated, “Nursing of BSN (Bachelor of Science in Nursing) students success, personnel should have a complete say in matters of even as BSN student demographics and pre-nursing selection of students, which should be based on merit. educational backgrounds change. Authors discuss that Aptitude tests should be introduced for selection of nurse educators should focus their attention on core candidates.” In a study titled, perceptions on nurses, predictor variables that are known and that continue to be nursing practice and nursing education system (2010),one predictive of BSN student attrition. BSN students to have of the physicians was of the opinion that nursing students' holistic knowledge necessary for safe and efficient nursing aptitude should be assessed. He said:“Practicing nurses practice; they must have not only a sufficient math need qualities like 'care and compassion' without which no aptitude to do clinical calculations but also the ability to amount of education can help. A study held in Bangalore, read at the level demanded by the clinical questions being India on aptitude towards nursing among nursing posed.8, 9. professionals' recommended to test the aptitude of The Aptitude test developed by the Asian Psychological students at entry level. ”5, 6, 7 Services and Assessment, Inc., admits that the ANP The alarming increase in the number of unemployed (Assessment of Nursing Potential) is a valid and reliable graduate nurses during the past three decades has caused measure to form a strong base for selecting students for the heads of professional schools to seek means of admission to the upper nursing division level. It is identifying students who will be able to measure up to the composed of a combination of three tests, namely: (1) higher standards necessary if the profession of nursing is to Nursing attitudinal inventory (earlier known as the Nursing maintain its position in the fields of medical and social Quality Scale) which assesses the traits that are essential in service. Such identifications, to be effective, must be made contributing to one's success in the nursing profession; (2) prior to admission to schools of nursing. The alternative Aptitude test that measures the “innate-based” learned method of selecting qualified nurses by permitting them to abilities; and (3) Achievement test measuring what has "try" nursing for one, two or three years before being been learnt in the lower nursing division level. The ANP test rejected is too wasteful of time, money, and morale. Thus battery has been widely used by nursing schools in the the problem becomes one of testing for nursing aptitude at Philippines. It is the only locally made test used for the time a candidate applies for admission to a selection and placement of nursing students. It has been school/college of nursing. It may seem that the task of seen as a good preparation for the Nursing Board identifying students with aptitude for nursing is a simple Examinations and foreign-based tests such as the NCLEX one wherein a nurse administrator looks at and talk to an and CGFNS. 10 applicant and differentiates the able from the unable The review of literature suggested that nursing is yet to find candidates. But the task is not that easy. It becomes a tool to assess the aptitude of nursing students at entry necessary, therefore, to use the painstaking methods of level and this encouraged the researcher to attempt research to discover more dependable methods to identify development of a tool for this purpose. Currently, majority

Keywords: Aptitude towards nursing, caring, tool development 4 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science of Schools and Colleges of Nursing in India admit students and informed consent from partcipants were obtained. The purely on their pre university course marks. A very few have average time taken by the participants to complete the an entrance examination for undergraduate or diploma questionannire was 85 minutes. The Cronbach's alpha for courses. Most of the personal interviews held at the time of the overall likert scale for 108 items was r= 0.932; overall admission are not true counseling sessions per se in most scale test retest reliability (with a gap of 8 days between of the nursing schools and colleges. There is dissatisfaction tests) was r= 0.7. The overall Split half reliability of MCQ expressed by experienced clinical nurses on the ability of items (caring scenario 1 & 2, abstract reasoning, academic graduated nurses to function effectively in clinical nursing aptitude, reading comprehension, verbal ability) was r = practice. However, in these contexts, assessment of 0.42. aptitude at the time of admission to nursing courses is Though the overall scale and test retest reliability were in believed to be useful in selection of right candidates for the acceptable range, it was decided to condense the tool nursing courses. as time for administration was nearly 85 minutes. There Materials, Methods and Results: were three decisions taken after the first attempt for the The study assumed that aptitude is the product of innate modification of the tool as follows. and acquired abilities and is measurable. 1. An opinion on excluding the subscale of academic Table 1 summarizes the first attempt. The subscales aptitude was considered apt as the same is projected in the selected for the tool were based on the Philippines study report card (pre-university) of the student. Moreover, as (Assessment of Nursing Potential) and the items were these items were based on 'science' subjects, there is developed based on those operational definitions. likelihood that the art and commerce background students However these tools were not comparable as the purpose (of few diploma nursing students) may either guess for which the tools were developed and items were answers or show no interest in attempting for the items. different. There were eight subscales in the developed tool However the pilot study scores revealed that even students namely, caring, compassion, connectedness, commitment, with science background could not perform on these items abstract reasoning, academic aptitude, reading better. comprehension and verbal ability and vocational 2. One of the nursing experts from USA opined that, adjustment. “English is not the primary language in India, and hence The items in the academic aptitude and abstract reasoning assessment of verbal ability and reading comprehension at were based on the 12th standard syllabi and the items were pre entry level may not be commendable.” This suggestion from the Science subject including Environment and was considered apt as in Karnataka, there are few students biodiversity. Content validation was done by 11 experts: (Arts, Science, Commerce) who enter nursing with Clinical Psychologist (2); teaching at PU college Kannada as the medium of instruction in their pre- (2); and Nursing (7). Two validators suggested to university programme. Moreover majority of students who use care scenarios than the likert scale alone, thus two study nursing in Karnataka, are from the neighboring state scenario based subscales for caring were developed and of Kerala, where also similar options for the choice of the revalidated among 5 nursing experts. The samples were medium of instruction exist. Thus the suggestion of the first year nursing students (diploma and B. Sc.) who were expert was considered valid, as there is scope of admitted to the course a month ago, in the Schools and development of this ability during the course even if it is Colleges of Nursing in Udupi and South Canara districts of not possessed at entry level. (The medium of instruction Karnataka. Official permission from Heads of Institutions for diploma and graduate nursing programmes in India is English and English is taught as a subject in the first year of

Keywords: Aptitude towards nursing, caring, tool development 5 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science the nursing course). The test-retest reliability of this scale was not tested, as the reliability of the subscales were comparatively lower as 3. Nursing requires scientific knowledge but nursing is also compared to the first attempt. The split half reliability of an art. Nursing is a team work and the independent life MCQ items was found to be comparatively better (r=0.7). saving decisions taken by nurses are of less complexity in The comparison of means of each subscale (presented in public health care practice. In hospital settings, the health table 3) revealed that there was significant difference team is available within the reachable distance. The between the groups in caring, reading comprehension, absence of abstract reasoning ability from nursing students vocational adjustment(commitment) and mechanical at basic level will be supplemented by the health team ability. members in clinical practice. Abstract reasoning is nurtured through experience and this will be developed as The researcher planned to pretest the same tool among students undergo the training programme. Assessing these the public (receptionists and clerks), the students of other at pre entry level may give more importance to science courses in health care (Respiratory therapy and Health than the art form of nursing. Information System), the practicing nurses of a selected teaching hospital, second, third and fourth year students of Considering these suggestions, a second attempt was diploma and B. Sc. Nursing courses of a and made and a tool was prepared with the components College attached to the same teaching hospital in Udupi presented in table 2. The subscale on reading District. The tool was administered after obtaining the comprehension was retained as it was believed that informed consent and official permission from respective nursing students are taught the course in English. The items authorities, in a group under supervision, ensuring no of the likert scale namely caring, compassion, copying or discussion among participants. The tool took 50 connectedness and vocational adjustment were modified minutes for its completion on an average. The public group as per the item analysis findings of the first attempt. The was administered only the likert scale. An analysis of the component of commitment was clubbed with vocational findings is presented in table 4. Analysis of scores of adjustment in a separate section as part 2. (Part 1 was students year wise is shown in table 5 and 6 for B. Sc. named as adaptation) Caring scenarios were framed as Nursing and diploma nursing students respectively. Though decision making ability items which included eight MCQ on the scale appeared handy to administer within an hour, the positioning and feeding a bedridden adult in a family findings were not suggestive of acceptable reliability (at setting. Pictorial presentations were presented in order to least r = 0.6 for each subscale). assess visual-spatial abilities, e.g.: reading of a thermometer, graphic recording, selection of Table 4 reveals that difference was found in commitment accessories/supplies for a equipment (based on the and mechanical ability among groups however the abilities diameter of tips) or for simple dressing of a minor wound or of staff nurses and the final year B. Sc. Nursing students hand hygiene. Abstract reasoning was replaced with were a near match. Arithmetic ability, assuming nurses need to possess this Table 5 shows that there was significant difference in the ability as medication errors are considered serious errors in scores of B. Sc. Nursing students year wise. Post hoc test nursing. The items were pretested for readability and were revealed difference in scores of caring, arithmetic and given to seven experts for content validation (Two clinical mechanical ability between all four groups; compassion psychologists and five nursing doctorates). The tool was between 1st and 3rd as well as 3rd and 4th year; connectedness administered in a group, ensuring a minimum distance of 3 between 1st and fourth as well as 2nd and 3rd; adaptation feet between participants to avoid discussion and copying. between 1st and 3rd as well as 1st and 4th; commitment Table 2 summarizes the findings. between 1st and 3rd as well as 3rd and 4th; reading

Keywords: Aptitude towards nursing, caring, tool development 6 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science comprehension in 3rd and 4th; decision making between 1st reading comprehension and mechanical ability were and 4th year students. There was significant difference in retained as a part of the tool and it was decided to pretest total scores of reading, arithmetic, decision making and the same with first year graduate students of arts, mechanical ability among all four year students, whereas in commerce and science stream after obtaining the official total scores of caring, compassion, commitment, permission from the college authority and participants. As connectedness and adaptation, there was difference in 1st construct validity of the scale in second attempt was not and 3rd as well as 1st and 4th years; 2nd and 4th years as well as testable because the items were not based on a sound 3rd and 4th year students. Among diploma students in table theory, the third attempt was made to base it on Swanson's 6, significant difference was noted only in adaptation theory of caring, and this attempt is not described in this 11 among all three batches and reading comprehension in 1st article. and 2nd year students as revealed through the post hoc test. Discussion : The assessments in second attempt revealed that nursing The idea of measurement of aptitude towards nursing has entrants of diploma and graduate nursing program differed been though suggested by the high power committee in key abilities of caring and commitment wherein the before 20 years, review reports two such attempts made in mean scores of caring were higher among diploma India to measure it scientifically. As discussed in the students compared to that of graduate programme and introduction, the published aptitude measurement scales vice versa was true with regard to commitment. The outside India, had not been tested for their efficacy in difference was notable in terms of reading and mechanical selection of nursing students. The nursing institutes abilities which were attributable to their background in abroad, seem to be assessing nursing aptitude at entry pre university education. The difference in caring and level however published reports on their efficacy are not commitment was not acceptable by the researcher as found. these were considered important qualities of a nurse. Nursing Aptitude test (NAT) for students seeking admission At the end of the second attempt, researcher thought to to nursing institutes was attempted by Triza Jiwan (2011) seek answer to a question, “What abilities one should look who found the reliability (α) of r = 0.85 for cognitive and for among pre entry students apart from caring?” A survey affective aptitude as well as 0.72 for conative aptitude. The was held among the Professors (n=7) of a selected college one hour paper and pencil test was built around and two external experts. The experts were not intelligence, emotional strength and psychomotor skills. comfortable to pinpoint the abilities, however agreed on The article reports that it was built on a theory and the variables listed as subscales in the second attempt. construct validity of the tool was tested on 10 experts. There was no unanimous agreement on the assigned However the materials, methods used and the theory on weightage, however five of them weighed decision making which the tool was developed and tested is not clear in the 12 and caring 25% each. However one of the external expert report. (from USA) opined that though nursing is art and science, A study by Pataliah used the subscales of memory, the science component of nursing should be assigned a knowledge, vocabulary, judgment in nursing situation, weightage of 65%, which includes, arithmetic, decision ability to comprehend instructions and follow. The study making, mechanical and verbal abilities. One of the used reading and verbal ability as well, however the Professors from India (externl expert) gave a higher rating assessment of these abilities in the current study did not (90%) for caring and the Professors of the selected college display good aptitude. The current study found majority of ranked each ability between 10-20%. the entrants to nursing courses were females (95.7% in first Thus the section of arithmetic ability, decision making, attempt; 98.8% in second attempt) and Christians (61% in

Keywords: Aptitude towards nursing, caring, tool development 7 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

1st attempt; 55.6% in second attempt) which is very evident Nursing is a skill and assessment of nursing potential has in most of the nursing studies.7, 13 been the need of the hour in Indian context. General aptitude tests are available and are widely used, however Existing Aptitude tests have been well critiqued by several growing complex health care industry of today is in the authors. A study of UK concludes stating UKCAT (United lookout for efficient and effective nurses, who touch the Kingdom Clinical Aptitude Test) scores are predictive of lives of patients shortening their length of stay. Nurses with Year 1 and 2 examination performance at medical school, nursing aptitude may fit well in this caring industry and whereas interview scores are not. The results challenge, moreover nurse trainers may find it easy to mould these claims made by other authors that aptitude tests do not nurses at a faster rate to meet the increased demand for have a place in medical school selection in the UK.3 nurses worldwide. Screening entrants to nursing does not In an article David McDonald discussed on the role of mean to close the door for those who are interested but do intelligence and aptitude tests and how they are to be not have the right aptitude, however this screening is only interpreted. The steps delineated by the author in to prevent burnout from repeated trying. The entrant development of an aptitude test, are commendable. In when finds herself/himself capable to nurture the existing nursing, the psychomotor skills required are numerous skill to the level required may find the profession enjoyable though not complex. However, the introduction of and aid growth of the profession. technology in health care today especially in nursing Conclusion: situations, has brought in complexity thereby welcoming Measurements in psychosocial sciences have been tried to technical competency in nurses. The major areas which simplify the understanding of the concept or construct. The require clarity in nursing would be professional boundary effectiveness of nursing is largely dependent on the and specificity of psychomotor skills. Most of the nursing psychosocial elements of care. Nursing is a broad concept responsibilities in today's health practice is shared by and a construct (as a verb and noun), which employ several allied professionals, moreover complexity of skills comparatively simple motor skills. Nursing is a universal are not similar in different nursing units, let that be adult or phenomena and ina broader sense it is self transcendence. pediatric, family, community or institution based settings.14 The complexity of nursing is in its contextual factors, which Caring has been conceptualized as the central and vary in settings and from person to person. Nursing is significant factor in nursing science and patient healing. percieved and experienced differently by different people However is caring measurable? Jean Watson, a pioneer in that is how measurement of aptitude towards nursing has caring science states, “Caring instruments serve as appeared complex. indicators along the way and point back to a deeper Acknowledgment : dimension of human caring relational practices, which The investigators thank the participants and the validators remain forever elusive and non-measurable. Deep of the tool. Special thanks to administrative authorities of philosophical ethical and ontological subjective dimension institutions for permission to conduct the study and for of caring cannot be measured, but some measurement can providing the necessary physical environment for elucidate the manifest field of caring practices, while some administration of the tool. pointing towards the non-manifest whole.” The complexity in finding the construct validity for the caring phenomena justifies Dr. Watson's statement however, painstaking efforts need to be ongoing and continued to capture the meaning of the construct to the extent possible and to be included as a measure towards nursing aptitude. 15

Keywords: Aptitude towards nursing, caring, tool development 8 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 1: Components and reliability of the tool: Nursing aptitude Subscales Number of Range of Sample Reliability Median Mean (SD) items scores (Range) Caring* 21 21-105 First 0.726 52 52.48 (Personal attributes) year (54) (10.547) Caring scenario 1 10 0-10 B.Sc. 0.296 4 4.29 Nursing (8) (1.639) Caring scenario 2 6 2-12 students 0.331 9 8.83 (n=51) (10) (1.993) Compassion* 16 16-80 0.755 45(43) 43.54(8.436) Commitment* 22 22-110 First 0.833 61(72) 59.73(11.31) Connectedness* 20 20-100 year 0.858 60(69) 58.48(10.389) Abstract reasoning 10 0-10 diploma 0.219# 3(6) 3.09(1.544) Academic aptitude 45 0-45 Nursing 0.446# 11(18) 11.39(3.884) Reading Comprehension 5 0-5 students 0.274# 2(4) 2.38(1.031) Verbal comprehension 06 0-6 (n=42) 0.009# 3(5) 2.56(1.058) Verbal comprehension 04 0-4 0.026# 1(3) 1.32(0.874 (reading a passage) Vocational adjustment* 11 11-55 0.810 32(35) 31.45(6.618) (Social relationships) Vocational adjustment* 10 10-50 0.795 29(35) 28.39(6.33) (Academic) Vocational Adjustment* 8 8-40 0.734 24(28) 23.54(4.736) (Personal emotional) * Five point likert scale: Never, Rarely, Occasionally, Most of the times, Always # Split half reliability

Table 2: Components and reliability of the tool: Nursing aptitude Subscales Number of Range of Sample Reliability Median Mean (SD) items scores (Range) Caring 15 15-75 B.Sc. 0.707 62 (34) 61.4 (6.185) Compassion 18 18-90 Nursing 0.568 67(41) 66.53(7.234) Connectedness 22 22-110 first year 0.543 86(35) 84.84(6.933) Vocational adjustment 17 17-85 (n=86) 0.594 65(44) 64.20(6.834) (Part 1) Vocational adjustment 9 9-45 Diploma 0.530 33(25) 32.41(4.976) (Part 2) nursing Reading comprehension 6 0-6 (n=38) 0.577** 3(6) 2.96(1.605) Decision making ability 8 0-8 0.048** 3(6) 2.85(1.338) Mechanical ability 8 0-23 0.296** 12(19) 11.47(4.205) Arithmetic ability 8 0-8 0.322** 3(8) 2.63(1.6) Total# 81 81-405 0.846 311(144) 309.29(23.909) Total## 29 0-29 0.7** 20(36) 19.9(6.409) * Five point likert scale: Never, Rarely, Occasionally, Most of the times, Always ** Split half reliability #: Total scores of Caring, compassion, connectedness and vocational adjustment ##: Total scores of Reading comprehension, decision making, mechanical and arithmetic ability

Keywords: Aptitude towards nursing, caring, tool development 9 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 3: Comparison of diploma (n= 36)and B. Sc. Nursing students (n=86) scores Subscales t value P value Confidence interval (df= 120) lower upper Caring 2.008 0.047 0.035 4.839 Compassion 1.919 0.057 -5.577 0.088 Connectedness 0.263 0.793 -2.391 3.128 Vocational adjustment(Part 1) 1.869 0.064 -5.087 0.146 Vocational adjustment (Part 2) 4.216 0.001 -5.628 -2.031 Reading comprehension 6.403 0.001 -2.327 -1.225 Decision making ability 1.482 0.141 -0.919 0.132 Mechanical ability 6.056 0.001 -5.866 -2.975 Arithmetic ability 0.572 0.568 -0.810 0.447 Total# 1.316 0.191 -15.630 3.149 Total## 6.115 0.001 -8.966 -4.580 * Five point likert scale: Never, Rarely, Occasionally, Most of the times, Always #: Total scores of Caring, compassion, connectedness and vocational adjustment ##: Total scores of Reading comprehension, decision making, mechanical and arithmetic ability. Table 4: Mean standard deviation of scores on nursing aptitude among health care staff

Subscales Staff nurses Clerks Respiratory Health B. Sc. Nursing Diploma (n= 58) (n=49) therapy information final year nursing final students (n=14) system students students year students (n=27) (n=85) (n=48) Caring 62.16 60.86 59.79 60.52 63.04 62.46 (5.547) (4.912) (4.886) (4.449) (5.81) (5.299) Compassion 66.81 65.08 67.14 66.22 68.28 65.31 (6.387) (6.010) (5.057) (6.002) (5.15) (7.6) Connectedness 90.4 84.78 85.07 87.85 89.44 87.52 (6.64) (6.182) (6.367) (6.049) (5.88) (5.231) Vocational adjustment(Part 1) 64.93 62.16 64.07 65.11 65.69 62.17 (5.69) (7.198) (7.385) (5.033) (5.604) (5.737) Vocational adjustment (Part 2) 29.83 31 26.93 30.3 35.08 29.04 (3.56) (5.091) (3.54) (3.582) (4.124) (5.251) Reading comprehension 3.57 3.36 3.81 4.12 2.33 (1.788) (1.55) (1.495) (1.524) (1.521) Decision making ability 3.12 2.79 1.96 3.66 2.29 (1.352) Not (0,975) (1.675) (1.366) (1.051) Mechanical ability 16.05 assessed 11.93 7.93 15.94 8.58 (4.438) (3.97) (5.349) (4.098) (5.287) Arithmetic ability 3.74 3.5 1.81 3.59 2.5 (1.702) (1.743) (1.841) (1.841) (1.238) Total# 314.72 303.88 303 310 321.42 306.5 (20.509) (22.568) (18.794) (15.214) (19.678) (21.5) Total## 26.48 Not 21.57 15.52 27.33 15.71 (7.361) applicable (5.345) (8.045) (6.5) (5.946) * Five point likert scale: Never, Rarely, Occasionally, Most of the times, Always #: Total scores of Caring, compassion, connectedness and vocational adjustment ##: Total scores of Reading comprehension, decision making, mechanical and arithmetic ability.

Keywords: Aptitude towards nursing, caring, tool development 10 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 5:Mean, standard deviation of scores on nursing aptitude of B.Sc. Nursing students Subscales 1st year (n=86) 2nd year (n=48) 3rd year (n=46) 4th year (n=85) F Value (df) P value Caring 60.67 59.33 58.07 63.07 7.747 0.001 (6.503) (6.409) (5.579) (5.813) (3, 261) Compassion 67.38 66.65 63.98 68.18 4.643 0.004 (7.439) (6.466) (5.741) (5.157) (3, 261) Connectedness 84.74 85.79 83.43 89.44 11.584 0.001 (7.346) (5.996) (5.905) (5.883) (3, 261) Vocational 65.08 64.08 61.74 65.69 4.191 0.006 adjustment(Part 1) (7.151) (6.86) (5.523) (5.604) (3,261) Vocational 33.36 53.5 31.04 35.08 8.664 0.001 adjustment (Part 2) (4.636) (4.292) (4.158) (4.124) (3,261) Reading comprehension 3.5 3.96 3.3 4.12 3.692 0.012 (1.493) (1.798) (1.658) (1.524) (3,261) Decision making ability 2.98 3.21 3.28 3.66 3.285 0.021 (1.447) (1.487) (1.486) (1.368) (3, 261) Mechanical ability 12.84 13.79 12.2 15.94 12.522 0.001 (3.564) (3.585) (4.651) (4.098) (3, 261) Arithmetic ability 2.71 2.42 2.26 3.59 8.906 0.001 (1.7) (1.302) (1.512) (1.841) (3, 261) Total# 311.55 309.35 298.26 321.42 10.688 0.001 (21.844) (24.455) (19.774) (19.678) (3, 261) Total## 22.02 23.38 21.04 27.33 14.852 0.001 (5.959) (5.491) (6.415) (6.5) (3, 261) * Five point likert scale: Never, Rarely, Occasionally, Most of the times, Always. #: Total scores of Caring, compassion, connectedness and vocational adjustment. ##: Total scores of Reading comprehension, decision making, mechanical and arithmetic ability.

Table 6: Mean, standard deviation of scores on nursing aptitude of diploma students Subscales 1st year (n=38) 2nd year (n=50) 3rd year (n=48) F Value(df) P value Caring 63.06 63.08 62.46 0.22 0.801 (5.099) (4.915) (5.299) (2, 133) Compassion 64.61 66.10 65.31 0.509 0.603 (6.429) (6.606) (7.611) (2,133) Connectedness 85.05 84.96 87.52 2.894 0.059 (5.982) (6.276) (5.231) (2,133) Vocational adjustment(Part 1) 62.21 65.38 62.17 4.631 0.011** (5.648) (6.233) (5.737) (2,133) Vocational adjustment (Part 2) 29.58 30.22 29.04 8.67 0.423 (4.589) (3.328) (5.251) (2,133) Reading comprehension 1.74 2.38 2.33 3.489 0.033** (1.107) (0.987) (1.521) (2,133) Decision making ability 2.55 2.28 2.29 0.767 0.466 (1.005) (1.278) (1.051) (2,133) Mechanical ability 8.37 9.32 8.58 0.492 0.613 (3.921) (4.963) (5.287) (2,133) Arithmetic ability 2.45 2.16 2.5 0.983 0.376 (1.350) (1.267) (1.238) (2,133) Total# 304.5 309.74 306.5 0.831 0.438 (18.182) (17.975) (21.5) (2,133) Total## 15.11 16.14 15.71 0.383 0.682 (4.572) (5.675) (5.946) (2,133) * Five point likert scale: Never, Rarely, Occasionally, Most of the times, Always. ** p<0.05 #: Total scores of Caring, compassion, connectedness and vocational adjustment ##: Total scores of Reading comprehension, decision making, mechanical and arithmetic ability.

Keywords: Aptitude towards nursing, caring, tool development 11 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Mangal S L. General Psychology. Fifteenth reprint. : Sterling council licensure examination – . Journal of Publishers Pvt. Ltd; 2008 professional nursing. 2009: 25(5); 273-278. 2. Williamson E. G, Stover R D, Fiss C B. Testing for nursing aptitude. The 9. Newton S E, Harris M, Pittiligo L, Moore G. Nursing student math Parrot, the yearbook of the Memorial Hospital School of Nursing, aptitude and success on a medication calculation assessment. Nurse Rhode Island, July 1937. educator. 2009: 34(2); 80-83. 3. Wright S R, Bradley P M. Has the UK clinical aptitude test improved 10. Magno C. Integrating Nursing Quality with Achievement and Aptitude: medical studentselection? Journal of Medical Education. 2010:44 Towards Assessing Nursing Potential. The International Journal of (11); 1069-76. Research and Review. Vol 4, 2010. 4. Berman A, Snyder S,Kozier B, Erb G. Kozier and Erb's fundamentals of 11. Swanson K M. Empirical development of a middle range theory of nursing. 18th edition. Delhi: Dorling Kindersley Pvt. Ltd; 2008 caring. Nursing research. 1991 May June; 40 (3): 161-166. 5. Indian Nursing yearbook. 1993-95. 12. Jiwan T. Aptitude test for students seeking admission to nursing 6. Andrade M. Perceptions of health care consumers, deliverers and institutes. The nursing journal of India. 2011; 102(8): 174-175. nurse educators on nurses, nursing practice and nursing education 13. Andrade M. Choice of nursing career: Pleasure or pressure. system. Manipal University, Manipal: 2010. International journal of nursing education. 2012; 4(1): 42-44 7. Pataliah B A. Aptitude towards nursing among nursing professionals. 14. Mc.Donald D. Testing for competence rather than for intelligence. The Nursing Journal of India. 2004; 95 (11): 253- 257. American Psychologist. Jan 1973; 1-14 8. Newton S E, Moore G. Use of aptitude to understand bachelor of 15. Watson J. Assessing and measuring caring in nursing and health science in nursing student attrition and readiness for the national sciences. 2nd ed. New York: Springer publishing company; 2009.

Keywords: Aptitude towards nursing, caring, tool development 12 -Maxie Andrade NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article DIAGNOSTIC HYSTEROSCOPY IN ABNORMAL UTERINE BLEEDING & IT'S HISTOPATHOLOGIC CORRELATION: OUR EXPERIENCE Neetha Nandan1, Lakshmi Manjeera2, Supriya Rai3 & Mangala Gowri4 1Assistant Professor, 2Associate Professor, 3Professor, 4Junior Resident, Department of OBG K.S. Hegde Medical Academy, Nitte University, Deralakatte, Mangalore, Karnataka, India. Correspondence: Neetha Nandan Assistant Professor, Department of OBG, K.S. Hegde Medical Academy, Nitte University Deralakatte, Mangalore, Karnataka, India. Mobile : +91 99000 01287 E-mail : [email protected] Abstract : Aims & objectives: 1) To study the accuracy of hysteroscopy in evaluation of abnormal uterine bleeding in perimenopausal and postmenopausal women. 2) To correlate hysteroscopic findings with histopathologic results. Materials and methods: It is a retrospective study done in the department of OBG at K.S.Hegde Medical Academy, Mangalore. All patients who underwent diagnostic hysteroscopy for abnormal uterine bleeding in the past 6 years were included in this study. Patients underwent clinical and sonographical evaluation. Following hysteroscopic evaluation, patients had undergone dilatation and curettage and endometrial curetting were sent for histopathological examination (HPE). The correlation between findings on hysteroscopy & HPE were tabulated. Results: On hysteroscopy, endometrium was classified as suggestive of normal, hyperplasia, atrophic, polyp, fibroid, cancer. Histopathological diagnosis was taken as gold standard to determine the efficacy of hysteroscopy in diagnosing endometrial pathologies. Out of 175 patients, 108 patients were diagnosed to have endometrial hyperplasia on hysteroscopy, however only 53 confirmed to have on histopathologically. Similarly 25 patients were said to have normal findings on hysteroscopy but by histopathology 85 were having normal endometrium. Hysteroscopy was highly specific for diagnosis of polyp (95.9%), cancer (100.0%), and atrophy (96. 9%), normal endometrium (92.2%) but low specificity for diagnosing hyperplasia (48.4%). The sensitivity of hysteroscopy in diagnosing polyp and endometrial hyperplasia were 100% and 84.9% respectively but it was low in case of cancer (16.7%) and normal endometrium (21.2%). Conclusion: Hysteroscopy is a highly accurate diagnostic tool in diagnosing intrauterine lesions like endometrial polyp and submucous fibroid. In fact, it was also found to be highly specific in conditions like endometrial cancer, polyp, atrophic and normal endometrium. Keywords : hysteroscopy, abnormal uterine bleeding, dilatation & curettage

Introduction : present themselves to the gynecologist when there is Abnormal uterine bleeding is the commonest complaint variation in the normal cyclical pattern. The variation could which is noticed in a gynecology out patient setting. be due to physiological, hormonal change or may be due to Goldstein et al1 has defined abnormal uterine bleeding as benign or malignant condition. Age specific association of “patients having either metrorraghia defined as vaginal endometrial lesions are known to occur2.Hence, this needs bleeding separated from a proper evaluation. Hysteroscopy guided biopsy is the expected menses or recommended diagnostic test in the present day. The Access this article online Quick Response Code menorraghia defined as traditional blind dilatation and curettage can miss focal patient's subjective intrauterine lesions like polyp, sub mucous fibroid and complaints of either cancer. The other diagnostic tests involve transvaginal increased duration or sonography (TVS) and saline infusion sonography (SIS)3. increased volume of flow Hysteroscopy illuminates the darkness of the uterine or both. Patients usually cavity. So hysteroscopy is considered as a gold standard in

Keywords : hysteroscopy, abnormal uterine 13 bleeding, dilatation & curettage - Neetha Nandan NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science the evaluation of abnormal uterine bleeding in hypertensive, 1.7% were diabetic, whereas 2.3% patients perimenopausal and postmenopausal age group. had both diabetes and hypertension and 0.6% were hypothyroid. Only 2 patients out 175 had a family history of Aims and Objectives : breast cancer. Among 12 patients who had endometrial 1) To study the accuracy of hysteroscopy in evaluation of cancer on histopathology, 7 patients had associated abnormal uterine bleeding in perimenopausal and medical co-morbidities (Table 1). postmenopausal women. 2) To correlate hysteroscopic findings with histopathologic The commonest symptom for hysteroscopy was results. m e n o r ra g h i a a b o u t 8 7 ( 4 9 . 7 % ) fo l l owe d by postmenopausal bleeding 29(16.6%). Other indications for Materials and methods : hysteroscopy were irregular cycles, polymenorraghia, It is a retrospective study of 175 cases who have attended continuous bleeding per vaginum and dysmenorrhoea the department of OBG at K.S.Hegde Medical Academy, (Table 2). All hysteroscopy were done in operation theatre Mangalore in the last 6 years with complaints of abnormal under general anesthesia. Normal saline was used as the uterine bleeding. All patient's history and clinical distending medium for diagnostic hysteroscopy. For all examination findings were noted. All patients had an patients, endometrial tissue was sent for histopathological ultrasonography done. Those patients who underwent examination. diagnostic hysteroscopy followed by dilatation and curettage were selected for this study. There hysteroscopy The hysteroscopy findings were tabulated as normal, findings and histopathological reports were analyzed. hyperplasia, atrophy, polyp, fibroid and cancer (Table 3). 53 cases of hyperplasia were diagnosed on histopathology, Patients who underwent hysteroscopy for infertility were but 108 cases were suspected as hyperplasia on excluded. Patients who had an obvious cause of bleeding hysteroscopy. Out 53 cases of hyperplasia on from cervix or vagina were also excluded. Patients who histopathology, 35 cases were simple hyperplasia without were on anticoagulant therapy, hormone replacement atypia, 10 cases were simple hyperplasia with atypia, 5 treatment and who were known case of bleeding cases of complex hyperplasia without atypia and 3 cases of dyscrasias were excluded. complex hyperplasia with atypia. Out of 85 cases of normal Records of hysteroscopy findings were classified as normal, endometrium, only 25 cases were diagnosed as normal on hyperplasia, atrophy, polyp, fibroid, cancer. hysteroscopy. Out of 16 cases which were diagnosed as Histopathological diagnosis was taken as gold standard to atrophy on hysteroscopy, 5 were confirmed as atrophic on determine accuracy of hysteroscopy findings for histopathological examination (HPE) & 6 were insufficient diagnosing endometrial abnormalities. Their sensitivity, endometrium obtained again probably due to atrophic specificity, positive predictive value (PPV) and negative endometrium (Table 4). predictive value (NPV) were assessed. Data collected was 13 cases of polyp were seen on hysteroscopy, whereas on statistically compiled using SPSS 20 version. HPE, 6 cases were confirmed to be polyp. In case of Results : detection of submucous fibroid, 10 cases were diagnosed In our study, 29 cases (16.6%) were postmenopausal and on hysteroscopy. Since none underwent resection of the remaining 146 cases (83.4%) were perimenopausal. fibroid at the same sitting it could not be confirmed by HPE. Women in age group of 41-50 years formed a major group Of 12 cases of endometrial cancer diagnosed on HPE, 3 of 95 cases (54.3%). Majority of the patients were parous, cases were suspected as cancerous growth on that is 159 (90.9%). Among the study group, 27 cases hysteroscopy, 8 appeared hyperplasia & 1 was diagnosed (15.4%) had co-morbid medical disorders.11.4% were as submucous fibroid on hysteroscopy.

Keywords : hysteroscopy, abnormal uterine 14 bleeding, dilatation & curettage - Neetha Nandan NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

The correlation between hysteroscopy findings and Discussion : histopathological examination of endometrial curetting In gynecology, the most frequently encountered problem is were studied (Table 5). Of those 108 patients with abnormal uterine bleeding. Abnormal uterine bleeding hyperplasia on hysteroscopy, 45 patients (41.6%) had contributes to 30-40% of all gynecological problems. hyperplasia, 52 patients (48.1%) had normal endometrium In our study, 16.6% had postmenopausal bleeding & the and 8 patients (7.4%) had cancer. Of 25 patients with rest had other menstrual abnormalities as an indication for normal hysteroscopies, 18 (72%) had normal endometrium hysteroscopy. Among which, menorraghia (49.7%) being and 4 patients (16%) had hyperplasia on hispathological the commonest complaint which was found similar to examination. On hysteroscopy 16 patients were suspected study done in Bahrain4 where menorraghia was seen in 62% to have atrophic endometrium, 5 were confirmed , 6 patients & postmenopausal bleeding in 14%. The age group turned out to be insufficient endometrium which is ranged from 30 to 75years in our study. We did not include probably because of atrophy.13 patients were diagnosed hysteroscopy done for infertility purpose. So in our study, to have polyp on hysteroscopy, however 6 (46.1%) were the perimenopausal age group of 41 to 50 years formed the confirmed to have polyp on curettage and 2 (15.3%) each major bulk (54.3%). Most of the study group patients were were normal and hyperplastic. Submucous fibroid was multiparous (90.9%). diagnosed in 10 patients on hysteroscopy but none were confirmed on curettage. Of the 12 patients (6.9%) with Most studies have shown hysteroscopy was more sensitive histological diagnosis of cancer, the hysteroscopic study in diagnosing uterine abnormalities like polyps & showed cancer in 3 patients (25%), hyperplasia in 8 submucous fibroid4, 5. Even in our study, sensitivity in patients (66.6%) and submucous fibroid as in 1 patient diagnosing polyp on hysteroscopy was 100% but (8.3%). However, in 3 patients where hysteroscopic submucous fibroid could not be assessed as therapeutic impression was cancer, all 3 were confirmed as cancer on hysteroscopy was not attempted in the same sitting. On the histology too. other hand, hysteroscopy had a low sensitivity in diagnosing cancer (16.7%) and normal endometrium Hysteroscopy was highly specific in diagnosing cancer (21.2%). This is comparable with other study findings. Like however sensitivity was low. The sensitivity of in Sameera et al's study4, sensitivity of hysteroscopy in hysteroscopy in diagnosing cancer was 16.7%, specificity diagnosing cancer was 40% and Ben Yehoda et al's study6 was 100%, positive predictive value (PPV) being 100% and was 20%. Torrjeon R et al reported hysteroscopy was 100% negative predictive value (NPV) was 94.2%. Hysteroscopy sensitive, with specificity 99.4% and global diagnostic was found to be highly specific in diagnosing normal precision 99.5% in diagnosing adenocarcinoma in endometrium (92.2%), atrophy (96.9%), polyp (95.9%) and premenopausal patients7. On the contrary, sensitivity of cancer (100%). It was found to have low specificity in diagnosing endometrial hyperplasia was high (84.9%) in diagnosing hyperplasia (48.4%). The sensitivity of our study compared to 30% and 52% in Sameera and Ben hysteroscopy in detecting normal endometrium and Yehoda's reports. Hysteroscopy performed alone has cancer were 21.2% and 16.7% respectively which is reported high false positive rate for detecting endometrial extremely low. The sensitivity in diagnosing polyp was hyperplasia. So hysteroscopy targeted biopsy or dilatation found to be 100% and hyperplasia was 84.9%. Overall, and curettage has been advisable8. Hysteroscopy showed hysteroscopy was highly sensitive and specific in detecting high PPV (100%) and NPV (94.2%) in regard to cancer polyp. Following table shows the sensitivity, specificity, PPV detection in our study. Even in postmenopausal bleeding, and NPV of all the parameters except submucous fibroid as hysteroscopy has been reported to have an overall none were confirmed by histological examination (Table 6). sensitivity of 97% and specificity of 98.6% in detecting

Keywords : hysteroscopy, abnormal uterine 15 bleeding, dilatation & curettage - Neetha Nandan NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science endometrial pathologies9. but that is not feasible in all the cases. In our study, out of 175 cases, only 20 underwent hysterectomy at a later date. A similar study10 done in medical institute in Maharashtra At last, the number of cases obtained in this study to concluded that hysteroscopy affords a more accurate analyze was limited for an accurate interpretation. diagnosis than dilatation and curettage for intrauterine pedunculated pathologies. But for hyperplasia and Conclusion : carcinoma endometrium, histopathology is 100% Hysteroscopy was more sensitive in detecting endometrial diagnostic. Diagnosis of endometrial atrophy is best made polyp, submucous fibroid and endometrial hyperplasia but by hysteroscopy. it was found less sensitive than curettage in detecting cancer and normal endometrium. On the other hand, The limitations of this study were the hysteroscopy hysteroscopy was highly specific in conditions like procedure was carried out by many gynecologists with endometrial cancer, polyp, atrophic and normal different level of experience (junior resident to professor) endometrium. Hysteroscopy guided biopsy and and not by a consistent hysteroscopist, secondly it was a histopathology compliment each other in evaluation of a retrospective study and thirdly the curettage was patient with abnormal uterine bleeding for accurate performed after the hysteroscopy. Well, it is true you need diagnosis and further treatment. to have a hysterectomy specimen for an accurate diagnosis

Table 1: Demographic parameters of patients Table 3: Hysteroscopy findings Parameters No. of Percentage Hysteroscopy finding Number of patients Percentage patients Hyperplasia 108 61.7 Age (years) 31-40 53 30.3 Normal 25 14.3 41-50 95 54.3 Atrophy 16 9.1 51-60 18 10.3 Polyp 13 7.4 >60 09 5.1 Submucous fibroid 10 5.7 Total 175 100 Cancer 03 1.7 Parity Nulliparous 16 9.1 Total 175 100 Multiparous 159 90.9 Total 175 100 Table 4: Histopathological examination of Menopausal status Not menopause 146 83.4 endometrial curetting Menopause 29 16.6 Histopathological finding Number of patients Percentage Total 175 100 Hyperplasia 53 12.3 Family H/O cancer Present 02 1.1 Normal 85 48.6 Absent 173 98.9 Atrophy 07 4.0 Total 175 100 Insufficient 09 5.1 Medical co-morbidity Hypertension (HT) 20 11.4 Polyp 06 3.4 Diabetes mellitus (DM) 03 1.7 Cancer 12 6.9 HT + DM 04 2.3 Pill endometrium 03 1.7 Hypothyroid 01 0.6 Total 175 100 Total 175 100

Table 2: Indication for hysteroscopy Complaint Number of patients Percentage Menorraghia 87 49.7 Postmenopausal bleeding 29 16.6 Irregular cycles 23 13.1 Polymenorraghia 19 10.9 Continuous bleeding P/V 14 8.0 Dysmenorrhoea 3 1.7 Total 175 100

Keywords : hysteroscopy, abnormal uterine 16 bleeding, dilatation & curettage - Neetha Nandan NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 5: Comparison of hysteroscopy findings and histopathological examination of endometrial curetting Hysteroscopy Histopathology Total Normal Hyperplasia Atrophy Polyp Cancer Insufficient Pill Hyperplasia 52 45 00 00 08 00 03 108 Normal 18 04 01 00 00 02 00 25 Atrophy 04 01 05 00 00 06 00 16 Polyp 03 02 01 06 00 01 00 13 Fibroid 08 01 00 00 01 00 00 10 Cancer 00 00 00 00 03 00 00 03 Total 85 53 07 06 12 09 03 175

Table 6: Shows sensitivity, specificity, PPV and NPV of hysteroscopy finding Parameter Sensitivity (%) Specificity (%) PPV (%) NPV (%) Hyperplasia 84.9 48.4 41.7 88.1 Normal 21.2 92.2 72.0 55.3 Atrophy 68.8 96.9 68.8 96.9 Polyp 100.0 95.9 46.2 100.0 Cancer 16.7 100.0 100.0 94.2

References : 1. Goldstein SR, Zeltser I, Horan CK. Ultrasonography based triage for upon the sensitivity of dilatation and curettage in the diagnosis of perimenopausal patients with abnormal uterine bleeding. Am J Obstet endometrial hyperplasia or carcinoma? Gynecol Oncology 1998;68:4- Gynecol. 1997;177:102-108. 7. 2. Doraiswami S, Johnson T, Rao S, Rajkumar A, Vijayaraghavan J, 7. Torrejon R, Fernandez Alba JJ, Carnicer I, Martin A, Castro C, Garcia Panicker VK. Study of endometrial pathology in abnormal uterine Cabanillas J et al. The value of hysteroscopy exploration for abnormal bleeding. J Obstet Gynecol India. 2011;61:426-430.189-194. uterine bleeding. J Am Assoc Gynecol Laparosc 1997;4:453-456. 3. Dasgupta S, Chakraborty B, Karim R, Aich RK, Mitra PK, Ghosh TK. 8. Julia E Palmer, Branko Perunovic, John A Tidy. Review: Endometrial Abnormal uterine bleeding in peri-menopausal age: diagnostic hyperplasia. The Obstetrician and Gynecologist. 2008;10:211-216. options and accuracy. J Obstet Gynecol India. 2011;61: 189-194. 9. Tandulwadkar S, Lodha P, Agarwal B, Deshmukh P, Naik S. 4. Madan SM, Zainab A. Abnormal uterine bleeding. Diagnostic value of Hysteroscopy – A mode of screening women with postmenopausal hysteroscopy. Saudi Medical Journal 2001;22:153-156. bleeding: our experience. Journal of South Asian federation of 5. Jaiswar SP, Schan R, Srivatava PK, Madumathi G, Monika P. A obstetrics and gynecology. 2011;3:10-13. comparative diagnostic evaluation of hysteroscopy, transvaginal 10. Sheetal G Patil, SB Bhute, SA Inamdar, Neelam S Acharya, Deepti S. ultrasonography and histopathological examination in cases of Role of diagnostic hysteroscopy in abnormal uterine bleeding and its abnormal uterine bleeding. J Obstet Gynecol India. 2006;56:240-243. histologic correlation. Journal of gynecological endoscopy and 6. Ben Yehoda OM, Kim YB, Leuchter RS. Does hysteroscopy improve surgery. 2009;1:98-104.

Keywords : hysteroscopy, abnormal uterine 17 bleeding, dilatation & curettage - Neetha Nandan NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article NURSING INFORMATICS R. Ponchitra Associate Professor, Hiranandani College of Nursing, Mumbai, Maharashtra. Correspondence : R. Ponchitra Hiranandani College of Nursing, Knowledge Park, Hill Side Avenue, Hiranandani Garden, Powai , Mumbai , Maharashtra - 400 076. Mobile : +91 91676 94489, Fax : +91 22 2570 1615, E-mail : [email protected] Abstract : Computers have opened for us a world of information. New and emerging technologies will continue to have an effect on the health care delivery system. Nurses as a major player in health care, will be part of this ever growing era technology. A nurse must know generalized applications such as word processing, as well as specialized applications such as clinical information system. Virtual reality (simulation) and ubiquitous(every where) computing are emerging and being used in education and other areas in health care nursing knowledge workers must be able to understand the evolving specialty, nursing informatics, in order to begin to harness and use the tools available for managing the vast amount of health care data and information. This article mentions in detail about Nursing Informatics and therefore highlights that nursing informatics capabilities be appreciated, promoted, expanded and advanced to facilitate the work of the Nurse, improve patient care, and enhance the Nursing profession. Keywords: Clinical Information System, Virtual reality, Ubiquitous computing

Introduction : the science of automating information interactions. “The Future is here. It's just not evenly distributed…” Nursing Informatics : (William Gibson, Novelist and visionary) “Nursing Informatics is the specialty that integrates nursing Computers have moved from the realm of a “nice to know” science, computer science, and information science to luxury item to a “need to know “essential resource for manage and communicate data, information, knowledge, professional practice. Nurses are knowledgeable workers and wisdom in nursing practice.” (ANA 2008) who require accurate and up to date information for their professional work. Trends in computing will affect the work Figure 2 : Nursing Informatics Model ( Turley. 1996) of the professional nurses in areas beyond the development of Clinical Information systems. Nursing Science

Computerized patient Records, Research advances, new Computer Cognitive devices, monitoring equipment, sensors and 'smart body Science Science parts' will all change the way that health care is conceptualized, practiced and delivered. Every nurse need Information Science to be computer literate. For health care professional's Nursing computer literacy requires having an understanding of Informatics systems used in clinical practice, education and Access this article online EVOLUTION OF NURSING INFORMATICS Quick Response Code research settings. lNurses have been involved in “informatics” since the 1960s Informatics : lSan Jose Hospital (1965): Nurses recorded their The term was coined as a observation on a check list which was then converted c o m b i n a t i o n o f into punched cards for computer entry " i n f o r m a t i o n " a n d l1966 Institute of Living in Hartford: Nurses used "automatic" to describe

Keywords: Clinical Information System, Virtual reality, 18 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

machine readable pencil “bubble sheets” to document GOAL OF NURSING INFORMATICS is to get the.... patient status RIGHT information to the l1970s: Nursing Diagnoses researched and approved by RIGHT people at the the North American Nursing Diagnosis Association RIGHT time to do the (NANDA). RIGHT job at the l1974: Nursing research papers presented at an RIGHT Cost international medical informatics conference NURSING INFORMATION SYSTEMS (NIS)5 - is one of the (MEDINFO) major clinical systems and allows for assessment of the o Four research papers on NI from the UK and one from patient and the documentation of the care and teaching US nurses adapting and implementing an delivered.5 information system at the NIH l1979: The Journal of Nursing Administration features a TWO APPROACHES OF NIS5 monthly column on “automation in nursing” 1. Menu driven screens- It presents content in pre l1980: The term “Nursing Informatics” originated by Scholes and Barber arranged categories that allow practitioner to select the most applicable items. The categories are designed l1985: Nursing Minimum Data Set (NMDS) researched/developed by Werley and Lang. around the nursing process from admission through to discharge based on the nursing diagnosis. l1990: ANA House of Delegates recognizes the Nursing Minimum Data Set (NMDS). 2. Care Protocols- In this type of documentation, a specific l1992: NI approved as a nursing specialty by American protocol is selected based on the admission diagnosis. Nurses Association (ANA) The protocol lists the elements of care to be initiated l1992: ANA Database Steering Committee formally and monitored during each patient day. The recognizes four nursing vocabularies: documentation is related to the ability of the patient to l1995: ANA credentialing exam achieve the established daily protocol goals.

According to Thompson (2005), three main shifts catalyzed Standardized Nursing Terminology1: Nursing Informatics: Without a standardized nursing terminology, it would o Moving from centralized data storage to remain difficult to quantify nursing and the nursing decentralized data access component of electronic health record systems would o Moving from paper charts to electronic health remain at best rudimentary. ANA has recognized 13 records standardized nursing languages o Moving from relying on memory to continuously using information resources

DATA ELEMENT SETS SETTINGS CONTENT 1.NMDS-Nursing Minimum Data Set All Nursing Clinical Data Elements 2.NMMDS-Nursing Management Minimum Data Set All settings Nursing Administrative data elements 3.CCC-Clinical Care classification All nursing care Diagnoses, Interventions and out come 4.ICNP-International classification of Nursing Practice All nursing care Diagnoses, Interventions and out come 5.NANDA All nursing Diagnosis 6.NIC-Nursing Intervention Classification All nursing Interventions 7.NOC-Nursing Outcome Classification All nursing Outcomes 8.OMAHA system Home care, Public Diagnosis ,Interventions, Outcomes Health and Community 9. PCDS-Patient Care Data Set Acute Care Diagnosis, Interventions, Outcomes

Keywords: Clinical Information System, Virtual reality, 19 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

DATA ELEMENT SETS SETTINGS CONTENT 10.PNDS-Perioperative Nursing Data Set Perioperative Diagnosis ,Interventions, Outcomes 11.ABC-Alternative Billing Codes Nursing And Other Interventions 12.LOINC-Logical Observation Identifiers Nursing And Other Out come and Assesments Names and Codes 13.SNOMED CT-Systematic Nomenclature of Nursing And Other Diagnosis ,Interventions, Outcomes Medicine Clinical Terms

All the 13 languages were designed to record and track the Disadvantages in Utilizing Nis5 clinical care process for an entire episode of care for 1. Charting may be longer due to need for review of patients in acute, home or ambulatory care settings. The content prior to selection use of standardized nursing languages has many 2. Wording may not be common to users language. advantages for the direct care/bedside nurse. These Standard Dictionaries are not readily available include: better communication among nurses and other 3. Pre established content and need to make sure health care providers, increased visibility of nursing protocols are individualized for patients with interventions, improved patient care, enhanced data comorbidities collection to evaluate nursing care outcomes, greater Types of Nursing Hit (health Informationtechnology) adherence to standards of care, and facilitated assessment Applications of nursing competency • Automation of documentation – Nurse rounding tools 4 General Application Soft Ware For Nurse Leaders • Bar-coded Rx management 1. Communication software – provides link for access • Nurse staffing systems between computer • Tele Nursing 2. Database management system- for storing and retrieving data Application of Nursing Informatics 3. Word processing software- to produce documents such Nursing Practice as memos, letters, signs, books and resumes • accesses, enters and retrieves data related to client care 4. Spreadsheets- to develop budgets, maintain staff via available hospital or nursing information systems record, calculate, track and create graphs on statistics relating to staff and patient data • uses computer applications to plan Computer- 5. Personal Information Manager Applications – contains generated nursing care plans ,Order entry, results address book, calendar, email, a journal, notes and reporting, documentation and clinical path ways, work tasks. lists, including discharge planning Advantages in Utilizing Nis5 • uses computer applications to enter client data 1. Increased observation due to forced recall (demographic, vital signs, physiological data) 2. Increased Accuracy and reliability of observations • uses information management systems for client 3. legibility with less time required to read and interpret education accurately • uses technology based client monitoring systems 4. Decrease time in writing notes • operates peripheral devices (bedside and hand held) 5. Available for statistical analysis. Elements already coded • automatic billing while nursing documentation can be selected. • uses e-mail systems to communicate 6. Teaching tool to guide observations.can develop • Uses presentation applications to create slides, displays, elements to help staff with what they need to look for overheads (PowerPoint, Corel Presentation, etc.) 7. Errors and omissions are decreased or eliminated with • participates in the design and develop design and protocol followed

Keywords: Clinical Information System, Virtual reality, 20 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

development of new applications for nursing practice and actions • participates in developing new methods for data and • Online registration, scheduling, attendance tracking, information organization test administration and grade management of courses • upholds ethical standards related to data security, through learning management systems confidentiality and clients' right to privacy • Remote access to libraries or online publications Nursing Administration : • Web based Education • Workload measurement systems that collect statistics Nursing Research for internal and external reporting requirements a. Problem identification and literature review • Indenting and stocking • Search databases for current research • Online computer policy, protocols and procedure • Availability of full text journal articles manuals that guide organizational practices • Research design • Staff scheduling systems that either automate schedules or allow for self-scheduling through rules- • Search the literature for instruments based protocols • Design and test instruments

• Internal email and/or systems for improved b. Data collection and analysis communication • Create forms for data collection • Cost analysis of specific patient populations • Calculate descriptive and analytic statistics • participates in design of data collection tools for practice • Display output in tables, charts, lists, and other easily decision making and record keeping read formats • participates in quality management initiatives related to patient and nursing data in practice c. Research dissemination • participates in patient instructional program • Word processing programs used to author the final development reports • Trending & forecasting • Send the reports to various readerships • Safety and quality • Frequently used to present research at meetings

• Make judgments based on data trends and pattern d. Grants ? participates in ergonomic design of work stations, bed • Locate side access stations and portable apparatus equipment • Download and submit funding applications • uses decision support systems, expert systems and 1 other aids for clinical decision making and care planning Nurse Informatics Role • User liaison- involved in installation of a CIS and Nursing Education interfaces with system vendors, the users and • Presentation software management of health care institution • Computer labs or resource centers • Project manager- planning and implementing • Computer assisted Instruction informatics project • teleconferencing • Educator- develops and implements educational • Simulation labs with lifelike mannequins that mimic real materials and educational sessions about system to patient scenarios and respond to nurses' interventions employees

Keywords: Clinical Information System, Virtual reality, 21 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

• Product developer-participate in design, production • Measurement of performance against standards of and marketing of new informatics solutions practice to identify systems issues and opportunities for • Decision support/outcomes manager- use tools to improvement maintain data integrity and reliability Decision Support • Systems analyst- serves as link between nursing and • Cues and information built into the system to assist in information services making care decisions • Consultant- provide expert advice, opinions and recommendations based on her area of experience Data Management • Advocate/policy developer- develop the infrastructure • Workload statistics of health policy • Performance monitoring • Entrepreneur- analyzes nursing information needs and • Performance improvement projects develops market solutions • Identification of problem areas • Researcher- conduct research to create new informatics • Before and after data knowledge • Regulatory compliance • Chief information officer-provides leadership and Issues Related to Computers In Nursing7 management at the executive level for both the organization and the vendors 1. Legal/Ethical Issues • Web developer-Web development responsibilities • privacy/confidentiality • Programmer-ability to code identified specifications for • access to data for research and other purposes system development, enhancement or issue resolution • informed consent • Net work administrator-ensures networks continuously • License issues with telenursing runs smoothly • Copy right of materials on the Web

Benefits of Information Technology in Healthcare10 2. Ergonomics Safety - Computer technologies can place safety barriers Most common injuries- muscle and eye strain within high risk processes to improve patient safety Guidelines and Strategies to Minimize Risk4 Efficiency - 1. Never give out your computer password • Achieved through the use of computers and computer 2. Always log off when you leave a computer terminal technology as a data management tool 3. Follow procedures for correcting mistakes before • Moving away from paper records – improves access to computer entries are permanent the data you need without flipping through a bulky 4. Don't leave patient information displayed on a screen, patient record keep track of printed information and dispose of it • Easier retrieval of data associated with a particular properly process 5. Follow institutions confidentiality policies and • Data sharing is improved between disciplines procedure Quality Improvement Informatics Attitudes10 • Allows for auditing to assure a consistent standard of • Appreciate the necessity for all health professionals to care seek lifelong, continuous learning of information

Keywords: Clinical Information System, Virtual reality, 22 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

technology skills leader in informatics will most certainly be integral to the • Value technologies that support clinical decision- industry's future. making, error prevention, and care coordination Strategic Directions for Nursing Informatics Future10 • Protect confidentiality of protected health information • Include informatics in nursing education in electronic health records • Prepare nurses with specialized informatics skills Value nurse's involvement in the design, selection and • Enhance nursing practice and education through implementation of information systems informatics projects 12 Building A New Future • Increase nursing faculty preparation in informatics Healthcare organizations can do much to support the • Encourage collaboration evolving role of nursing informatics. Emerging Technologies to Improve Nursing Practice • Develop nurses' potential to fulfill emerging informatics management roles by focusing on leadership skills such 1. Wireless communication as communications, strategic and systems thinking, 2. Real time location system clinical, financial and business operations, and technical 3. Delivery robots skills. 4. Work flow management systems • Build a culture that supports nursing informatics 5. Wireless patient monitoring through programs organized around reward and 6. eMAR with Bar coding recognition, professional development, mentoring, 7. Clinical documentation performance planning and assessment, and career path 8. Interactive Patient system development. • Conduct research and explore new models focusing on Conclusion : the roles, responsibilities, competencies of chief DREAM, DARE, AIM to be an INNOVATOR. The nursing medical information officers (CMIOs), chief nursing profession has a strong commitment to the specialty of informatics officers (CNIOs) and CNOs, as well as the nursing informatics. The demand for professional nurses function and scope of relationships with other members with informatics backgrounds will likely continue to rise of the C-suite: CIOs, CEOs, CMOs, CFOs and CTOs. .The demand for Clinical IT leadership has provided new Explore new models that also create a strong tie roles and opportunities for nurses in all areas of healthcare. between informatics and professional practice and Many of the reasons why nurses are being sought for IT interdisciplinary practice. leadership positions are based on fundamental skills • Develop and champion leaders with the ability to unique to their profession including being knowledge develop, deploy, re-engineer and integrate clinical experts in the clinical care process, global systems view, information systems; function as members of strategic ability to manage large projects or staff, and understanding management teams; and collaborate on goals and the need to access patient information. This is the time to implementation of clinical information systems. move forward, if you are a nurse seeking advancement in As the healthcare landscape continues to shift, nurses are healthcare information technology. Now is the time to key leaders to navigate the need for coordinated care and craft a successful career path in nursing informatics. Keep enable better data infrastructure. The role of the nurse abreast of “latest greatest” technology trends.

Keywords: Clinical Information System, Virtual reality, 23 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : st 1. MC Gonigle. Nursing Informatics .1 Edition. New Delhi: Jones and 8. Nursing Roles in Informatics - Philadelphia University Barlet India Pvt. Ltd; 2010 www.philadelphia.edu.jo/academics/rabia_allari/.../informatics. st 2. Clark .creative Nursing Leadership & Managmenet. 1 Edition. New 9. Brian Mongrain NURS 457 Trends in Nursing Informatics - Delhi: Jones and Barlet India Pvt. Ltd; 2010 www.personal.psu.edu/.../nurs-457-trends-in-nursing-in... - United rd 3. Cherry. Barbara, Jacob. R. Contemporary Nursing 3 Edition.USA: States ELSEVIER MOSBY; 2002 10. Evolution of Nursing Informatics Role, VHA eHealth University 2010 ... 4. Roussel.Linda .Management an dLeadership for Nurse administrators, www.vehu.va.gov/vehu2010/ppt/222_NUR.pptx - United States 5th edition. New Delhi: Jones and Barlet India Pvt.Ltd.2010 11. RUTH H. SCHLEYER Defining and Integrating Informatics 5. Barker.M.Anne .Advanced Practice Nursing. 1st edition . New Delhi: Competencies Into a Hospital Nursing Department Jones and Barlet India Pvt.Ltd.2010 http://itnep.org/sites/default/files/Article%205.pdf 6. Ann shepherd. Nursing Informatics - Iowa Chapter HIMSS 12. Michelle Troseth, Informatics & the Future of Nursing Practice www.iowahimss.org/pubs/NursingInformaticsPastPresentFuture. http://nursing.advanceweb.com/Features/Articles/Informatics-the- 7. Nursing Informatics - Oakton Community College www.oakton.edu Future-of-Nursing-Practice.aspx /user/~mikey/155lecture1.ppt

Keywords: Clinical Information System, Virtual reality, 24 Ubiquitous computing - R. Ponchitra NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article TRENDS OF POISONING AMONG CHILDREN AT KASTURBA HOSPITAL, MANIPAL Pratik Vijay Tarvadi1, Shankar M. Bakkannavar2, Manjunath S.3, Vikram Palimar4, G. Pradeep Kumar5 & Mahabalesh Shetty6 1 Assistant Professor, Department of Forensic Medicine, KSHEMA, NITTE University, Mangalore 2 Assistant Professor, 3 Associate Professor, 4 Additional Professor, 5 Professor & HOD, Department of Forensic Medicine, Kasturba Medical College, Manipal University, Manipal. 6 Professor & HOD, Department of Forensic Medicine, KSHEMA, NITTE University, Mangalore Correspondence: Pratik Vijay Tarvadi Assistant Professor, Department of Forensic Medicine, K.S. Hegde Medical Academy (KSHEMA), NITTE University Nitynanada Nagar, Deralakatte, Mangalore 575018, Karnataka, India Mobile : +91 9845306634, Tel. : +91 824 2203030. E-mail : [email protected] Abstract : Background :Pediatric poisoning is a common medical emergency and also associated with a high morbidity and mortality in children. In developing countries like India, poisoning emergencies are becoming a major cause of mortality in infants and toddlers. Among the various studies conducted on poisoning in our country, the study on poisoning is predominantly on adults and hence this study is taken up to understand the incidence of childhood poisoning cases. Method : A ten year retrospective study from January 1999 to December 2008 was conducted at the Department of Forensic Medicine & Toxicology, Kasturba Medical College, Manipal, to comprehend the magnitude of childhood poisoning cases at Kasturba Hospital, Manipal. Results : Insecticide poisoning was the most predominant poisoning followed by venomous bites. Conclusion : Our study examines the most common poison involved and route of intake among children to identify specific ages at risk and give suggestions so as to reduce the morbidity and mortality. Keywords : pediatric, poisoning, insecticide

Background : may consume the contents before taste aversion leads to discontinuing the drink.4 Intentional poisonings becomes Poisoning causes considerable morbidity and mortality more likely after the age of five.4 Children aged 5 to 9 years worldwide. Irrespective of circumstances of poisoning the are less frequently involved in toxic exposures.5 Teenagers, victim can be of any age group ranging from an infant to on the other hand, are more often involved with poisonings elderly1. Although pediatric poisoning most often refers to related to substance abuse or suicidal behavior.6 poisonings occurring among children and adolescents aged less than 18 years, there is an inter-country variation, The present study attempts to gather epidemiological data usually indicating differences between the healthcare regarding poisoning in children in Manipal, so as to systems.2 Most exposures formulate recommendations that could probably help to among children are reduce the morbidity and mortality associated with Access this article online 3 Quick Response Code unintentional. If the poisoning in these age groups. h a r m f u l a g e n t , f o r Material and Methods : example is stored in a soft The data for the present study is a retrospective research drink container, children undertaken at the Kasturba Hospital, Manipal, which is a may fail to recognize the tertiary care teaching hospital, situated in coastal suitability of the liquid and Karnataka, South India, for a period of 10 years (January

Keywords : pediatric, poisoning, insecticide 25 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

1999 to December 2008). related to academics in children. It is not only the adult population that is affected by poisoning but of late, even All the poisoning cases admitted to Kasturba Hospital, children are affected. As health care providers, it is our Manipal, in the pediatric age group (up to 18 years) 7 during duty to prevent this rise of morbidity and mortality due to the study period were included. poisoning cases. The present task was undertaken to study The relevant data like age, sex, place of poisoning and the pediatric poisoning so as to reduce the morbidity and outcome was obtained from the Clinical case records from mortality. medical records department, Kasturba Hospital, Manipal. Age The data obtained was tabulated and analyzed using SPSS Our findings from the pediatric poisoning study revealed (Statistical Package for Social Services) 11 software. that the majority (33%) of the victims to be in the age group Results : of less than 5 years (preschool age group), followed by 11 to A total of 214 cases of poisoning in the pediatric age group 15 years (29%). The high incidence of poisoning in the age were admitted at the Kasturba Hospital, Manipal, during group of less than 5 years is in accordance with the trends the period of 10 years from January 1999 to December observed nationally 8, 9, 10, 11 and globally. 12, 13, 14, 15, 16, 17 The 2008, as depicted in the table no. 1. vulnerability of the preschool age group could be attributed to inquisitiveness and high exploratory activity Our study showed that, the maximum numbers of pediatric associated with their developing mobility and hand skills. poisoning cases were found to be in the age group of less They also try imitating their parents or grandparents taking than 5 years, followed by the age group of 11 to 15 years, 16 medication. Children cannot differentiate between to 18 years, and 6 to 10 years respectively, as depicted in harmless and harmful substances. Incidence of poisoning the Table No. 2. can also be precipitated by lack of safety measures taken by In our study, we observed that, the most common parents regarding safe storage of medications and substance in the pediatric poisoning cases was insecticide pesticides. followed by venomous bites, drug over-dosage, kerosene Studies conducted at Pakistan, Finland and South consumption, corrosives etc, as depicted in the Table No. 3. Carolina18, 19, 20 observed high incidence of poisoning The route of poisoning reported in our study was by amongst adolescent and teen age group. ingestion, 84% (180) and by injection, 16% (34). Injection Poisoning : included snake bite and bee stings, as depicted in the Table Insecticide compounds were predominantly consumed by No. 4. children in our study. This is in concurrence with the 21 Our study revealed that, most of the poisoning cases studies conducted earlier by Palimar et. al. and Vaswani 9 8, 22, 23, 11, 24, 16, 17 occurred at home, as depicted in the Table No. 5. et. al. , however other studies revealed that kerosene was the most common poison. The reason for Our study revealed that, 95.3% of cases reported at high incidence of insecticide consumption in our study may Manipal hospital had survived while 4.7% cases had be attributed to its easy availability in agricultural expired, as depicted in the Table No. 6. households. It also reflects the lack of safety measures Discussion : adopted by the parents in handling these hazardous Rise in poisoning is a global phenomenon seen in all age substances. The high incidence of kerosene poisoning in groups amongst all strata of people. This increase in the several other studies were linked to its usage in most of the incidence of poisoning in recent times is due to stress households as an alternative fuel for cooking and

Keywords : pediatric, poisoning, insecticide 26 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

18 19 Illumination. Studies conducted in Pakistan ,Finland and lStorage of poisonous substance out of reach of children South Carolina20 revealed that habit forming drugs and lProper disposal of poisonous substance and their alcohol showed high prevalence in the teen age group containers after use which could be attributed to their adolescent age, lBasic health education during schooling academic stress, peer pressure and inappropriate group of lEducating the teen age population regarding handling of friends, thereby increasing their vulnerability for stressful situations poisoning. Acknowledgements : Route of poison : I am extremely thankful to staff of Medical Records Our findings revealed, ingestion to be the major route of Department, Kasturba Hospital, Manipal for their kind help poisoning which may be attributed to its convenience and and assistance in collecting data. easy availability of orally consumable poisons, a feature 10 Table No. 1: Year wise distribution of cases of poisoning observed, which is not only a national phenomenon but in pediatric age groups (n=214) 25, 20 also a global one. Year Number of cases 1999 21 Place of Poisoning : 2000 24 Eighty percent of pediatric poisoning incidents took place 2001 16 in the victims own home both in accidental and suicidal 2002 19 2003 15 events. High suicidal incidence at home can be attributed 2004 15 to the preference of the victims for a confined home 2005 15 environment. Similar findings were observed in previous 2006 28 10 20,25 2007 32 studies conducted at national and international level. 2008 29 Total 214 Outcome : The mortality rate in our study of pediatric poisoning was Table No. 2: Age incidence (n=214) 5%, where as the mortality rate ranged from 0.1% to 16% in Age in years Number of cases Percentage various national 8, 9, 21 and international19, 12, 14, 24 studies. No < 5 70 32.7 6 -10 28 13.1 deaths were reported in the studies conducted at Pakistan 11 -15 63 29.4 17 and United Arab Emirates.2 16 -18 53 24.8 Total 214 100.0 Conclusion : Table No. 3: Type of poisoning (n=214) Thirty-three percent of pediatric poisoning cases were in Poison Total Percentage the age group of less than 5 years. Insecticides 86 40.2 Ingestion constituted the major route of entry and was Venomous bites 34 15.9 seen in 84% of the cases. Drug Over-dosage 27 12.6 Kerosene 20 9.3 Insecticide poison was the most common type of poison Corrosives 18 8.4 that was observed in 40% of the cases. Rodenticides 12 5.6 Poisoning most commonly occurred inside the house (80%) Plant Poisons 11 5.1 The survival rate was 95%. Metallic Irritants 3 1.4 Herbicides 2 1 Following measures are suggested to decrease the Unknown/ unidentified poisons 1 0.5 morbidity and mortality amongst the pediatric population: Total 214 100.0 lParental education and awareness lChild-resistant packaging

Keywords : pediatric, poisoning, insecticide 27 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table No. 4: Route of poisoning (n=214) Table No. 6: Outcome (n=214) Ingestion Injection Total Outcome Total 180 34 214 Survived Expired 204 (95.3%) 10 (4.7%) 214 (100%) Table No. 5: Place of poisoning (n=214) Poisoning Total Indoor Outdoor 171 43 214

References : 1. The Injury Chart Book. Geneva: Department of Injuries and Violence 13. Dawson KP, Harron D, McGrath L, Amirlak I, Yassin A. Accidental Prevention Non-Communicable Diseases and Mental Health Cluster Poisoning of Children in the United Arab Emirates. Eastern World Health Organization. 2002 Mediterranean Health Journal. 1997; 3(1): 38-42. 2. Gauvin F, Bailey B, Bratton SL. Hospitalizations for Pediatric 14. Lucas GN. Acute Drug Poisoning in Children. Sri Lanka Journal of Child Intoxication in Washington State, 1987–1997. Archives of Pediatrics Health. 2000; 29: 45-48. and Adolescent Medicine. 2001; 155: 1105–1110. 15. Moghadamnia A, Shirvani AK, Esmaeili MR, Bayati Z, Gholitabar ZM. A 3. Hoy J, Day L, Tibballs J, Ozanne-Smith J. Unintentional poisoning Report of Childhood Poisoning in Babol. Archives of Iranian Medicine. hospitalisations among young children in Victoria. Injury Prevention. 2004; 7(4): 297-299. 1999; 5(1): 31–35. 16. Koushanfar A. A Study of Accidental Children Poisoning. Archives 4. Bryant S, Singer J. Management of Toxic Exposure in Children. Iranian Medical Journal. 2000; 3: 25-29. Emergency Medicine Clinics of North America. 2003; 21: 101–119. 17. Shideh A, Shiva H, Elena L, Mohamad P, Morteza J. Acute Poisoning in 5. Reith DM, Pitt WR, Hockey R. Childhood Poisoning in Queensland: An Children. Pakistan Journal of Medical Sciences. 2009; 25(1): 51-54. Analysis of Presentation and Admission Rates. Journal of Paediatrics 18. Jan MA, Siddiqui TS, Haq IU, Khan Z. Mushroom Poisoning in Children: and Child Health. 2001; 37: 446–450. Clinical Presentation and Outcome; Journal of Ayub Medical College 6. Cheng TL, Wright JL, Pearson-Fields AS, Brenner RA. The spectrum of Abottabad. 2008; 20(2): 99-101 Intoxication and Poisonings among Adolescents: Surveillance in an 19. Kivisto JE, Arvola T, Parkkari J, Mattila VM. Paediatric Poisonings Urban Population. Injury Prevention. 2006; 12: 129–132. Treated in One Finnish Main University Hospital Between 2002 and 7. https://www.pediatriccareonline.org/pco/ub/view/Pediatric-Drug- 2006. Acta Paediatrica. 2008; 97: 790-794. Lookup/153856/0/ Definition_of_Age_Group_Terminology accessed 20. Teresa A, Campbell, Collins KA. Paediatric Toxicology Deaths a 10-year on 16th May 2011. Retrospective Study. The American Journal of Forensic Medicine and 8. Dutta AK, Seth A, Goyal PK, Aggraval V, Mittal SK, Sharma R, et. al. Pathology. 2001; 22(2): 184-187. Poisoning in Children: Indian Scenario. Indian Journal of Pediatrics. 21. Surjit S, Sunit S, Sood NK, Lata K, Walia BNS. Changing Pattern of 1998; 65: 365-370. Childhood Poisoning (1970-1989): Experience of a Large North Indian 9. Vasvani V, Patil VD, Spectrum of Childhood Poisoning: A Belgaum Hospital. Indian Pediatrics. 1995; 32: 331-336. Experience. Journal of Forensic Medicine and Toxicology. 1998; 15(1): 22. Sharma U, Saxena S. Accidental Poisoning in Children in Jaipur 50-52. (Rajasthan). Indian Journal of Pediatrics. 1974; 41(5): 174-178. 10. Gupta SK, Peshin SS, Srivastava A, Kaleekal T. A Study of Childhood 23. Sarker AK, Ghosh S, Barik K. A Study of Accidental Poisoning (in Poisoning at National Poison Information Centre, All India Institute of Children) in a Rural Medical College Hospital of West Bengal. Indian Medical Sciences, New Delhi. Journal of Occupational Health. 2003; Journal of Public Health. 1990; 34(3): 159-62. 45: 191-196. 24. Rashid AKM, Sultana R, Ahasan HAMN, Rasul CH. Seasonal Variation of 11. Deeths T, Breeden J. Poisoning in Children - A Statistical Study of 1,057 Childhood Acute Poisoning. Pakistan Journal of Medical Sciences. Cases. The Journal of Pediatrics. 1971; 78 (2): 299-305. 2007; 23(3): 443-445. 12. Ossy MJ, Kasilo. A Pattern of Acute Poisoning at Urban Zimbabwe: 10 25. Sharif F, Khan RA, Keenan P. Poisoning in a Pediatric Hospital: Irish yrs experience. Human and Experimental Toxicology. 1992; 11(5): 335- Journal of Medical Science. 2003; 172(2): 78-80. 340.

Keywords : pediatric, poisoning, insecticide 28 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article COMPARISON OF TRADITIONAL VERSUS VIDEO BASED TEACHING ON NEUROLOGICAL ASSESSMENT AMONG UNDERGRADUATE NURSING STUDENTS Sushma Prabhu Assistant Professor, Nitte Usha Institute of Nursing Sciences, Nitte University, Mangalore - 575 018, India Correspondence: Mobile: 09964242765 Email : [email protected] Abstract: Background: The new computer assisted and interactive video instructions have been merged into teaching system as an efficient method. This method is an effective medium for student learning, regardless of discipline and its potentials have encouraged instructors and learners to opt this method. Purpose: The current study has aimed to compare the traditional lecture method with video based teaching, in improving the knowledge and skill of Undergraduate Nursing students on Neurological assessment. Methods: This quasi experimental study was conducted on 30 undergraduate nursing students who were randomly assigned to two groups. Group A attended a lecture cum demonstration method and group B underwent video based teaching on neurological assessment. Learning level of both the groups was compared by using independent't' test. Results: In both the groups the post test scores were significantly higher than the pretest scores, but there was no statistically significant difference between group A and B. Hence both the teaching methods were found to be equally effective in improving the knowledge and skill of undergraduate nursing students on neurological assessment. Keywords: video based lecture, traditional lecture, learning, undergraduate nursing students, teaching, knowledge and skill.

Introduction: sensory modalities, which would make them more One of the most important principles in education is motivated to pay more attention to the information adopting a teaching method in concordance with presented and retain the information better. In this paper objectives, contents, and learners. New research indicates we focus on comparing the traditional lecture method with that people can learn more and at a faster rate, than was video based teaching in improving knowledge and skill of previously thought, by means of improved teaching undergraduate nursing students on neurological strategies' aimed specifically at enhancing memory storage assessment. and retrieval, cognition and learning [1]. Statement of the problem: Multimedia, is the combination of various digital media A study on “comparison of traditional versus video based types such as text, images, audio and video, into an teaching on neurological assessment among integrated multi-sensory interactive application or undergraduate nursing students in selected college of presentation to convey Mangalore” Access this article online i n f o r m a t i o n t o a n Objectives: Quick Response Code a u d i e n c e . B y 1. To assess the knowledge and skill of undergraduate incorporating digital nursing students on neurological assessment. media into the system of 2. To find out the effectiveness of traditional lecture cum education, the students demonstration on neurological assessment. are able to learn better 3. To find out the effectiveness of video based teaching on since they use multiple neurological assessment.

Keywords : video based lecture, traditional lecture, learning, 29 undergraduate nursing students, teaching, knowledge and skill. - Sushma Prabhu NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

4. To compare the effectiveness of Traditional lecture observational checklist were administered on day 1 to method and video based teaching on neurological assess the pretest knowledge and skill on neurological assessment. assessment. After the pre test they were exposed to two different teaching sessions on neurological assessment. Hypotheses: All hypotheses are tested at 0. 05 level of significance. The traditional lecture method with the demonstration was administered for group A. At the same time Group B H : There will be a significant difference between pre and 1 was administered with video based teaching on post test knowledge and skill scores of undergraduate neurological assessment. To minimize the contact between nursing students of Group A. two groups, the post test was given after 1 week of each presentation. The difference between pretest and posttest H2: There will be a significant difference between pre and post test knowledge and skill scores of undergraduate scores was considered as their learning level and was nursing students of Group B. categorized in three levels as poor, average and good. Data were analyzed by using descriptive and inferential H : There will be a significant difference between post test 3 statistics. knowledge and skill scores of Group A and Group B. Results and Discussion: Material and Methods: Objective 1: To assess the knowledge and skill of Study has adopted evaluative approach and quasi undergraduate nursing students on Neurological experimental design. 30 undergraduate nursing students assessment were selected from third year BSc.Nursing by simple random sampling technique, and they were randomly Table1: In the group A(Traditional Lecture cum assigned to two groups. Group A attended a lecture cum demonstration method)pre test results of the study reveals demonstration method and group B underwent video that, 73.3% of the students were having poor knowledge based teaching on neurological assessment. The data were and 26.6% had average knowledge on neurological collected from pretest and post test by using structured assessment, post test results shows that 26.6% of students knowledge questionnaire and an observational checklist had good knowledge, 66.6% had average and only 6.6% on neurological assessment. Knowledge questionnaire had poor knowledge on neurological assessment. consisted of 22 multiple choice questions and each correct In Group B(Video based teaching) pretest results revealed response was scored one and wrong response was scored that 40% of the students had poor knowledge and 60% had zero. Observational checklist on neurological assessment good knowledge on neurological assessment, post test consisted of 67 steps of neurological assessment, which results shows that 86.6% of the students had average includes pre procedure, Glasgow coma scale,mental status knowledge and 13.3% had good knowledge after examination, assessment of cranial nerves, reflexes and attending video based teaching sessions on neurological post procedure care. This was rated by the researcher as assessment yes or no. The correct step was scored one and incorrect step as zero. Validities were determined by content validity Table 2: In the group A (Traditional Lecture cum evaluation. Reliability of the knowledge questionnaire was demonstration method) pre test results of the study found out by using split half method, and reliability of reveals that, 66.6% of the students had poor skill and observational checklist was found by inter rater method 33.3% had average skill on neurological assessment, post and found reliable. test results shows that 60% of students had average skill, 40% had gained good skill on neurological assessment. The structured knowledge questionnaire and an

Keywords : video based lecture, traditional lecture, learning, 30 undergraduate nursing students, teaching, knowledge and skill. - Sushma Prabhu NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

In Group B(Video based teaching) pretest results revealed significant. However, in each group the posttest scores that 66.6% of the students had poor skill and 33.3% had were significantly higher than the pretest scores [1]. average skill on neurological assessment, post test results Objective 4: To compare the effectiveness of Traditional shows that 86.6% of the students had average skill and lecture method and video based teaching on neurological 13.3% had gained good skill after attending video based assessment teaching sessions on neurological assessment. Table 5 and 6 shows that there is no significant difference in Objective 2: To find out the effectiveness of traditional knowledge and skill of students of group A (lecture cum lecture cum demonstration on Neurological assessment demonstration) and group B (video based teaching) Table 3 shows that the mean post test knowledge and skill Hence both the methods were found to be equally effective scores were significantly higher than the mean pretest in terms of gain in knowledge and skill on neurological scores, hence traditional lecture cum demonstration assessment. This study supports the study conducted by method was effective in improving knowledge and skill of schare et al. They found that both lecture and video undergraduate nursing students on neurological instructions were equally effective, with video achieving assessment. slightly better result [2]. Table 4 shows that the mean post test knowledge and skill This also supports the study conducted by Nikopoulos C, scores were significantly higher than the mean pretest Smyrni NP. On evaluating the impact of video based versus scores, hence video based teaching was effective in traditional lectures on students learning, they found that improving knowledge and skill of undergraduate nursing all of the students 'responding was higher during students on neurological assessment. intervention and follow-up conditions demonstrating that This supports the study conducted by Nasab et al on effect video based lectures were at least as equally effective as of video based instruction on students' cognitive learning standard teaching lectures. Nevertheless, average showed that the difference of the pretest and posttest performances of all students demonstrated a slight scores between the two groups was not statistically superiority of video based lectures over traditional ones [3].

Table 1 - Frequency distribution of Pre test and post test Knowledge scores of group A (lecture cum demonstration) and group B (video based teaching) N=15 Group A Group B Pre test Post test Pre test Post test Poor (1-7) 11(73.3%) 1(6.6%) 6(40%) 0(0%) Average (8-14) 4(26.6%) 10(66.6%) 9(60%) 13(86.6%) Good (15-22) 0(0%) 4(26.6%) 0(0%) 2(13.3%)

Table 2 - Frequency distribution of Pre test and post test skill scores of group A (lecture cum demonstration) and group B (video based teaching) N=15 Group A Group B Pre test Post test Pre test Post test Poor (1-22) 10(66.6%) 0(0%) 10(66.6%) 0(0%) Average (23-45) 5(33.3%) 9(60%) 5(33.3%) 13(86.6%) Good (46-67) 0(0%) 6(40%) 0(0%) 2(13.3%)

Keywords : video based lecture, traditional lecture, learning, 31 undergraduate nursing students, teaching, knowledge and skill. - Sushma Prabhu NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 3 - Distribution of the t value between pre test and post test knowledge and skill scores of Group A. N=15 Mean Mean Standard t value df LOS difference deviation difference Pre test 6.33 0 knowledge scores p<0.05 Post test 11.93 5.6 3.18 6.82 14 HS knowledge scores Pre test skill scores 19.8 0 Post test skill scores 42.53 -2.27 9 9.79 14 p<0.05 HS

Table 4 - Distribution of the t value between pre test and post test knowledge and skill scores of Group B. N=15 Mean Mean Standard t value df LOS difference deviation difference Pre test 7.6 0 knowledge scores p<0.05 Post test 13.4 5.8 4.77 4.71 14 HS knowledge scores Pre test skill scores 19.27 0 Post test skill scores 37.53 -1.826 12.39 5.708 14 p<0.05 HS

Table 5 - Comparison of knowledge scores of group A and B. N=30 Group Mean Mean Standard t value df LOS difference deviation difference Group A -5.6 0.266 4.33 0.192 28 0.849 Group B -5.33 p>0.05 NS

Table 6 - Comparison of skill scores of group A and B. N=30 Group Mean Mean Standard t value df LOS difference deviation difference Group A -22.73 4.46 3.95 1.13 28 0.268 Group B -18.26 p>0.05 NS

References : 1. Nasab MM, Rahemi S, Ayatollahi A, Aeen M. The effect of video based instruction on students' cognitive learning. Medical education journal of Iran Spring 2002; 1(3):129-32. 2. Schare BL, Clark HM. The effects of interactive video on cognitive achievement and attitude towards learning. Journal of nursing education 1991; 30(3):100-13. 3. Nikopoulos C, Smyrni NP. Evaluating the impact of video based versus traditional lectures on student learning. Educational research 2010; 1(8):304-11. 4. Polit D, Hungler B. Nursing Research-Principles and methods. 6th edition. Philadelphia, JP. Lippincott Company. 1992.

Keywords : video based lecture, traditional lecture, learning, 32 undergraduate nursing students, teaching, knowledge and skill. - Sushma Prabhu NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article FOOD ADULTERATION AND FAMILY'S KNOWLEDGE ON FOOD ADULTERATION IN SELECTED VILLAGE OF UDUPI TALUK, KARNATAKA. Abidfaheem T.K.1, Baby S. Nayak2 & Maxie Andrade3 1 Department of Community Health Nursing, 2 Professor & Head, Department of Child Health Nursing, 3 Assistant Professor, Department of Community Health Nursing, Manipal College of Nursing, Manipal University, Manipal, Udupi - 576 104 Correspondence : Abidfaheem T.K. Department of Community Health Nursing, Manipal College of Nursing, Manipal University, Manipal, Udupi - 576 104 Mobile: +91 98096 49910 E-mail : [email protected] Abstract : A cross sectional survey was under taken among 75 families using structured knowledge questionnaire and observation technique. The collected data was analysed using SPSS version 16. The study findings showed that majority (60%)of the subjects had moderate knowledge on food adulteration. Out of 75 samples tested, 2.7% chili powder samples were adulterated with artificial color and 10.7% of the common salt samples were adulterated with insoluble impurities. In tea powder 12 % were adulterated with iron fillings and 2.7% 2 were adulterated with artificial color. There was significant association of knowledge score on food adulteration with age (χ (2) =8.627, p= 2 0.013) and educational status (χ (4) =9.876, p= 0.043) of the respondents. The study concludes that the food adulteration even though low, still it is existing. However awareness of the public in relation to food adulteration should be ongoing especially to the general public with lower level of education. Keywords: Food adulteration, knowledge, family, detection, food items.

Introduction : mediaemphasis and food adulteration. As a result the Food is the basic requirement of all living beings for their ultimate victim is a consumer, whoinnocently takes growth.It is the right of every citizen to have access to adulterated food and suffers1. clean, safe and nutritious food. The health and the Ensuring food safety has been recognized as an important productivity of population depend on the nature of the component in protecting the health of the people. Public's food theyconsume and its wholesomeness in terms of their best defense is knowledge of his or her rights as consumer nutritive value. One works hard and earns to satisfy his/her and of the remedies which exists to resolve these hunger. But at the end of the day, many of us are not sure of problems when they occur. The purpose of this study was what we eat. We may be eating a dangerous dye, sawdust, to assess knowledge on food adulteration and to detect soapstone, industrial starch, aluminum foil and so on! food adulteration of selected food items with a view to Contaminated foods and drinks are common sources of prepare pamphlets which will further help to create infection. Often, we invite awareness among family members on food adulteration diseases rather than good Access this article online and food adulteration detection methods, thereby reduce health.It has become Quick Response Code the risk caused by food adulteration. The objectives of the verydifficult for the study were to assess the knowledge on food adulteration consumer to select food among families, detect food adulteration in selected food i t e m s b e c a u s e o f items, and to find the association between the knowledge m i s l e a d i n g with selected variables. advertisements, improper

Keywords : Food adulteration, knowledge, family, detection, 33 food items. - Abidfaheem T.K. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Materials and Methods : the sample a pamphlet was prepared and distributed. A descriptive cross sectional survey was carried out in Statistical analysis : select village of Udupi District. In this study one panchayat Statistical package for social sciences software (version 16) under field practice area attached to medical college was was used for statistical analysis of raw data. Frequency, selected by convenient sampling. The selected panchayt percentage, mean, standard deviation and Chi-Square test consisted of 13 wards. Among these 13 wards, one ward (p0.05) were applied. was selected by using simple random sampling technique. The selected ward consists of 486 families. Sample size was Results : calculated based on pilot study using the formula Sample characteristics and nature of buying and storing of estimation of population mean by relative precision as n= food items are described in table 1and 2. 2 2 2 2 Z (1-α/2)σ /? µ The Z value is taken with 95% of confidence Description of knowledge score : interval. As per the computation the needed sample for the The maximum possible knowledge score was 24. Minimum study was 59, total 75 sample were included in the study score obtained by the sample was 4 and maximum score considering the 10% non-response rate. Systematic was 19. The mean score of the participants were 12.31with th random sampling was adopted. Since the K number was 6, S.D. of 3.897.Among 75 participants, 14 (18.7%) had poor th every 6 family was selected. The administrative knowledge(0-8), 45 (60%) had average knowledge (9-16) permission for conducting the research study was obtained and 16 (21.3%) had good knowledge(17-24) on food from concerned authorities. Written consent was taken adulteration. The percentage distribution of sample based from each of the participants who were willing to on knowledge score is shown in the figure : 1 participate in the study, after ensuring the confidentiality. Total three tools were used for data collection; Tool I : Detection of food adulteration : Sample characteristics Tool II: Structured knowledge Out of 75 samples, none of the turmeric powder samples questionnaire on food adulteration. Tool III : Detection were adulterated with metanil yellow, while 2 (2.7%) chilli record. Knowledge of the family was assessed by powder samples were adulterated with artificial color. The test revealed that 8 (10.7%) of the common salt sample administering structured validated, reliable(r(df) = 0.867(19)) knowledge questionnaire which was administered to head were adulterated with insoluble impurities. Out of 75 of the family or wife of the head of the family and detection samples, 9 (12%) samples of the tea powder were on food adulteration conducted in home setting by simple adulterated with iron fillings and 2 (2.7%) were adulterated detection methods. The reliability of the testing methods with artificial color. Out of 47 available coriander powder was achieved by inter rater reliability with the food samples, none of them showed positive reaction to inspector of the district. Pilot study was conducted by adulteration test. administering the tools to 20 sample and sample Association between knowledge score and demographic calculation was done by using the formula estimation of variables : population mean by relative precision. The data was The Association between knowledge score on food collected in the month of January 2012. The questionnaire adulteration and demographic variables revealed that was administered to Head of family or wife of head of there was a statistically significant association between family after obtaining informed consent and ensuring 2 knowledge on food adulteration and age (χ (2) =8.627, p= confidentiality. After that specimens for detection were 0.013) and interpreted that the people with 25 -50 years of collected from each family and detection was done age had better knowledge than people above 50 years of through simple detection methods in home set up in age. The statistically significant relationship was also found selected five food items. Based on the knowledge level of between knowledge on food adulteration and educational

Keywords : Food adulteration, knowledge, family, detection, 34 food items. - Abidfaheem T.K. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

2 5 status (χ (4) =9.876, p= 0.043)and interpreted that sample by Beniwal A and Khetarpaul N among 60 women of Hisar who had PUC and above level of education had better city in India, who reported that sample of turmeric powder knowledge. There was no statistically significant were found to be adulterated with chalk powder. Water association found between knowledge on food soluble colour was also added to 36.6% of the samples, all adulteration and demographic variables such as gender (χ2 samples of red chilli powder were adulterated with 2 (2) =2.601,p = 0.272), occupation ( χ (4) =8.766, p=0.067) and artificial colour, and oil-soluble coal tar dye was detected in 2 36.6 percent of them, while brick powder was present in monthly family income in rupees ( χ (2 =4.257, p= 0.119). 23.3 percent. .Another Survey conducted by Mysore The computed value of chi-square between knowledge Grahakara Parishat3in 2008 in Mysore, Karnataka also score on food adulteration and variables on buying and revealed Metanil yellow and lead chromate were the storing of food items revealed that the knowledge scores common adulterants found in food products. Out of four on food adulteration were independent of place of hundred samples collected from 38 local shops, 43 %of 2 2 purchase (χ (4) =1.593, p=0.810), type of packing (χ (2) = 2.39, toor dhal was found adulterated. 50 % of Bengal gram was p=0.664), average duration of storage of general grocery of poor quality, 28 % samples had Metanil yellow, 6 %had 2 items (χ (2) = 1.647, p=0.439), average duration of storage of auramine dye and 29 % of green gram was adulterated. 2 turmeric powder (χ (2) =3.208, p= 0.201), average duration Other samples such as turmeric, chilli powder, cumin 2 of storage of common salt (χ (2) =3.089, p=0.213), average seeds, ghee and butter were also highly adulterated. duration of storage of chilli powder (χ2 =2.101,p=0.350) , (2) The present study revealed that there was association 2 average duration of storage of tea powder (χ (2) =1.085, 2 between knowledge on food adulteration and age (χ (2) p=0.581), and average duration of storage of coriander =8.627, p= 0.013).The study also revealed that there was powder/coriander (χ2 =1.647, p =0.439). (2) association between knowledge on food adulteration and 2 Discussion : educational status (χ (4) =9.876, p= 0.043). The findings are The findings of the present study indicate that among 75 supported by other studies available in the respondents 18.7% had poor knowledge, 60%had average literature1Anotherstudy was conducted by Bhatt, and Anita knowledge and 21.3% had good knowledge on food Singh on impact analysis of knowledge and practice for adulteration. This finding is supported by a similar food Safety. Study revealed that age and awareness were descriptive study conducted by Gupta Nidhi and Panchal not interlinked which is contradictory to the present study Priti in 2007 among 60 families of Mahadev village of finding, while education was interlinked with good Gujarat state, 15% of the sample had low awareness, 60% practices which supporting the findings of present study6. had moderate awareness and 25% had high awareness on Conclusion : food adulteration. The maximum possible score was 33. The prevalence of adulteration among selected food items The mean score obtained by the participants was 23.15 even though is low, adulteration is existing in village. The with S.D of 2.77.1The present study is also supported by present study found 60% of the sample population had another study conducted in 1999 on knowledge of average knowledge on food adulteration. Awareness of the consumers regarding the nature and extent of adulteration public in relation to food adulteration should be ongoing of Indian foods among 60 women of Hisar city in India, especially to the general public with lower level of showed that majority, 61.6% of respondents had medium education. knowledge on food adulteration, 40.0% and 10.0% had high knowledge.5 Limitations : The detection of adulteration is limited to five specific food The present study is supported by many studies conducted items and knowledge is assessed only from head of the

Keywords : Food adulteration, knowledge, family, detection, 35 food items. - Abidfaheem T.K. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science family or wife of the head of the family. Community Medicine, Kasturba Medical College, Manipal University, Manipal for giving administrative permission to Acknowledgment : conduct the study. We express my sincere thanks to Mr. We express our sincere thanks to Dr. Anice George, Dean Chandrakanda Manjerekar, Food Inspector, Udupi District, MCON Manipal and Dr. Veenakamath, HOD, Department of for his support and guidance throughout the study.

Table 1: Description of demographic variables (n=75) Sl. No. Sample characteristics frequency Percentage(%) 1. Age in years 25 to 50 44 58.7 51 to 75 31 41.3 2. Gender Male 34 45.3 Female 41 54.7 3. Education SSLC and below 39 52.0 PUC 20 26.7 Diploma, graduate and above 16 21.3 4. Occupation Coolie 21 28.0 House wife 26 34.7 Government /private job 28 38.3 5. Monthly family income in Rupees Less than 6000 25 33.3 6000 and above 50 66.7

Table 2: Description of variables related to food items (n=75) Sl. No. Sample characteristics frequency Percentage(%) 1. Place of purchase of food items Local shop 34 45.3 Branded shop 11 14.7 Both 30 40.0 2. Type of packing of food items Loose 30 40.0 Packed 14 18.7 Both 31 41.3 3. Average duration of storage of general Grocery items after purchasing Less than 1 month 32 42.7 1 month and more 43 57.3 4. Buying member of the family Head of the family 36 48.0 Wife of Head of the family 39 52.0

Keywords : Food adulteration, knowledge, family, detection, 36 food items. - Abidfaheem T.K. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 3: Association between knowledge score on food adulteration and demographic variables. ( n = 75) Sample Characteristics Knowledge Category χ2(df) P value Poor f(%) Average f(%) Good f(%) Age in years 25 - 50 4 ( 9.1) 27(61.4) 13(29.5) 8.627(2) 0.013* 51 - 75 10(32.3) 18(58.1) 3(9.70) Education SSLC 11(28.2) 20(51.3) 8(20.5) PUC 3(15) 14(70) 3(15) 9.876(4) 0.043* Diploma/ graduate & above 0(0) 11(68.8) 5(31.2)

Fig. 1.Pie diagram showing the knowledge scores of sample on food adulteration

Poor Knowledge

Average knowledge

Good knowledge

References 1. Gupta N, Panchal P. Extent of awareness and food adulteration detection in selected food items purchased by home makers. Pakistan journal of nutrition 2009; 8: 660-667. 2. DTE News. Food Adulteration, Food Safety, Food Standards, Health Effects, India, Karnataka, Mysore (T) . May 15, 2008 3. Working of the Prevention of Food Adulteration Act, 1954 in different states /UTs,-2002(commodity wise). Available from URL :http://cbhidghs.nic.in/hia2005/14.03.htm 4. http://en.wikipedia.org/wiki/Food. 5. Beniwal A and Khetarpaul N. Knowledge of consumers regarding the nature and extent of adulteration of Indian foods. Sage publications.Nutrition and Health1999;13(3): 153- 60.DOI: 10.1177/026010609901300303. 6. Bhatt SR, Bhatt SM, Singh Anita. Impact Analysis of Knowledge Practice for Food Safety.Pakistan Journal of Nutrition. 2010. 9 (2): 186-190.

Keywords : Food adulteration, knowledge, family, detection, 37 food items. - Abidfaheem T.K. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article HEALTH BELIEFS ON MANAGEMENT OF DIABETES MELLITUS Jijomon P.P.1, Teena Sharon2, Ruby Xavier3 & Malathi G. Nayak4 1,2,3Post Basic B.Sc. (N) Students, Manipal College of Nursing, Malathi G. Nayak4, Assistant Professor (Sr. Scale), Department of Community Health Nursing, Manipal College of Nursing, Manipal University , Manipal, Karnataka, India. Correspondence: Malathi G. Nayak Mobile : +91 94495 86431 E-mail : [email protected], [email protected], [email protected] Abstract : Prevalence of type 2 diabetes is increasing globally, more so in developing countries like India due to rapid urbanization. Health-related behavior is important in maintaining health and which is determined by individual beliefs and practice about health and illness. The objectives of the study were to assess the health beliefs among diabetic adults on management of diabetes mellitus and to find the association between the health beliefs and study variable. A descriptive cross sectional survey conducted among 125 diabetic adults, data collected by using structured questionnaire. The study finding reveals that out of 125 diabetic adults, the majorities 49.6% were in the age group of 46-55 years, 51.2% were believed that diabetes caused by eating more sugar and 81.6% disagree that it's God's curse, 30% of diabetic adults agree with the statement that diabetes is because of past sin, 28% of subjects believe that it's a communicable disease. There was significant association between health beliefs and selected demographic variables such as age, religion, duration of illness and education. Beliefs about health and illness that may affect self-care practice and health care seeking behavior in persons diagnosed with Diabetes mellitus Keywords : Diabetes Mellitus, Belief, Adult

Introduction : overweight and wrong diet in combination with Diabetes is an 'iceberg' disease. Diabetes mellitus (DM) is supernatural factors such as fate, punishment from God one of the most challenging health problems of 21st and witchcraft were mentioned3. According to WHO, 46 century and is now a global epidemic with devastating million people worldwide have diabetes. In 2004, an humanitarian, social and economic consequences. Type 2 estimated 3.4 million people died from consequences of diabetes mellitus is the commonest form of diabetes and high blood sugar. More than 80% of diabetes deaths occur accounts for over 90% of diabetes mellitus. It is estimated in low and middle-income countries4. that prevalence of diabetes will rise to 5.5% in 2025 as WHO projects those diabetes deaths will double between compared to 4% in year 1995. The total direct cost for 2005 and 2030. The International Diabetes Federation diabetes management has doubled from 1998 to 20051,2. estimates that the number of diabetic patients in India Various studies have shown that the high incidence of more than doubled from 19 million in 1995 to 40.9 million diabetes in India is mainly because of sedentary lifestyle, in 2007. It is projected to increase 69.9 million by 2025. lack of physical activity, Currently, up to 11 per cent of India's urban population and o b e s i t y, st re s s a n d Access this article online 3 per cent of rural population above the age of 15 has consumption of diets rich Quick Response Code 4 diabetes . in fat, sugar and calorie. A mixture of causes of Indian population consists of people from different cultural d i a b e t e s m e l l i t u s backgrounds and there is a very strong influence of the predominantly individual various myths on health seeking behavior in the factors such as heredity, population. Therefore, understanding the myths and

Keywords: Diabetes Mellitus, Belief, Adult 38 - Malathi G. Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science misconceptions about the disease, like diabetes mellitus is Variables : important in providing excellent care and health education Primary outcome variable: to both patients and healthy individuals. People believe in Health beliefs on diabetes mellitus spiritual treatment and alternative forms of medicine, Extraneous variable: instead of coming to a doctor they visit a local traditional Age, Gender, Religion, Education, Income, Duration of the practitioner. There have been emergencies reported in illness, Source of information. cases of diabetes mellitus where the patients delayed their presentation to the doctor due to their myths and belief. Materials and methods : Keeping these myths as background for the present study A community based cross sectional descriptive study was researcher has decided to seek the information on diabetic carried out in order to explore the health beliefs on the myths present in Udupi district. management of diabetes mellitus. A non probability purposive sampling was used to select 125 diabetic adults. Problem statement : Data was collected by using structured questionnaire on An explorative study to assess the health beliefs on belief on the management of diabetes mellitus. management of diabetes mellitus among the diabetic adults in the selected villages of Udupi District Diabetic adults above 25 years who are willing to participate in the study were included in the study. The Purpose of the study : exclusion criteria were the diabetic adults who have The purpose of the study is to assess the health beliefs on psychological disorder and gestational diabetes mellitus. diabetes mellitus among diabetic adults and improve health seeking behavior among the diabetic adults in the Based on the objectives of the study the following tools community. were used for the study. Tool-1: Demographic proforma Objectives of the study were to : Tool-2: Beliefs on diabetes mellitus. âassess the health beliefs among diabetic adults on management of diabetes mellitus Demographic Proforma consisted total 11 items, were age, âfind the association between the health beliefs and gender, education, occupation, religion, type of family, study variable such as age, gender, religion, education, monthly income, type of diet, duration of illness and income ,duration of illness and source of information source of health related information. Beliefs on diabetes mellitus tool consisted of 30 items on 4 point likert scale Hypothesis : related to various beliefs and the total maximum score 145 All hypotheses were tested at 0. 05 level of significance. and the minimum score was 29. Both the tools were given H1: There will be significant association between health to 7 experts for validation and reliability of the tool was beliefs and selected variables on management of determined by Cronbach's Alpha method. The reliability diabetes mellitus. was r=0.8 and questionnaire was found reliable. Pilot study Assumptions : was conducted after obtaining administrative permission The study assumes that diabetic adults may: and written consent from 20 diabetic adults. The main âhave some health beliefs on the management of the study data was collected from 125 diabetic adults and data diabetes mellitus. was analyzed by using descriptive and inferential statistics. âgive willingness to take part in the study. Result : âhave awareness of the disease through the mass media. The study finding reveals that out of 125 diabetic adults, âgive free and frank opinion about their practices on the majorities 49.6% were in the age group of 46-55 years, management of diabeties mellitus .

Keywords: Diabetes Mellitus, Belief, Adult 39 - Malathi G. Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

63.2% were females, and 44% of them had primary gods will or punishment, they believed that diabetic education. Most of them (53.6%) were housewife, majority mellitus is serious illness and that they could not identify of them (85.6%) were Hindu by religion and 53.6% had many of the symptoms. They identified the management of income of 6000-8999 rupees per month. Most of them both medical and herbal treatment. Negative attitude (57.6%) were suffering from diabetes mellitus for the towards insulin were common among the people4. A survey duration of 6-10yrs. All the participant of the study had the conducted to identify the Cultural Influences in the previous knowledge on diabetes from health care etiological beliefs of Saudi Arabian Primary Care Patients professional (Table 1). about their Symptoms. The study revealed that religious and supernatural aspects of culture affect patient's The major findings of the beliefs were that 51.2% believe symptom beliefs, that their symptoms were a test or that eating more sugar causes diabetes mellitus, 81.6% punishment from Allah, was the most common belief7. Raj disagree that it's God's curse, 3.2% believe that diabetes is PK et al., conducted hospital based cross sectional study to caused due to overweight, 40.8% of the subject agrees that assess knowledge attitude and practice among diabetics, food restriction can control diabetes, 44.8 % believe that at Bijapur in India. Study consisted of 730 type 2 diabetic diabetic adults may show delayed wound healing , 30.4% patients, aged ≥ 20 years. Results shows that 15.35% of of diabetic adults agree with the statement that diabetes is respondents had poor, 59.9% average and 24.8% had good because of past sin, 28% of subjects believe that it's a knowledge. Majority 60-90% of the respondents had communicable disease, 71.2% agreed with the statement positive attitudes. 36.4% of the respondents were taking that they need to carry sugar with them in case of extra care in case they were injured and 40.7% were unexpected hypoglycemia (Table 2). exercising regularly. Study revealed that though good Data in fig.1 indicate that 87.2 % of the diabetic adults fall number of respondents had positive knowledge and under the positive health beliefs and only 12.8 % of subject attitude regarding diabetes, the same cannot be said about had negative health beliefs. The study also revealed that practices8. there is significant association between health beliefs and Conclusion : selected demographic variables such as age (p < .010), In this study only 28% of diabetic clients practicing regular religion (p < .000), monthly income (p< .007), duration of exercise (walking, jogging) very often, 15% of them illness (p< .000) and education ( p <.001). Hence null practicing pranayama and 84.8% of them not at all hypothesis was rejected on these variables and research practicing meditation. Since many studies have been hypothesis was accepted (Table 3). proved that yoga, meditation and exercises control the Discussion : glucose level among diabetic clients. So awareness This study reveals most common myth in the population programs (interventions/educational sessions) required such as, eating more sugar causes diabetes mellitus (51%), for the future among the diabetic population. The scientific diabetes mellitus is the result of past sin (3.2%) and base of the health practice shows that most of the people diabetes mellitus can be cured by spiritual treatment have the knowledge pharmacological activity of the nature (0.8%). This findings supported by Rai M et al., found most which they pass through traditionally. Massive health common myth in the population (22%) was that eating education to the community will help to improve the public more sugar causes diabetes, diabetes can only occur in old knowledge of health beliefs and practices on diabetes as age (7.2%), Soaking feet in water can help control blood India is turned capital of the diabetes. sugar (11.8%), diabetes is a result of past sins and it can be cured by spiritual treatment (9.4%).3 A study in America revealed that many of them believed that diabetes is due to

Keywords: Diabetes Mellitus, Belief, Adult 40 - Malathi G. Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 1: Frequency and percentage distribution of sample characteristics based on demographic data n=125 Sl. No Sample characteristics f % Sl. No Sample characteristics f % 1. Age (in years) 6. Monthly income (in rupees) 25-35 01 0.8 Less than 2999 01 0.8 36-45 08 6.4 3000-5999 33 26.4 46-55 62 49.6 6000-8999 67 53.6 Above 56 54 43.2 9000-11999 24 19.2 2. Gender 7. Source of information Male 46 36.8 1. Health professional Female 79 63.2 Yes 125 100.0 3. Education 2. Newspaper Uneducated 54 43.2 Yes 30 24.0 Primary 55 44.0 No 95 76.0 Secondary 13 10.4 3. TV, Radio, Internet Higher secondary 03 2.4 Yes 30 24.0 4. Occupation No 95 76.0 House wife 67 53.6 4. Relative Agriculture 27 21.6 Yes 17 13.6 Cooley 5.6 5.6 No 108 86.4 Business 24 19.2 5. Friends 5. Religion Yes 02 1.6 Christian 09 7.2 No 123 98.4 Hindu 107 85.6 8. Duration of illness Muslim 09 7.2 0-5 28 22.4 6-10 72 57.6 11-15 24 19.2 >16 01 0.8 Table 2: Health beliefs on diabetes mellitus: (n=125) Health Beliefs SD % DS % UD % AG % SA% 1. Eating more sugar causes diabetes mellitus - 0.8 02.4 45.6 51.2 2. Diabetes mellitus is a curable condition - - 43.2 42.4 14.4 3. Diabetes mellitus is predominantly due to individual factor - - 13.6 45.6 40.8 4. Diabetes mellitus is occurring due to God's curse 44.0 37.6 18.4 -- -- 5. Tension free mind helps to keep blood sugar under control 00.8 -- 09.6 42.4 47.2 5. Controlling blood sugar is not a big task 32.8 40.8 23.2 03.2 -- 6. If blood sugar is not controlled well it will lead to other deadly complication 00.8 19.2 40.0 40.0 7. Diabetes due to overweight 39.2 33.6 24.0 03.2 -- 8. There is need for reduced intake of meat, oily food and fried food items. 00.8 18.4 40.0 40.8 9. Diabetes occurs most commonly among old age. 33.6 28.0 32.8 04.8 00.8 10. There is delayed wound healing -- 03.2 15.2 36.8 44.8 11. Soaking feet in water can help to control blood sugar 40.8 32.0 22.4 04.8 -- 12. Diabetes mellitus is inherited -- 01.6 13.6 38.4 46.4 13. Diabetes mellitus is the result of past sin 33.6 36.8 26.4 03.2 -- 14. Having chapatti will help to control diabetes -- 1.6 19.2 32.8 46.4 15. Diabetes mellitus can be cured by spiritual treatment 36.0 37.6 19.2 06.4 0.8 16. Having rice will increase blood glucose level -- 02.4 10.4 41.6 45.6 17. Diabetes mellitus is communicable disease 40.0 32.0 27.2 0.8 -- 18. Herbal medicine is the treatment for diabetes mellitus 45.6 31.2 19.2 02.0 – 19. Medication will control blood glucose level. -- 00.8 13.6 38.4 47.2

Keywords: Diabetes Mellitus, Belief, Adult 41 - Malathi G. Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Health Beliefs SD % DS % UD % AG % SA% 20. There is no role of lifestyle change in treatment of uncontrolled blood sugar 32.8 42.4 20.8 04.0 -- 21. Yoga helps to keep blood glucose under control. -- 01.6 20.0 40.8 37.6 22. Consuming alcohol helps to keep blood sugar under control 36.8 32.0 26.4 04.8 -- SD – Strongly disagree, DA – Disagree, UD – Undecided, AG – Agree, SA – Strongly Agree.

Table 3: Association between health beliefs and selected demographic variables n=125 Beliefs category Variable Positive Negative df χ2 p value 1. Age 25-35 1 0 36-45 4 4 3 11.31 .010* 46-55 57 5 > 56 47 7 2. Gender Male 38 8 1 1.375 .241 Female 71 8 3. Religion Christian 3 6 Hindu 97 10 2 25.86 .001* Muslim 9 0 4. Monthly income in rupee Less than 2,999 0 1 3,000-5,999 26 7 3 12.03 .007 6,000-8,999 63 4 9,000-11,999 20 4 4. Monthly income in rupee Less than 2,999 0 1 3,000-5,999 26 7 3 12.03 .007 6,000-8,999 63 4 9,000-11,999 20 4 5. Duration of illness 0-5 19 9 6-10 68 4 3 20.01 .001* 11-15 22 2 >16 0 1 6. Education Uneducated 52 2 Primary 47 8 3 15.17 .001* Secondary 9 4 Higher secondary 1 2 Source of information: 1. Newspaper Yes 25 5 1 .529 .467 No 84 11 2. TV, Radio, Internet Yes 27 3 1 .277 .598 No 82 13 3. Relatives Yes 16 1 1 .844 .358 No 93 15 4. Friends Yes 2 0 1 .298 .585 No 107 16

Keywords: Diabetes Mellitus, Belief, Adult 42 - Malathi G. Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Fig 1: Pie diagram showing frequency and percentage References : distribution of health beliefs among diabetic adults. 1. Behera S. Kumar, Behera R. Rekha, Thakur Harshad. Knowledge and practice in prevention of type 2 diabetes mellitus among Bhilai stel plant employees Indian journal of medical specialities 2012 BELIEFS CATEGORY http://dx.doi.org/10.7713/ijms.2012.0048. 2. Shah Viral N, Kamdar PK, Shah Nishit. Assessing the knowledge, 12.80% attitudes and practice of type 2 diabetes among patients of Saurashtra (16) region, Gujarat. Int J Diabetes Dev Ctries. 2009 Jul-Aug; 29(3): 118–122. 3. Rai M, Jugal K. Myths about diabetes and its treatment in North Indian population. International Journal of Diabetes in Developing Countries 87.20% 2009; 3(29):129-132. (109) 4. http://www.who.int/media 5. Hjelm K, Mufunda E. Zimbabwean diabetics' beliefs about health and illness: an interview study. BMC International Health and Human Rights 2010; 7(10):1-10. 6. Hatcher E, Whittemore R. Hispanic adults beliefs about type 2 diabetes: Clinical implications. J Am Acad Nurse Pract 2007; 19(10):536-45. POSITIVE NEGATIVE 7. Alqahtani MM, Salmon P. Cultural influences in the etiological beliefs of Saudi Arabian Primary care patients about their symptoms: the association of religious and psychological beliefs. Journal of religion and health 2008; 47(3):302-313. 8. Raj PK, Angadi MM. Hospital-based KAP Study on Diabetes in Bijapur, Karnataka. Indian journal of medical specialties 2010; 1(2):80-83.

Keywords: Diabetes Mellitus, Belief, Adult 43 - Malathi G. Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article VALIDATION METRICS OF THE MASTOID TRIANGLE Bhagya B.1, Hema N.1 & Ramakrishna A.2 1 Lecturers, 2 Professor, Department of Anatomy, Yenepoya Medical College, Yenepoya University, Deralakatte, Mangalore 575018, Karnataka, India Correspondence: Ramakrishna Avadhani Professor & HOD, Department of Anatomy, Yenepoya Medical College, Yenepoya University Deralakatte, University Road, Mangalore – 575018. Phone : +91 824 220 4668/69/70, Mobile : +91 9845905220, Fax: +91 824 220 4667 E-mail : [email protected] Abstract: The purpose of this study was to validate the technique developed by Paiva and Segre for sex identification using the mastoid process. Total mastoid area is calculated by adding the right and left triangular areas defined by three distinct craniometric points: the Asterion, Porion and the Mastoidale. Eight skulls (40 males and 40 females) were analysed and total area calculated using Heron's formula. The mean total area of the male skulls is higher compared to females (1461.06 mm2 vs 1222.79 mm2). Independent t-tests reveal that there are significant differences between males and females, with p-values less than 0.0001.

Keywords : Mastoid process, Mastoid triangle, sexual dimorphism, metrics

Introduction: indicates a female skull (95% confidence). Total area is used The mastoid process is a pyramidal shaped posterior for the study due to asymmetry of the mastoid process projection of the temporal bone located on each side of the between the skulls. Unequal mastoid process is formed head behind the ear. It is situated just behind the auditory due to pneumatisation (air-filled cavity) and the size of the meatus, and lateral to the styloid process. The mastoid mastoid air cell system is determined by the degree of bone forms the attachment area for many muscles which is pathological involvement of the middle ear during the reason for the process to be more robust in males due childhood.3 to larger muscles compared to females.1 The mastoid Materials & methods: process has been studied by various researchers in The study sample was taken from the Department of different populations for sexual dimorphism.1-6 A technique Anatomy, Yenepoya Medical College, Yenepoya University, reported by Paiva & Segre2 for sex differentiation in the Mangalore, Karnataka, India, which represents the South mastoid process is made by calculating the total area of the Indian Population. The skulls which presented trauma or mastoid triangle. The technique involves measuring the deformations were excluded from the study. A total of 80 distance between three triangular points (Porion, skulls (40 male and 40 female) aged between 35 to 60 years Mastoidale and Asterion), calculating the area of this in department record book were selected for the study. triangle, adding the left & right mastoid triangle areas of Three points forming the landmarks of the mastoid triangle the skull which gives the were located and marked by a single investigator (HU) on total area used to identify Access this article online both sides of the skull. The dimensions of the mastoid sex. If the value of the total Quick Response Code triangle are formed between Porion (Po - superior point of area is greater or equal to the external auditory meatus), Mastoidale (Ms - lower tip 1 4 4 7 . 4 0 m m 2 , i t of the mastoid process) and Asterion (As – the meeting represents a male skull, point of the lambdoid, occipitomastoid and and values less than or parietomastoid sutures) (Fig 1). The linear measurements equal to 1260.36 mm2, between the points were made using a vernier calliper

Keywords: Mastoid process, Mastoid triangle, sexual 44 dimorphism, metrics - Ramakrishna Avadhani NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

(0.01mm). The mastoid triangle area was calculated using Table 1: Descriptive statistics of the mastoid triangle 2 Heron's formula: with sides of triangle a, b & c. (mm ) (n=40; mean±SD) Sex Mean Total area (a+b+c) A= (s(s-a)(s-b)(s-c)) and s = Right area Left area 2 Male 726.76±58.12a 734.3±57.3a 1461.06±115.29a Statistics: Female 607.63±78.10b 615.16±77.82b 1222.79±155.82b Using SPSS Win 13 program descriptive statistics of the Figures across the rows with different letters are significantly different (p<0.0001, paired t-test) linear dimensions of the mastoid triangle area was calculated; the significance of the mean differences in Figure 1: Lateral view of the cranium depicting the relation to sex was calculated using t-test (p<0.05). landmark points: Porion (Po), Asterion (As) and Mastoidale (Ms) forming the mastoid triangle. Results: The values of right, left and total mastoid triangle area of both male and female are presented in Table 1. Descriptive statistics reveal clear differentiation between male and female mastoid processes. In the 80 skulls analyzed, all the lineal dimensions of the mastoid triangle and the calculated areas were higher in males than in females (Table 1). The mean total area of the male skulls is higher compared to females (1461.06 mm2 vs 1222.79 mm2). Independent t-tests reveal that there are significant differences between males and females, with p-values less than 0.0001. References : 1. Bernard K A, Moore-Jansen P H. Quantifying male and female shape Discussion: variation in the mastoid region of the temporal bone. The mastoid region is considered as the most protected 2. De Paiva L A, Segre M. Sexing the human skull through the mastoid process. Rev Hosp Clin Fac Med São Paulo. 2003; 58(1): 15-20. and resistant to damage, due to its anatomical position at 3. Tos M, Stangerup S E. The causes of asymmetry of the mastoid air cell 4 system. Acta Oto- Laryngologica. 1985; 99:564-570. the base of the skull. The qualitative assessment of the 4. Kalmey J K, Rathbun T A. Sex determination by discriminant function mastoid process has been widely used to estimate the sex analysis of the petrous portion of the temporal bone. Journal of Forensic Science. 1996; 41: 865-867. of an individual due to characteristics such as their size, 5. Suazo G I C, Zavando M D A, Smith R L. Sex determination using mastoid process measurements in Brazilian skulls. International ruggedness for muscular inserts, or mastoid process Journal of Morphology 2008; 26(4):941- 944. inclination are very good indicators of sexual dimorphism.5 6. Kemkes A, Gobel T. Metric assessment of the “mastoid triangle” for sex determination: a validation study. Journal of Forensic Science. In the present study quantitative assessment of the 2006; 51: 985-989. mastoid triangle total area is used for sex prediction. The 7. Day J D, Tschabitscher M. Anatomic position of the asterion. Neurosurgery. 1998; 42: 198-199. results of our study support the technique developed by Paiva & Segre2 which is an easy and quick method for sexing skulls. One of the limitations of this technique is its use in sexing individual skulls6, and also due to asterion point localization, which position changes during the course of life.7

Acknowledgement: The authors are grateful to Yenepoya University for permission to carry out this study at the Department of Anatomy.

Keywords: Mastoid process, Mastoid triangle, sexual 45 dimorphism, metrics - Ramakrishna Avadhani NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article KNOWLEDGE REGARDING RCH SERVICES AMONG HEALTH WORKERS, PREGNANT MOTHERS AND ADOLESCENTS IN RURAL FIELD PRACTICE AREA Anusha Rashmi1, Rashmi2 & N. Udaya Kiran3 Post Graduate Student1, Associate Professor2, Professor & Head3, Department of Community Medicine, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018 Correspondence: Anusha Rashmi E-mail : [email protected] Abstract : Maternal mortality and morbidity are significant health problems in developing countries .Improving maternal health has been an essential element for achieving health for all and has been included in MDG to be achieved by 2010. Apart from mothers and children, the health of adolescents came into light as one of the important area mainly because of their role as future or immediate mothers. Role of health care providers especially the grass root level workers becomes particularly important not just in imparting the intending services, but also in imparting knowledge about reproductive health. To assess the knowledge about RCH services among the health care workers, pregnant women, mothers and adolescent girls. A cross sectional study was conducted in the rural field practice areas of K. S. Hegde Medical Academy. A total of 37 health workers, 50 pregnant women and mothers and 56 adolescents were interviewed using a pre tested questionnaire for assessing their knowledge regarding RCH services. Descriptive statistics was used in the analysis. Knowledge regarding high risk pregnancy identification, normal birth weight and identifying anaemia in the field was good among health workers. Only 10.8% of them knew the minimum strength of medical officers in a FRU and only 5.4% knew about fast breathing in less than 2 months old infant. With regard to mothers knowledge 64% were aware of the number of ANC visits, 44% knew about correct interval between 2 pregnancies, 38% knew about methods to prevent STI transmission. 82% of adolescents had good knowledge regarding legal age for marriage.75% were aware of various methods of contraception. Keywords : RCH, Health workers, Pregnant mothers, Adolescent girls.

Introduction : has become client centred, demand driven approach. For The ICPD defines reproductive health as 'a state of this purpose, sub centres and PHC's which form the main complete physical, mental and social well-being in all portal of 1st contact as health facility in rural India have matters relating to the reproductive system and to its been improvised. Health care workers act as a main link functions and processes.' Implicit in this is the right of men between the community and the primary health care and women to be informed and to have access to safe, facilities. Thus the role of health care providers, especially effective, affordable and acceptable methods of family grass root level workers becomes important not just in planning of their and the right of access to health care imparting the intending services but also in imparting services that will enable knowledge about reproductive health. Access this article online women to go safely Quick Response Code Maternal health care package of antenatal care is the main through pregnancy and programme of NRHM to strengthen RCH care. Antenatal childbirth.1 care is a systematic supervision of women during With the introduction of pregnancy to monitor the progress of foetal growth and to NRHM, the delivery of ascertain the well being of mother and foetus. As a services to the community provider of ANC, health workers must ensure a healthy

Keywords: RCH, Health workers, Pregnant mothers, Adolescent girls. 46 - Anusha Rashmi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science outcome for the mother and her baby. In Karnataka ANC universal sampling. After reviewing appropriate literature coverage is reasonably good with 90.2% of women a pre-tested validated questionnaire was made. receiving any ANC irrespective of their background.2,3 Each of the 3 study groups were given 3 different An integrated agenda of NRHM is to promote awareness questionnaire which contained multiple choice questions and knowledge of RTI/STI and HIV/AIDS and make health and close ended questions. For the health workers facilities accessible for diagnosis and treatment seeking to questions were based on IPHS standards. Questions on ensure healthy sexual life free from fatal infections. It is the basic must know knowledge regarding reproductive and responsibility of the health personnel to provide correct child health were included for pregnant mothers and the knowledge of RTI/STI, HIV/AIDS and to encourage adolescents. Questions were introduced by interview prevention and treatment. According to the DLHS data in method. The questions were given weighted scores and Dakshina Kannada, the awareness about RTI/STI is 73.9%. 3 the final knowledge score was calculated. Certain common questions were included in all the 3 questionnaires. All The public health also faces challenges with regards to study subjects were clearly told about the purpose of the adolescent health who constitute 18-25% of population in study and a written consent was obtained from them. The member countries in South-East Asia Region.4 Pregnancy, study was carried out over a period of one month (June 1 – excess risk of maternal and infant mortality, ST/RTI, rapidly July 1, 2012). The data entry and analysis was done using rising incidence of HIV in this group are some of the major Microsoft excel 2007. The results were expressed as concerns. Hence it is important to influence health seeking percentage of number of subjects with correct responses. behaviour of adolescents as their situation will be central in determining the country's health. Addressing the Results : adolescents will yield dividends in terms of delaying Certain common questions were asked to all the 3 groups marriage, reducing incidence of teenage pregnancy, and their results are shown in Figure 1. The health workers prevention and management of obstetric complications had good knowledge which varied from 94% to 100%. including access to early and safe abortion services and Knowledge of pregnant women varied from 44% to 100% reduction of unsafe sexual behaviour.5 and that of adolescents varied from 44% to 96%. With regards to questions that were exclusively asked to the Hence, the present study was undertaken with the pregnant women and the adolescent the pregnant women following objective to study the knowledge regarding RCH had good knowledge (72%) regarding fluids to be given to services among health workers (ASHA's, anganwadi the child in case of loose stools while it was poor (18%) workers), pregnant mothers and adolescent girls. knew about the vaccines to be given to the baby in Materials and Methods : neonatal period. The adolescents had a good knowledge A cross sectional study was carried out in the rural field (75%) regarding the various method contraception. Figure practice areas of K.S.Hegde Medical Academy, Deralakatte. 2 shows the percentage of health workers and pregnant Health care workers (ASHA's, anganwadi workers), women who answered correctly to common questions that antenatal mothers and adolescent girls formed our study were asked to them. subjects. The study subjects were administered the The health workers were asked questions in accordance to questionnaire during the group meetings held at the health the IPHS standards and the results are shown in Table 1. centres respectively. The study sites were Natekal PHC, The health workers knowledge regarding birth weight, NITTE CHC and Muki CHC which were selected by anemia and Janani Suraksha Yojna was good (100%, 97.2%, convenience. A total of 37 health care workers, 50 86.4% respectively). The knowledge score for each of the 3 antenatal mothers, 56 adolescent girls were selected by groups was calculated separately. Scores from the

Keywords: RCH, Health workers, Pregnant mothers, Adolescent girls. 47 - Anusha Rashmi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science individual questions were added up to calculate the final checkups was good being 81%, 100% of them had correct scores which are shown in Table 2. knowledge regarding TT injections. 64.8% of them knew about MTP which was better than the study done in Discussion : Gujarat7which showed that though 95.2% of the health The National Rural Health Mission (NRHM) foundation is workers had correct knowledge about ANC visits and 93.7% built on community involvement in of them knew about the number of TT injections to be drawing a village health plan under the auspices of Village taken, only 33.3% of them knew about MTP. Health & Sanitation Committee In this study about 56.96% had correct knowledge about (VHSC), making rural primary health care services prevention of STD while another study8 showed that only accountable to the community and giving authority to the 19.43% among 243 girls had a correct knowledge of District Health Mission for implementation of inter- contraception. Most of the girls were ignorant about STD. sectoral District Health Plan including drinking water, Our study shows that 82% of the adolescents knew about sanitation, hygiene and nutrition. The interface between the legal age for marriage while another study9 showed the community and the public health system at the village that though the girls were aware that there was a minimum level is entrusted to a female Accredited Social Health age for marriage only 65% could accurately define the age as 18yrs of age. The better knowledge among the Activist (ASHA), a health volunteer receiving performance adolescents in our study as compared to the others could based compensation for promotion of universal be attributed to the ARSH programs that are running in the immunization, referral and escort services for reproductive health centers. Also the literacy status is higher in Dakshina & child health (RCH), construction of household toilets, and Kannada as compared to the northern states. This could be other health care delivery programmes. To promote another factor contributing to higher level of knowledge institutional delivery, cash incentive programme under among the adolescents in our study. Regarding menstrual Janani Suraksha Yojana (JSY) is made an integral hygiene only 55.18% of the adolescents in our study knew component of NRHM. ANC provided by a doctor, an ANM about the regularity of changing pads which was just or other health professionals comprises of physical checks, average as compared to another study10 which showed that checking the position and the growth of foetus and giving 97.8% of them knew about sanitary napkin/clean cloth to TT injection at periodic intervals during the time of be used during menses and changed regularly. This shows pregnancy. At least three check-ups are expected to that there are certain areas in personal hygiene which may complete the course of ANC to safeguard women from not have been properly communicated to the adolescents. pregnancy related complications.2 With regards to pregnant mothers our study showed that In our study we found that the knowledge of health an average of 62.3% were aware of ANC services, though workers was better wherein 81% of the health workers the overall knowledge regarding RCH services among were able to enumerate all criteria's of high risk pregnancy, pregnant women was 53.2% which was less than a study 100% knew about the tablets to be taken during pregnancy, done among 2 tribals11 which showed that 83.78% were 86.4% knew about JSY. These findings were better as aware of ANC services. 9.46% gave a history of inadequate compared to a study done among health workers in utilization of ANC services because of inappropriate advice Jamnagar district 6 where only 71.56% were able to from health workers.. Previous studies show that illiteracy, enumerate at least 5 criteria of at-risk mothers, 47.71% increasing age and poor socio economic status, increasing knew about the strength and dose of IFA tablets, 80.73% birth order have an effect on ANC and that utilization of knew about JSY and its beneficiaries. In our study the services was more where there was associated medical knowledge of health workers with regards to antenatal

Keywords: RCH, Health workers, Pregnant mothers, Adolescent girls. 48 - Anusha Rashmi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science problems and lack of awareness about the available Figure 1: Knowledge regarding common questions asked to services was one of the reasons for non utilization.12,13,14 This health workers, pregnant mothers and adolescent girls.

98% 100%100% emphasizes the need for education to increase the 100 94.6% 94.6% 96.4% 97.3% 82.1% 83.8% awareness and utilization of services by the community. 80 76.8% 70% 60 57.1% While calculating the overall knowledge scores we found 44.6% 44% 40 38% that the health workers had good knowledge (78%) as compared to the pregnant women (54.8%) and 20 0 adolescents (53.2%). Also with regard to questions that Legal age for Methods to Desired birth Place for Place for marriage prevent STD interval conducting conducting were asked to health workers and the pregnant women of girls transmission between 2 delivery abortions pregnancies only, the health workers knowledge was better. These ADOLESCENTS ANTENATAL MOTHERS HEALTH WORKERS findings show that though that there is a knowledge dissemination gap from the health workers to the Figure 2: No of health workers and pregnant mothers who answered correctly to certain common questions ( in percentage) community.

100% 100% 100% Conclusion : 100 94% 81% The health workers knowledge regarding the RCH services 80 64% 65% 50% 60 44% was good while that for the pregnant mothers and the 36% 40 adolescents it was average. This shows that there is need to 20 conduct more training programmes for the health workers 0 Minimum Tablets to No. of TT Month till Fluids that to better their knowledge and also educate them about the no. of be taken injections which MTP can be used antenatal during to be taken is allowed for oral importance of informing the community regarding the RCH visits pregnancy rehydration HEALTH WORKERS ANTENATAL MOTHERS services. There is also a need to conduct more health education programmes for adolescent girls and women Table 1: Knowledge regarding questions asked exclusively to about various aspects of reproductive health and the health workers(n=37) services available. QUESTIONS AWARE UNAWARE (in percentage) (in percentage) Limitations of the Study : 1) Minimum strength of MO 10.8% 89.1% in FRU The sample that was taken in this study may not be 2) Whether PHC is a FRU 54% 45.9% representative of the population as only those who or not attended the clinic were taken into consideration. Also this 3) Normal birth weight 100% in India study did not take into consideration the socio 4) Advice to prevent and 97.2% 2.8% demographic status of the study subjects which would treat anaemia have given more insights to the factors contributing to their 5) What is Janani Suraksha 86.4% 13.6% Yojna knowledge. Also the health workers years of experience 6) Fast breathing in infants 5.4% 94.6% was not taken into account which again plays an important less than 2 months role in the knowledge level. This study also did not take into consideration the gravid status of the pregnant women Table 2: Knowledge scores of the 3 groups SUBJECTS SUBJECT SCORETOTAL SCORE PERCENTAGE which would be a contributing factor to the knowledge in Health workers 1327 1702 78% women regarding services available. Pregnant women 712 1300 54.8% Adolescents 417 784 53.2%

Keywords: RCH, Health workers, Pregnant mothers, Adolescent girls. 49 - Anusha Rashmi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. International Conference on Population and Development ICPD'94. Vol 1 Issue 2 Apr-Jun 2012. Summary on progress of action Chapter 7 'Reproductive Rights and 8. Ratna Majumdar and S.K. Ganguli . A study of adolescent girls in Pune. Reproductive health' Health and Population- Perspectives and Issues 23(2): 95-104, 2000 2. International Institute for Population Sciences (IIPS),2010: District 9. D. Pattanaik, J. Lobo, S. K. Kapoor, P. S. N. Menon .Knowledge and level household survey (DLHS-3), 2007-08: India, Karnataka: attitudes of rural adolescent girls regarding reproductive health Mumbai:IIPS. issues. The National Medical Journal of India 2000 Vol13, No.3, 2000 3. Guidelines for antenatal care and skilled attendance at birth by 10. K. Malleshappa, Shivaram Krishna, Nandini C . Knowledge and attitude ANMs/LHVs/SNs' Maternal health division MOHFW Government of about reproductive health among rural adolescent girls in Kuppam India 2010. mandal: An intervention study. Biomedical Research 2011; 22 (3): 4. Adolescence health and development'available from 305-310 www.searo.who.int last accessed on September 12, 2012 11. Mumbare SS, Rege R. Antenatal care service utilization, delivery 5. 'Adolescent Reproductive and Sexual Health (ARSH) Strategy under practices and factors affecting them in tribal area of North NRHM / RCH-II' available from mohfw.nic.in last accessed on Maharashtra. Indian J Community Med 2011;36:287-90 September 12, 2012. 12. Prabir Kumar Manna, Debasis De and Debidas Ghosh . Knowledge 6. Kaushik Lodhiya K, Pradeep Pithadiya R, Raman Damor D, Sumit attitude and practices for antenatal care and delivery of the mothers of Unadkat V, Sudha Yadav B .A study of knowledge and skills of female tea garden in Jalpaiguri and Darjeeling districts, westbengal. National health workers regarding maternal care under RCH programme. Journal of Community Medicine 2011 Volume 2 Issue 1 National Journal of Community Medicine Vol 3 Issue 1 Jan-March 13. Agarwal P, Singh MM, Garg S. Maternal health-care utilization among 2012. women in an urban slum in Delhi. Indian J Community Med 7. Naresh R Makhwana, Viral R Shah, Sudha Yadav. An evaluation of skill 2007;32:203-5 and knowledge in delivery of reproductive and child health services by 14. Manish K Singh, J V Singh, N Ahmad, Reema Kumari, A Kanna. Factors female health workers in Jamnagar district and corporation area, affecting utilization of ASHA services under NRHM in relation to Gujarat state, India. International Journal of Health and Allied sciences maternal health in Lucknow. Indian J Community Med 2010;35:414-19

Keywords: RCH, Health workers, Pregnant mothers, Adolescent girls. 50 - Anusha Rashmi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article BUTT AND HIT - THE HEART KIDNEY SAGA: A SNAP SHOT AND LONG TERM PERSPECTIVES Raghava Sharma1 & Shashank Shetty2 1 Professor, 2Sr Resident, Dept of Medicine, K.S. Hegde Medical Academy, NITTE University, Deralakatte, Mangalore - 575 018. Currespondence : Raghava Sharma, Professor, Department of Medicine K.S. Hegde Medical Acadamy, NITTE University, Deralakatte, Mangalore- 575 018. Mobile : +91 94487 70919 E-mail : [email protected] Abstract : Tobacco smoking is an universal problem. There are about 120 million smokers in India in the age group of 30-69 years and have an increased cardiovascular and renal risks in addition to other risks attributable to smoking. The present study was aimed to assess the cardiovascular and renal risks especially among the young smokers in the age group of 20-40 years. After all necessary administrative and ethical clearances a cross sectional study was conducted at the tertiary care medical college hospital located at Mangalore. 75 young male smokers in the age group of 20-40 years along with equal number of age, sex matched non smokers as controls were recruited and each one were assessed for Blood pressure(BP), Electro cardiographic changes(ECG changes), and Glomerular filtration rate(GFR). In the present study Smoking resulted in high systolic blood pressure and prolonged QT interval (QTc) as compared to the non smokers, thus increasing the risk of Sudden cardiac death among smokers. Longer duration of smoking of more than 10 years resulted in Pre hypertension and reduced GFR in comparison to smokers with lesser duration of smoking of less than 10 years. This study highlights the need to tackle “Smoking” among young adults more aggressively to avoid the potential cardiovascular and renal complications, as Tobacco smoking is a major modifiable risk factor for the same. Keywords: Tobacco smoking, Young adults, Cardiovascular and renal risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR).

Introduction : mixture of chemical substances has unique pro Tobacco smoking is an universal problem and a malady inflammatory and cyto toxic effects2 more so among young adults. Tobacco use in different Ill effects of smoking (Nicotine) on cardiovascular and renal population groups is reported to have a prevalence of 15% systems can be attributed to the following mechanisms: to over 50% among men1. Large household surveys in lSmoking (Nicotine) exerts effect on the proximal tubule recent years have shown that there are about 120 million and renal haemo dynamics resulting in increased GFR, smokers in India, of whom 37% are all men and 5% are all sodium chloride excretion, and urine flow3,4. women in the age group of 30-69 years. Smoking may soon lSmoking(Nicotine) causes marked attenuation of alpha account for 20% of all male deaths and 5% of all female and beta adrenergic blockade, prolonged increase in deaths among Indians in plasma norepinephrine and epinephrine, thus leading Access this article online the age group of 30-69 to a marked and prolonged increase in heart rate and Quick Response Code years1 blood pressure5 M o r e t h a n 4 0 0 0 lSmoking (Nicotine) accelerates atherosclerotic process compounds have been by its pro sclerotic and pro thrombotic effects. identified in the tobacco lSmoking (Nicotine) has an unfavorable influence on smoke. This complex autonomic balance leading to QT prolongation and

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 51 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

prolonged QTc with a lowered ventricular threshold and *Maximum smokers belonged to the age group of 26-30 occurrence of sudden cardiac death6. years (Table 2).

Materials and Methods : *Raised systolic BP in the pre hypertension range of 121- The present cross sectional study conducted at the tertiary 130 mmHg was noted in the 61.2% of smokers as compared care medical college hospital at Mangalore, coastal to 38.8% among non smokers.(Table 3, Fig 1). Out of this Karnataka comprised of 75 young male smokers in the age 65.2% had a smoking history of more than 10 years while group of 20-40 years, who smoked more than 10 cigarettes 28.8% had less than 10 years of smoking history, thus per day for more than 5 years. Age and sex matched demonstrating a clear statistically significant (P < 0.0001) controls were also drawn. Females, hypertensives, correlation between smoking, duration of smoking and diabetics, patients with known renal diseases, patients raised systolic BP (Table 4, Fig 2) There was no significant taking drugs that affect QT interval and patients taking correlation with respect to diastolic BP between smokers drugs affecting GFR were excluded from the study. and non smokers and with respect to duration of smoking.( Table 5, Fig 3 ). After obtaining written informed consent from each participant a detailed history with particular emphasis on *QTc interval was significantly prolonged in smokers as duration and number of cigarettes smoked was sought and compared to non smokers, which was statistically a thorough clinical examination was performed. Blood significant with P < 0.05. However no correlation was found pressure (BP) was recorded from the right arm in sitting in relation to the duration of smoking. (Table 6, Fig 4). posture using mercury sphygmomanometer by a single *GFR decreased with increased duration of smoking ( > 10 person (to avoid inter personal variability). An average of years ) as compared to lesser duration of smoking ( < 10 two BP readings taken five minutes apart was considered years ), which was statistically significant with P = 0.042. for analysis. Blood sample for creatinine estimation was However there was no statistically significant difference of drawn soon after BP measurement and GFR was calculated GFR between smokers and non smokers. (Table 7&8, Fig using creatinine clearance rate using the cockroftt gault 5&6). formula. Discussion : (140-Age) X weight [kg] C c r = ------Effect of smoking on cardiovascular and renal system is Cr [mg/dl] X 72 very vital and forms a long term perspective particularly among young adults. The present study being unique has Electro cardiograph (ECG) was obtained at the same time addressed this issue by involving young adults in the age and analyzed for any abnormalities in terms of rate, group of 20-40 years only. rhythm, axis deviation, chamber hypertrophy, ischaemia, and QT prolongation. Wang et al7 had observed that young smokers were at higher risk of developing cardiovascular risks as compared Chi square test was employed for analysis of observations to older adults. Study by Paola et al8 on older men and conclusions were drawn from the same. demonstrated a higher systolic BP among smokers as Observations and Results : compared to non smokers ( 144 mmhg Vs 140 mmhg ), but *In the present study, mean age of smokers was 31.27 with no such differences in diastolic BP among the two years while it was the same 31.78 years for the non smoker groups. However our study conducted on young men also control group also (Table 1). confirms the same, which was statistically significant too (P < 0.05).

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 52 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Study by Okubo et al9 found lesser systolic BP in light to functions among young smokers. moderate smokers as compared to non smokers (121 lYoung smokers form an important risk group who mmhg Vs 123 mmhg). However Our study contradicts the require to be “COUNCELLED TO QUIT SMOKING” to above findings as higher percentage of smokers were in the prevent long term smoking induced cardiovascular and Pre hypertension range (defined as systolic BP of 121-139 renal risks. THIS GOES A LONG WAY IN ACHIEVING A mmhg or diastolic BP of 81-89 mmhg by JNC 7) compared to POLLUTION FREE ENVIRONMENT AND ALSO A non smokers and systolic hypertension was evident in PRODUCTIVE, HEALTHY YOUNG POPULATION AND smokers with prolonged duration of smoking ( > 10 years ) SOCIETY. as compared to lesser duration of smoking (<10 years ). The Table1. Baseline characteristics between smokers and above findings of our study may be attributed to chronic non-smokers. smoking induced atherogenesis in large capacitance Smokers Non P value vessels which is easily amenable to correction by modifying smokers (mean) (mean) the risk factor of smoking. Age(yrs) 31.27 31.78 0.490 BMI(kg/m2) 26.55 27.66 0.066 6,9 Study by Mehmet illeri et al demonstrated smoking Creatinine(mg/dl) 1.01 1.06 0.069 predisposes to prolongation of QT interval and QTc GFR(ml/min) 88 85 0.289 dispersion, thus increasing the risk of sudden cardiac death SBP mmHg 124 115 0.00 DBP mmHg 73 73.32 0.099 in them due to lowered ventricular fibrillation threshold Pulse rate(rate/min) 81 78 0.577 and pro arrhythmic effect of catecholamine and nor Corrected QT (m s) 427 367 0.000 epinephrine spillover. Our present study reconfirms the Number of cigarettes /day 16.2 - - Duration of smoking in years 9.22 - - same and was statistically significant too with P < 0.05.

10 Table 2: Age distribution between smokers and non Halimi et al in his study on the effects of smoking on renal smokers. function concluded that creatinine clearance was higher in Smoker / NonSmoker Total smokers as compared to non smokers (100.6ml/min Vs Nonsmoker Smoker 98.8ml/min) and the glomerular hyper filtration was Age Group 20-25 Count 2 3 5 associated with increased intra glomerular pressure and % within Age Group 40.0% 60.0% 100.0% proteinuria. Our present study also confirmed a higher GFR 26-30 Count 33 35 68 among smokers compared to non smokers but was not % within Age Group 48.5% 51.5% 100.0% 31-35 Count 21 19 40 statistically significant ( P > 0.05 ). % within Age Group 52.5% 47.5% 100.0% 36-40 Count 19 18 37 Conclusions : % within Age Group 51.4% 48.6% 100.0% From the present study we conclude the following: Total Count 75 75 150 lSmoking predisposes to pre hypertension, systolic % within Age Group 50.0% 50.0% 100.0% hypertension and prolonged QT interval among young X2=0.386, p=0.943 smokers as compared to age, sex matched non smokers, thus increasing their risk to develop overt hypertension and associated cardiovascular complications including sudden cardiac death. lProlonged duration of smoking (> 10 years) results in GFR reduction and raised systolic blood pressure, thus increasing the risk of long term cardiovascular complications and also long term deterioration of renal

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 53 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 3 : Systolic Blood pressure distribution between the two groups.

Smoker / Non Smoker Total Nonsmoker Smoker SBP group 100-110 Count 27 11 38 % within SBP group 71.1% 28.9% 100.0% 111-120 Count 28 20 48 % within SBP group 58.3% 41.7% 100.0% 121-130 Count 19 30 49 % within SBP group 38.8% 61.2% 100.0% 131-140 Count 1 12 13 % within SBP group 7.7% 92.3% 100.0% >140 Count 0 2 2 % within SBP group .0% 100.0% 100.0% Total Count 75 75 150 % within SBP group 50.0% 50.0% 100.0% X2 =21.847, p=0.0001

TABLE 4 :Comparison between SBP and Duration of smoking. duration of smoking group Total <10 years >10 years SBP group 100-110 Count 9 2 11 % within SBP group 81.8% 18.2% 100.0% % within duration of smoking group 17.3% 8.7% 14.7% 111-120 Count 19 1 20 % within SBP group 95.0% 5.0% 100.0% % within duration of smoking group 36.5% 4.3% 26.7% 121-130 Count 15 15 30 % within SBP group 50.0% 50.0% 100.0% % within duration of smoking group 28.8% 65.2% 40.0% 131-140 Count 7 5 12 % within SBP group 58.3% 41.7% 100.0% % within duration of smoking group 13.5% 21.7% 16.0% >140 Count 2 0 2 % within SBP group 100.0% .0% 100.0% % within duration of smoking group 3.8% .0% 2.7% Total Count 52 23 75 % within SBP group 69.3% 30.7% 100.0% X2=13.844, p=0.008

TABLE 5.Diastolic Blood pressure distribution between smokers and non smokers. Smoker / Non Smoker Total Nonsmoker Smoker DBP group 60-70 Count 29 41 70 % within DBP group 41.4% 58.6% 100.0% 71-80 Count 40 27 67 % within DBP group 59.7% 40.3% 100.0% 81-90 Count 6 7 13 % within DBP group 46.2% 53.8% 100.0% Total Count 75 75 150 % within DBP group 50.0% 50.0% 100.0% X2=4.656, p=0.097

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 54 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 6: QTc between smokers and non smokers Smoker / Non Smoker Total Nonsmoker Smoker QTcgroup <444 Count 74 68 142 % within QTcgroup 52.1% 47.9% 100.0% >444 Count 1 7 8 % within QTcgroup 12.5% 87.5% 100.0% Total Count 75 75 150 % within QTcgroup 50.0% 50.0% 100.0% X2=4.754, p=0.029 Table 7 :GFR between smokers and non smokers Smoker / Non Smoker Total Nonsmoker Smoker GFRgroup 60 -75 Count 17 15 32 % within GFRgroup 53.1% 46.9% 100.0% 76- 90 Count 37 33 70 % within GFRgroup 52.9% 47.1% 100.0% 91-105 Count 14 22 36 % within GFRgroup 38.9% 61.1% 100.0% 106-120 Count 7 5 12 % within GFRgroup 58.3% 41.7% 100.0% Total Count 75 75 150 % within GFRgroup 50.0% 50.0% 100.0% X2=2.465, p=0.482 Table8:Comparison of GFR with duration of smoking duration of smoking group Total <10 years >10 years GFR group 60-75 Count 8 7 15 % within GFR group 53.3% 46.7% 100.0% % within duration of smoking group 15.4% 30.4% 20.0% 76-90 Count 20 13 33 % within GFRgroup 60.6% 39.4% 100.0% % within duration of smoking group 38.5% 56.5% 44.0% 91-105 Count 19 3 22 % within GFR group 86.4% 13.6% 100.0% % within duration of smoking group 36.5% 13.0% 29.3% 106-120 Count 5 0 5 % within GFR group 100.0% .0% 100.0% % within duration of smoking group 9.6% .0% 6.7% Total Count 52 23 75 % within GFR group 69.3% 30.7% 100.0% % within duration of smoking group 100.0% 100.0% 100.0% X2=8.201,p=0.042

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 55 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Figure 1. Figure 2.

SBP (pre hypertensive range) significantly higher among smokers with smoking duration more than 10 years. Higher percentage of young smokers in the pre-hypertension range as compared to age matched non smokers (61.2 % VS 38.8%). Figure 4. Figure 3.

Diastolic Blood pressure between the two groups comparable but not statistically significant. QTc in smokers significantly higher than non smokers.

Figure 5. Figure 6.

GFR between smokers and non smokers comparable but not statistically significant.

GFR reduction significantly higher with prolonged duration (>10years) of smoking.

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 56 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Rani M, Bonu S, Jha P, Nguyen SN, Jam joum L. Tobacco use in India : 6. Mehmet Ileri, Ertan Yetkin, Izzet Tandogan, Ismet Hisar, Ramazan Atak, Prevalence and predictors of smoking and chewing in a national cross Kubilay Senen et al. Effect of habitual smoking on QT interval and sectional household survey. Tobacco control 2003; 12(4). dispersion. American journal of cardiology 2001 : 88 ; 322-325 2. Rustemeier K, Stabbert R, Haussman HJ. Evaluation of the potential 7. Wang H, Shi H, Wang Z. Nicotine depresses the function of multiple effects of ingredients added to cigarettes. Part 2: chemical cardiac potassium channels. Life Sci ; 1999 : 65 ; 143-149 composition of main stream smoke. Food chem. Toxicol 2002; 40 : 93- 8. Poala Primatesta, Emanuel Falaschetti, Sunjay Gupta. Association 104 between smoking and blood pressure. Hypertension 2001 ; 37 : 187- 3. Orth SR. The renal risks of smoking. Kidney international.1997 :51 ; 193 1669-1677 9. Yokubo, T Miyamoto, Ysuwazono. An association between smoking 4. Orth SR, Hiroaki O, Eberhard R, Smoking and kidney. Nephro Dial and habits and blood pressure in normotensive Japanese men. Journal of transplant. 2000; 15 : 1509-1511 human hypertension. 2002 ; 16 : 91-96 5. Guido Grassi, Gino Seravalle, David A Calhoun, Gianni B Bolla, Cristina 10. Jean Michel Halimi, Bruno Giraudeau, Sylviane Vol, Emile Caces, Giannattasio, Monica Marabini, et al Mechanisms responsible for Hubert Nivet, Yvon Lebranchu and Jean Tichet. Effects of current sympathetic activation by cigarette smoking in humans. Circulation smoking and smoking discontinuation on renal function and 1994, 90: 248-253 proteinuria in the general population. Kidney international 2000 ; 58 : 1285-1292

Keywords: Tobacco smoking, Young adults, Cardiovascular and renal 57 risks, Sudden cardiac death, QT interval, Glomerular filtration rate (GFR). - Raghava Sharma NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Original Article THERMOREGULATION IN THE HEART AND THE BIOPHYSICS OF CORONARY ARTERIAL FLOW Arunachalam Kumar Professor of Anatomy, K.S. Hegde Medical Academy, NITTE University Mangalore - 575 018 India Correspondence: Arunachalam Kumar E-mail : [email protected] Abstract: The right and left coronary arteries are the principal sources of supply of oxygenated blood to the heart. Arising from the proximal rim of the ascending aorta, these arteries course along and over the surface of the organ, sending out branches that penetrate axial blood flow through arteries is governed or maintained by multifarious physical laws. The heart, an electrically stimulated muscular pump, squirts and receives circulating blood through its systolic and diastolic exertions. The non-stop life-long rapid action of the organ not just expends enormous energy but also generates considerable heat. While there are a number of factors that help the heart dissipate and reduce heat, a few other biophysical factors contribute hugely to maintain a thermostatic milieu. Circulation through vessels is maintained with a high degree of efficiency through combined actions of ejection systolic pressure, elasticity of the conducting arterial channels, and the proximo-distal decrease in diameters of arteries. This brief write-up discusses some of physics regulatng fluid flow dynamics and attempts to exemplify the significant role of 'centrifugal force' as a hitherto overlooked physical force in coronary haemodynamics. The application of biophysical postulates to cardiac cycle may help in furthering our understanding of coronary blood circulation and the multi-factorial influences on its functional integrity. It is inferenced that, the finding may have a number of applications and result in a better understanding of cardiac circulatory dynamics. Keywords : heart, biophysics, flapping coronaries, thermoregulation

Introduction: degree of efficiency through combined actions of ejection The left and right coronary arteries are the principal systolic pressure, elasticity of the conducting arterial sources of supply of oxygenated blood to the heart. Arising channels, and the procimo-distal decrease of diameters of from the proximal rim of the ascending aorta, these arteries. arteries course along and over the surface of the organ, To better comprehend blood transportation, one needs to sending out branches that penetrate axially in to cardiac understand simple physical laws.The application of tissue. biophysical postulates to cardiac cycle may help in Blood flow through arteries is governed or maintained by furthering our understanding of coronary blood circulation multifarious physical laws. The heart acting as an and the multi-factorial influences on its functional electrically stimulated integrity. muscular pump, squirts Access this article online This brief write-up discusses some areas of physics o u t a n d r e c e i v e s Quick Response Code regulating fluid flow dynamics, and attempts to exemplify circulating blood at its the undeniably significant role of 'centrifugal force' as a systolic and diastolic hitherto overlooked physical force in coronary exertions. Circulation haemodynamics. t h r o u g h v e s s e l s i s maintained with a high

Keywords : heart, biophysics, flapping coronaries, thermoregulation 58 - Arunachalam Kumar NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Discussion: that modulate the cardiovascular biomechanisms. Canalized and channeled flow of liquids is not as simple a In some conditions, the fluid itself, blood, can and does process as it first appears. The factors that allow channeled change its viscosity and composition. These are factors too free flow of liquids from point 'A' to point 'B' are apart from pathological changes in anatomical structures determined by many physical laws and principles. Some of too have a major impact on hemodynamics. the more readily obvious ones being: Considering that the organ functions at a frenetic pace, it 1.Gravity should generate heat. There appears to be no specialized 2.Atmospheric Pressure thermoregulatory mechanisms for the heart. Considering 3.Positive & Negative pressures that the heart produces electrical impulses, contracts and 4.Surface Tension relaxes seventy plus times a minute, controls the ejection 5.Viscosity and propulsion of nearly five liters of blood, it should be too 6. Inertia 'hot' an organ. Yet, the heart maintains a steady ambient Apart from these above cited physical dicta that determine temperature! Notwithstanding the vortex, turbulence and fluid displacement from one point to another, an additional friction of flow through coronary arteries, the heart factors, the centrifugal force, could play an adjunct, yet remains pretty 'cool'. How it achieves this near impossible vital role coronary arterial circulation. task has baffled biomedical engineers and biophysicists for long. Among the physical postulates that determine flow dynamics of fluids, Reyanuld's number, Re, is applied for Of course, there a few pretty obvious heat-offsetting calculations; it is the measure of the ratio of inertial forces mechanisms in place; to viscous forces and consequently quantifies the relative 1. The anatomical position of the heart itself, askew to the importance of these two types of forces for given flow left and away from the sternum, its housing in a conditions. Darcy - Weisbach friction factor used with Re fenestrated bony cage with 'slats' (costae) and cardiac gives an estimate of friction produced turbulence. Rate of notch of left lung flow through cylindrical pipes is determined applying the 2. The bathing of the organ in pericardial fluid Hagen-Poiseuille equation. 3. The location of the organ itself, smack in between two Under ideal conditions (long, straight, smooth blood pneumonic sacs, the aerated lung. vessels), the critical Re is relatively However, in branching 4. While the anterior, right and left surfaces of the heart vessels, there can be turbulence even at normal are related to the aerated lungs and intercostals space to physiological flow velocities. Turbulence generates sound dissipate heat, the posterior surface (base) which is waves that can be heard with a stethoscope. Because related to the vertebral column and has no means to higher velocities enhance turbulence, murmurs intensify radiate heat – maintains heat through the cooling as flow increases. Elevated cardiac outputs, even across brought about by venous blood filled atrial chambers anatomically normal aortic valves, can cause physiological which form the posterior surface. murmurs because of turbulence. Each one of these factors may have a specific role in Coronary blood flow cannot be determined through dissipating heat generated by the heart. This paper application of any physical law directly: the vessels are presents yet another, less studied in situ mechanism, a elastic, tortuous and branch, each factor influencing flow geometrical re-array of branching patterns in coronary dynamics. Moreover, laminar flow is constantly arteries, especially in its proximal segments as another determined by mechanical, hormonal or neuronal systems

Keywords : heart, biophysics, flapping coronaries, thermoregulation 59 - Arunachalam Kumar NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science factor that probably reduces turbulence generated rise in The amplitudes and radii of the elevation-depression or cardiac temperature. Of late a few have described cardiac abduction -adduction exercise of the arteries and the cycle as functioning chaotic systems. Chaos could also resultant angular velocity generated by the rapid whip- prove to be one of the non-linear mechanisms by which the lashing (flapping) generates centrifugal forces.The force heart stays thermostatic. (4) thus created, more than seventy times a minute and with every contraction-relaxation cycle of the heart, acts as an In order to flow, any liquid blood inclusive, must utilize one adjunct biophysical factor in the transmission and delivery or more of the above listed principles. While it is easy to of blood the target tissue. (Figure 2) decipher the application of all the above listed factors that govern motion, vis-a-vis blood circulation, 'centrifugal force' require some elaboration, especially so because it may a significant role in augmenting blood transport and delivery through the coronary arteries. (Figure 1)

Figure 2: Diagram shows amplitude of movement of artery during systole / diastole (CP: centripetal force; CF: centrifugal force; T: tangential force; R: radius)

It is obvious that any change in amplitude of coronary movement, or in the radius along which it occurs will decrese or increase the centrifugal force. In other words, Figure 1: Movements (A – B) of coronary arteries during systole any change in dimensions of the heart, will not only alter / diastole the radius, but also the amplitude of the coronary swing Both coronary arteries appear as abruptly branching twigs arc influencing flow volume dynamics. The right artery is from the main trunk of the proximal aorta. Their caudal better equipped for generaton of centrifugal forces descent on the surface of the atria, is angulated compared to the left: its direction is more rectilinear. downwards and outwards. Their further course is a It is interesting to note that anatomically, all the early continuum of tortuousness, spiraling or tangential. Since braches of the right coronary, run at right angles to the these vessels run on the surface, with each systole-diastole trunk, or tangential to the arc formed by the radius of the unit of the cardiac cycle, the arteries, are perforce arterial segmental length. This right-angled braching subjected to elevation- depression and abduction. The system, allows a les turbulent and chaotic flow of the movements of the coronaries are oar-like, the aortic- centrifugally ejected blood flow, which as per physical coronary junction becoming the fulcrum. The pump- principles is tangential or at right angle to the parent handle like arterial sorties engender centrifugal forces that arterial direction. Beyond the proximal segment, the right are determined by application of the physical tenet: m X v coronary, and alomost al the left, take a sinuous course, /r which can be re-written as: m X r O (where'm' is the the centrifugal forces diminishing distally. Therefore, the mass of the body,'v' is the velocity and 'O is angular branching pattern in the farther segments are acute angled velocity) or follow fractal orientation.

Keywords : heart, biophysics, flapping coronaries, thermoregulation 60 - Arunachalam Kumar NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

What or how tachycardia or bradycardia effect centrifugal The question raised is, if right- angled branching seen in outflow, or how the coronary flow is effected by proximal coronaries are inbuilt bio-regulators that counter pericardoa; effusions, or hypertrophy of the heart ? Will or minimize turbulence then how would cardiac any factor increasing the heart rate, by default, also raise hypertrophy influence flow? Can the forced reduction of the coronary arterial flagellation (whip-lash) rate? right to acute angle consequent to lengthening of parent coronary artery further compromise blood supply and flow Conclusions : to an already diseased heart? Observations presented here demonstrate that coronary flow is a complex dynamic system involving multiple There is little doubt that further research into this nebulous physical and biomechanical principles and processes. The area is required. The combined input from biomechanical course of the artery on cardiac surface to allow free flow, experts, fluid dynamic engineers and cardiologists could the tortuousness course of its anatomy, its synergic yield more information and understanding of this hitherto interaction with myocardial contraction and relaxation and neglected area in hemodymics of coronary flow8 its unusual branching pattern1,2 at right angles in the The purpose of this presentation is only to highlight a proximal segment and bifurcating into acute angled probably significant , but hitherto un-investigated branches in the more distal segment – all are factors that biophysical mechanism that could act on coronary regulate the hemodynamics of coronary circulation (Figure circulation haemodynamics. It is our conclusion that there 3). may yet be many principles of biophysics waiting for application into the medical world.

Among the lesser understood, is the role of centrifugally generated forces and the modulation of the coronary arteries towards enhancing their effect on outflow. The arteries, more so the right coronary, bears a singularly unique branching pattern in that almost all named branches, course out at right angles to the trunk. That this pattern maximally utilizes the coronary outflow corroborates the theory that the coronary arterial trunks act as mobile radii generating rapidly alternating centrifugally directed forces. The left trunk, being more Figure 3: Coronary arterial course on surface of heart. Note right sinuous and less linear, and thus less centrifugal force angled septal and surface branching from proximal segment generating potential, bears more branches that follow a It is observed that physicians, cardiologists, physiologists more conventional acute angled fractal pattern. have rudimentary knowledge on the physical principle regulating fluid motion. It is hoped that better What role, if any, does cardiac hypertrophy, resulting from understanding of cause and effect of compromise with the a bacterial or viral endocarditis induced cardiomyopathy, tenets of fluid mechanics, especially the role of inertia, have in altering angle of coronary branching ? Will the 4,5,6, 7 increase in lengths of proximal parts of the coronary tree centripetal, centrifugal and tangential forces . that result in conversion of its right-angled branches to Disturbance or disruption of laminar flow, either through acute, and thereby compromise coronary blood flow mechanical or physiological causes, lead to turbulence and dynamics in an already diseased heart ? friction, can upset thermoregulatory mechanisms In this brief hypothetical treatise on possible role of

Keywords : heart, biophysics, flapping coronaries, thermoregulation 61 - Arunachalam Kumar NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science centrifugal forces, raises questions and maybe, stimulate further research into cardiac circulation and physiology, it would have more than amply served that purpose

References 1. Hutchins GM, Miner MM, Boitnott JK. ; Vessel caliber and branch- angle of human coronary artery branch-points. Circ Res. 1976; 38(6):572-6. 2. Pflederer T, Ludwig J, Ropers D, Daniel WG, Achenbach S.; Measurement of coronary artery bifurcation angles by multidetector computed tomography Invest Radiol. 2006; 41(11):793-8. 3. Duncker DJ, Bache RJ. ; Regulation of coronary blood flow during exercise. Physiol Rev.2008; 88(3):1009-86. 4. Kumar JC & Arunachalam Kumar.; The biophysics and hemodynamics of coronary arterial flow. Proceedings of the 52nd Annual Conference, A. S. I., 2004 5. Kumar JC & Arunachalam Kumar.; Coronary arterial array and hemodynamics, Karnataka State Conference of the Cardiological Society of India, 2005 6. Kumar JC & Arunachalam Kumar; Coronary arterial geometry and cardiac circulation, Proceedings of the Indo-Australian Conference, Manipal, 2005 7. Kumar JC & Arunachalam Kumar; The physiodynamics and biomechanics of cardiac apex. BMJ (S. Asian Ed) 20; 3; 19-20, 2004 8. Arunachalam Kumar & Hegde BM.; Chaos Theory: Impact on and Applications in Medicine. Nitte University Journal of Health Science 2012, 2 (4) 93-99

Keywords : heart, biophysics, flapping coronaries, thermoregulation 62 - Arunachalam Kumar NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Short Communication A study on father`s knowledge and attitude towards their role in child care in selected areas of Mangalore with a view to develop an informational booklet. Roshin M.S.1 & Sujatha R.2 1 M.Sc. (N) Student, 2Professor and HOD, Child Health Nursing, Nitte Usha institute of Nursing Sciences, NITTE University, Mangalore

Correspondence : Roshin M.S. M.Sc. (N) Student, Nitte Usha institute of Nursing Sciences, NITTE University, Mangalore E-mail : Abstract : “It is a wise father who knows his own child” - William Shakespeare In today's modern and fast changing society, families are becoming nuclear; mothers are professionally oriented and having busy jobs. Father's participation in child care is necessary due to progressive involvement of mothers in jobs outside the home. Hence the responsibility of child rearing has extended to fathers also. In this study father's knowledge is assessed by self structured questionnaire and attitude using attitude scale. The findings revealed that majority of the fathers 88(44%) were in the age group of less than 30 years, 110 (55%) were having more than 2 siblings, 92 (46%) were on the 1st order of birth, (46.5%) completed Secondary school education,106 (53%) were having private job, 200(100%) were married and living with spouse,82 (41%) of their children have above 2yrs. 116 (58%) fathers were Hindus, 79 (39.5%) were having monthly income of less than Rs5000/ -and 124 (62%) fathers do not have previous information regarding child care. The result also shows 94 (47%) fathers were having average knowledge regarding child care, 69 fathers (34.45%) have poor knowledge and 37 (18.5%) fathers were having good knowledge. There is significant correlation between knowledge and attitude of fathers regarding their role in child care. There is significant association between knowledge and demographic variables but marital status has no significant association between knowledge and also significant association seen between attitude and demographic variables. Keywords : Knowledge, Attitude, Fathers, Child care

Introduction : their children. As a father they should know their child's Ancient time onwards it is believed that the father`s role is likes, dislikes and routines. Fathers are the important to protect the family. Child rearing and taking care of people in their child life like friends, teachers, and coaches. children during illness is always considered to be mother's They connect with their children on an emotional and responsibility. The parent's role is changing as a result of spiritual level and their willingness and active participation changing economy. Most of the women are in labour force is necessary for a proper child care. so father`s role is also changing.So now a day's child rearing Need For The Study : is not only the responsibility of mothers but also fathers. An Nowadays the trends are changing, mothers also have their active involvement of the Access this article online own jobs besides father and they also earns for their family. father in infant rearing is Quick Response Code Hence father has the responsibility to share with mothers important for family`s in child rearing and care of the child. It is beneficial for the health and well-being. fathers also. It helps to create a better bonding between Fathers can play and interact father and child and helps him to be aware about the needs in different ways that shows and problems of the child. In the psychological aspect also their love and affection to it is very beneficial, which results in better understanding

Keywords: Knowledge, Attitude, Fathers, Child care 63 - Roshin M.S. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science between partners and also between father and child. It also J Pender (1982; revised, 2002) was designed to be a helps the fathers to be aware about the growth and “complementary counterpart to models of health development of child, care during minor ailments and the protection.” prevailing family situation. Components of The Health Promotion Model : Fathers play a vital role in implementing childcare. They The Health Promotion Model classifies health behavior must have a adequate knowledge and positive attitude determinants into three specific propositional groupings: towards childrearing and child care. Recently some fathers âIndividual characteristics and experiences are well educated about child care and have good interest âBehaviour specific cognitions and affects to execute their role without any hesitations. Researches âBehavioural outcome regarding this topic in Indian set up are also very rare. Individual Characteristics And Experiences : Thus researcher felt it is necessary to explore fathers' Personal factors It is categorized as physical (e.g. age, knowledge and attitude regarding child care so that they number of children, marital status), psychological (e.g. self- can rear their children in a better way. It helps them to esteem, self-motivation), and socio-cultural factors (e.g. adopt better ways of child care which enhance father child religion, cultural beliefs, education, occupation, monthly bonding. income, type of family) of fathers.

Objectives of The Study : Prior related behaviors It includes father`s previous The study objectives were experience and knowledge regarding child care. âTo assess the father`s knowledge regarding their role in Behaviour Specific Cognitions And Affects : child care. Perceived benefits of action Anticipated benefits or âTo assess the father`s attitude towards their role in child outcomes affect the father's plans to participate in health care. promoting behaviors and may facilitate continued practice. âTo find out the association between father`s knowledge Here it includes better cognitive development of the child, about their role in child care and selected demographic father-child bonding, growth and development of the variables. child. âTo find out the association between father`s attitude regarding their role in child care and selected Perceived barriers to action A father's perception about demographic variables. availability of time, inconvenience, expense, difficulty in âTo find out the correlation between father`s knowledge performing the activity may act as barriers imagined or and attitude regarding their role in child care. real. Here it is father`s occupation, lack of knowledge, criticism by others, lack of time, failure of expectation of Hypotheses : child etc. H1: There will be a significant correlation between father`s knowledge and attitude towards child care. Perceived self-efficacy It refers to the conviction that a H2: There will be a significant association between father`s person can successfully carry out the behavior necessary to knowledge and selected demographic variables. achieve a desired outcome. Here it is father's awareness H3: There will be significant association between father`s about immunization, feeding and safety needs of the child attitude and selected demographic variables. Activity related affect: The subjective feelings that occur Conceptual Frame Work : before, during and following an activity can influence In this study the conceptual framework has been adopted whether a person will repeat the behavior again or from the health promotion model (HPM) proposed by Nola maintain the behavior. Here it is interest demonstrated by

Keywords: Knowledge, Attitude, Fathers, Child care 64 - Roshin M.S. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science fathers to improve knowledge about child care from characteristics, and the aesthetic features of the information booklet. environment. Here the situation influence is the fathers need more pressure to learn information booklet. Interpersonalinfluences: Interpersonal influences are person perceptions concerning the behavior, beliefs, or Commitment to A Plan Of Action : attitudes of others. Here it includes family friends, mass Commitment to a plan of action involves two processes: media and health personnel. commitment and identifying specific strategies for carrying out and reinforcing the behavior. Strategies are important Situational influences: Situational influences are direct because commitment alone often results in “good and indirect influences in health promoting behaviors and intensions” and not actual performance of the behavior. include perceptions of available options, demand Here it is father's commitment in child care. Fig No: 1. Conceptual framework based on Nola J. Pender's revised Health Promotion Model

Individual Special Behaviour Behaviour Characteristics & Cognitions & Affect Outcome Experiences

Perceived benefits of action Benefits anticipated by fathers in better l cognitive development of Prior related behaviour the child l father -child bonding Father's previous l growth and development experience and knowledge regarding Immediate child care Perceived barriers to action competing demands and Father`s occupation, lack of knowledge, criticism by preferences, others, lack of time, failure of benefits &barriers expectation of child Interest in the Perceived self-efficacy health and care of children Father's awareness about immunization, feeding and safety needs of the child. Commitment to Personal factors of plan of action fathers Activity related affect Father's Physical Interest demonstrated by commitment in fathers to improve childcare Age, number of knowledge about child care children, marital status. from information booklet Health promoting Socio-cultural behaviour Interpersonal influences Religion, cultural Fathers supporting beliefs, education, Family, friends, mass and engaging in Occupation, monthly media, health personnel childcare result in income, type of family high level wellness in children Psychological Situational influences

Self-esteem, Need-pressure to learn, self-motivation information booklet

Keywords: Knowledge, Attitude, Fathers, Child care 65 - Roshin M.S. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Immediate competing demands and preferences: administered a structured knowledge questionnaire and Competing demands are that behavior over which an an attitude scale. individual has a low level of control. Analysis : Competing preferences are behaviors over which an Analysis was done by both descriptive and inferential individual has a high level of control; however this statistics on the basis of objectives and hypotheses of the control depends on the individual's ability to be self- study. The plan for data analysis is as follows: regulating or to not give in. Here it is the father's interest lKnowledge and attitude was assessed by descriptive in the health and care of the children. statistics. (Mean, frequency, percentage). lAssociation between knowledge and attitude towards Materials and Methods : demographic variables with Chi square test. In this study a descriptive research approach and lThe correlation between knowledge and attitude with descriptive exploratory research design was adopted to Karl Pearson's correlation method. assess the knowledge and attitude of 200 fathers regarding their role in child care selected areas of Mangalore. The Results : setting of the study is OPD of Justice K.S Hedge charitable Demographic Performa of fathers shows 88(44%) were in hospital and Natekal Community area. Non Probability the age group of less than 30yrs, 110 (55%) were having Sampling technique was adopted and Purposive sampling more than 2 siblings. 92 ( 46%) were on the 1st order of method was used to collect samples. The tools used in the birth, 93 (46.5%) completed Secondary school study demographic Performa to assess demographic education,106 (53%) were having private job, all were variables, attitude scale to assess the attitude of the fathers married and living with spouse, 82 (41%) fathers were and structured knowledge questionnaire to assess their having child above 2yrs. 116 (58%) belongs to the Hindu knowledge religion, 79 (39.5%) were having monthly income of

Keywords: Knowledge, Attitude, Fathers, Child care 66 - Roshin M.S. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science selected demographic variables were analyzed using Chi- sectional study conducted by Karen.F.Pridham, Joan H. square test and the hypothesis was tested at 0.05 level of Zavoral involving families of 153 infants at 4months of age significance. Result shows there is significant association was done to identify factors associated with lack of active between knowledge of fathers and selected demographic involvement of fathers in infant care in USA revealed that variables (except marital status). There is also significant most of the fathers are having unfavorable attitude association between attitude of fathers and selected regarding child care which is contradictory to the present demographic variables. study findings.

Area-wise mean, mean knowledge score, median, This study shows there is a significant correlation between standard deviation of knowledge score of the fathers. knowledge and attitude of the fathers regarding child care. n =200 It is supported by a longitudinal study done by Sl. Areas Maximum Obtained SD Mean Lauren.B.Childers to assess father's involvement on No Possible Mean Percentage children's developmental outcome in USA. Score Score Score Nutrition 3 2.24 0.68 74.67 The result shows there is significant association between Immunization 4 1.96 1.18 48.88 Growth and 4 2.05 0.91 51.13 knowledge of fathers and selected demographic variables. development (except marital status ) supported by a comparative study Toilet training 2 0.47 0.67 23.5 conducted by S.Beryl Mohan raj, Chellarani Vijayakumar, Sleep 2 0.78 0.77 38.75 play 3 1.47 0.97 48.83 Bharathy Jacob, Paul S Russell to determine the role of safety materials 2 1.01 0.82 50.25 inexperienced and experienced fathers in infants rearing in Total 20 9.96 4.50 49.78 the villages of College of Nursing Community Health Centre in CMC Frequency and percentage distribution of attitude scores of fathers. The result shows there is significant association between n =200 knowledge of fathers and selected demographic variables. Score Range Frequency Percentage Highly favourable attitude (51-75) 70 35% It was supported by a longitudinal study conducted by Favourable attitude (26-50) 127 63.5% EiriniFlouri, A Buchanan in England to assess the role of Unfavourable attitude (≤25) 3 1.5% early father involvement in children. Discussion : Conclusions : The study result shows fathers were having average The findings of this study indicated the need for educating knowledge regarding child care. This study is supported by the about child care practices. They must be motivated to comparative study conducted by S. Beryl Mohanraj, participate in the child care . There is a need of proper and Chellarani Vijayakumar, Bharathy Jacob, and Paul S Russell regular educational to determine the role of inexperienced and experienced fathers in infants rearing in the villages of College of programs to make awareness in the community about the Nursing Community Health Centre in CMC, Vellore and areas they need to improve and create better awareness also by a longitudinal study conducted by RM Post, GS among fathers in child care. Leverich , E Fergus ,R Milter , D Luckenbaugh to assess the There is a need for health personnel to take active part in father`s involvement and cognitive & behavioral outcomes educational programs in upgrading knowledge of fathers in of preterm infants in U.K. child care. The result reveals that majority of fathers had favourable attitude regarding their role in child care. Another cross

Keywords: Knowledge, Attitude, Fathers, Child care 67 - Roshin M.S. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Arnette Anderson. Paternal influence on child care and development. Journal for specialists in 2000; 2(1): 83-92 2. S. Beryl Mohanraj, Chellarani Vijayakumar, Bharathy Jacob, Paul S Russell. Role of inexperienced and experienced fathers in infant rearing. Indian Journal of Continuing Nursing education 2010; 47(49): 69-72. 3. Liat Tikotzky, Avi Sadeh. Pediatrics psychological journal 2011; 36(1): 385-397. 4. Fam Marriage J. Fathers care on child care. 2007; 13(4): 972-976. 5. Pender J Nola; Health promotion model; 1983 (revised 2002). 6. Polit DF, Hungler BP. Nursing research principles and methods. Philadelphia: J.B. Lippincott Company; 1999. 7. Tabolt L A. Principles and practice of Nursing research.1st edition. St Louis: Mosby; 1995

Keywords: Knowledge, Attitude, Fathers, Child care 68 - Roshin M.S. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Short Communication GENDER DIFFERENCES IN CHILDHOOD POISONING Pratik Vijay Tarvadi 1, Shankar M. Bakkannavar2, Vikram Palimar3, G. Pradeep Kumar4, Mahabalesh Shetty5 & Sanjeev Badiger6 1 Assistant Professor, Department of Forensic Medicine, KSHEMA, NITTE University, Mangalore 2 Assistant Professor, 3 Additional Professor, 4 Professor & HOD, Department of Forensic Medicine, Kasturba Medical College, Manipal, 5 HOD, Department of Forensic Medicine, 6 Associate Professor, Department of Community Medicine, KSHEMA, NITTE University, Mangalore, Correspondence: Pratik Vijay Tarvadi Assistant Professor, Department of Forensic Medicine, K.S. Hegde Medical Academy (kshema), NITTE University, Nitynanada Nagar, Deralakatte, Mangalore - 575 018, Karnataka, India Mobile : +91 98453 06634, Phone : +91 824 2203030, E-mail : [email protected] Abstract : Background : Accidental paediatric poisoning is a common medical emergency and also associated with a high morbidity and mortality in children. In developing countries like India, the poisoning emergencies are becoming a major cause of mortality in infants and toddlers. Among the various studies done on poisoning cases in our country, the study on poisoning is more or less only on adults and hence this study is taken up to understand the number of childhood poisoning cases (based on gender). Method : A ten year record based cross sectional study from January 1999 to December 2008 was conducted at the Department of Forensic Medicine & Toxicology, Kasturba Medical College, Manipal, to understand the magnitude of childhood poisoning cases among males and females at Kasturba Hospital, Manipal. Results : Male children were predominantly affected (male: female::1.32: 1). Most of the poisoning cases occurred at home in both the genders with boy to girl ratio based on percentage in indoor poisoning being 0.92:1 and boy to girl ratio based on percentage in outcome being 1.06:1. Conclusion : Our study examines the difference in place and outcome of poisoning among boys and girls to identify population at risk and give suggestions so as to reduce the morbidity and mortality. Keywords: paediatric, poisoning, gender

Background : in pediatric wards at various hospitals in India (5). Most Poisoning is an important health hazard and one of the common agents involved in childhood poisoning are leading causes of morbidity and mortality worldwide. paraffin, kerosene, pesticides, including insecticides, Nearly one million people are affected globally every year rodenticides, herbicides, poisonous plants, animal or (1). The mortality worldwide is estimated to be 0.6% of all insect bites, over the counter medications, prescription deaths per year as per World Health Organization (WHO). drugs, household products such as bleach, disinfectants, In India deaths due to poisoning accounts for more than detergents, cleaning agents, cosmetics and vinegar (3,4). 50,000 people every year (2). Poisoning affects all age Studies done worldwide on poisoning are more groups viz. pediatric, adult and geriatric. concentrated on the adult population and hence there is an Access this article online Over 45,000 children and inadequate data on the extremes of age groups namely Quick Response Code teenagers, worldwide, die pediatrics and geriatrics. The pediatric age group in true from poisoning each year sense is the most vulnerable group due to persisting accounting approximately aggressiveness and immaturity in the children. 123 children per day (3,4). The present study attempts to gather pediatric poisoning Poisoning constitutes 0.33 % cases in Manipal, and the associated gender differences to to 7.6 % of total admissions

Keywords: paediatric, poisoning, gender 69 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science know the incidences in female category as female foeticide to our hospital had survived while 4.7% cases had expired. is still a problem of concern in our developing country. By It was clearly noted that the increased percentage of our study we also want to formulate recommendations survived children was seen among boys (97.5%) as that could probably help to reduce the morbidity and compared to girls (92.4%) and boy to girl ratio based on mortality due to poisoning in children (general and percentage in outcome being 1.06:1, as depicted in the specifically girl child). table no. 2.

Method : Discussion : Ethical approval was obtained from the Institutional ethical We noticed in our study that, there was a higher incidence committee of Kasturba Medical College, Manipal, of poisoning amongst boys in all the age groups Karnataka, India. corroborating with other studies (5,7,8,9,10,11,12,13,14,15,16). This finding can be attributed to the more active and restless The data for the present study is a retrospective research nature of boys as compared to girls. We also found that girl undertaken at the Kasturba Hospital, Manipal, which is a predominance in the age group of 16 to 18 years, showing a tertiary care teaching hospital, situated in coastal gender reversal. This gender reversal in the age group of 16 Karnataka, South India, for a period of 10 years (January to 18 years can be attributed to the sensitive nature of the 1999 to December 2008). females in the region where they are ready to take such All the poisoning cases admitted to Kasturba Hospital, extreme steps after slightest humiliation in any forms viz. Manipal, in the pediatric age group (up to 18 years) (6) failure in the examinations, love failure, forceful marriage during the study period were included. (against their will) etc. Second factor that could be responsible during this age group is due to the hormonal The relevant data like age, sex, place of poisoning and changes that take place in girls during their post puberty outcome was obtained from the Clinical case records from period. Studies done at Pakistan (15) showed that poisoning Medical records department, Kasturba Hospital, Manipal. victims were predominately girls at all age groups, The data obtained was tabulated and analyzed using SPSS indicating the varying trends at different places. (Statistical Package for Social Services) 11 software. It was also observed in our study that a majority of Results : incidences of pediatric poisoning cases (irrespective of A total of 214 cases of poisoning in the pediatric age group gender bias) had occurred at home which clearly shows were admitted at the Kasturba Hospital, Manipal, during that parental care was not adequate and also the the period of 10 years from January 1999 to December dangerous substances were in the reach of children. Similar 2008, as depicted in the graph no. 1. findings were observed in previous studies conducted at national and international level (12,13,14,15). Hence our study In the present study, we observed that the boys (122) helps in sending across a message to all pediatricians that outnumbered the girls (92), with boy to girl ratio being every parent has to be specifically explained about the 1.3:1, as depicted in the graph no. 2. continuous parental care that children should receive and Most of the poisoning cases occurred at home in both the also keeping dangerous substances out of reach of genders, boys being 77% and girls 83.7%; boy to girl ratio children. based on percentage in indoor poisoning being 0.92:1, as Our study showed low mortality rate among study depicted in the table no. 1. population, which could be owed to the early first aid given It was observed in our study that, 95.3% of cases reported to them. In our study the survival rate was higher in boys as compared to girls, which again can be attributed to the fact

Keywords: paediatric, poisoning, gender 70 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science that less care is given to girls when compared to boys as the present norms in society are still a male preferring. The mortality rate ranged from 0.1% to 16% in other worldwide studies (12,13,14). No deaths were reported in a study conducted at Pakistan (15) and another study done in Belgaum, India on 0-4 years age group (14).

In the present study, the poisoning cases were divided based on gender differences to know the incidences in male and female categories. Though there were more number of poisoning cases seen among boys, more deaths have occurred among girls. This shows that both the genders are susceptible for poisoning; hence every child irrespective of gender requires the same amount of care.

Our study was limited to a single hospital study and hence Graph 2 : Gender distribution in pediatric poisoning cases this study needs a further research on a wide area to give a better area based findings.

Conclusion : In our study we observed that boys were affected more often than the girls and poisoning occurred inside the house. Mortality rate was low because of appropriate first aid measures taken and immediate medical intervention.

Following measures can be suggested to decrease the Table No. 1: Gender wise distribution of poisoning cases morbidity and mortality of pediatric poisoning: according to the place of Poisoning (n=214) • Parental education and awareness Gender Poisoning Total • Child resistant packaging At home Outside home • Storage of poisonous substances out of reach of Boys 94 (77.05%) 28 (22.95%) 122 (100%) Girls 77 (83.7%) 15 (16.3%) 92 (100%) children. Total 171 43 214 • Proper disposal of poisonous substance and their containers after use Table No. 2: Gender wise distribution of Outcome of • Basic health education during schooling poisoning cases (n=214) Gender Outcome Total Acknowledgements : Survived Expired I am extremely thankful to staff of Medical Records Boys 119 (97.5%) 3 (2.5%) 122 (100%) Girls 85 (92.4%) 7 (7.6%) 92 (100%) Department, Kasturba Hospital, Manipal for their kind help Total 204 (95.3%) 10 (4.7%) 214 (100%) and assistance in collecting data.

Keywords: paediatric, poisoning, gender 71 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Arun M, Nagesh KR, Palimar V, Mohanty MK. Geriatric Poisoning 10. Mattila VM. Injuries and Their Risk Factors in Finnish Adolescents. Fatalities: A Manipal Perspective. Medico-legal Update. 2005; 5(1): 1- School of Public Health. Tampere: University of Tampere. 2005. 3. 11. Harel Y, Overpeck MD, Jones DH, Scheidt PC, Bijur PE, Trumble AC, et al. 2. Agarwal P, Handa R, Wali JP. Common Poisoning of India. Journal of The Effects of Recall on Estimating Annual Nonfatal Injury Rates for Forensic Medicine and Toxicology. 1998; 15(1): 73-78. Children and Adolescents. American Journal of Public Health. 1994; 3. http://www.who.int/violence_injury_prevention/ child accessed on 84: 599– 605. 25th October 2010. 12. Brayden RM, MacLean WE, Jr., Bonfiglio JF, Altemeier W. Behavioral 4. Dutta AK, Seth A, Goyal PK, Aggraval V, Mittal SK, Sharma R, et. al. Antecedents of Pediatric Poisonings. Clinical Pediatrics Poisoning in Children: Indian Scenario. Indian Journal of Pediatrics. (Philadelphia).1993; 32: 30–35. 1998; 65: 365-370. 13. Gauvin F, Bailey B, Bratton SL. Hospitalizations for Pediatric 5. Ahronheim JC, Howland MA. Geriatric Principles. In: Goldfrank's Intoxication in Washington State, 1987–1997. Archives of Pediatrics Toxicologic Emergencies. Edited by Goldfrank, Flomenbaum, Lewin, and Adolescent Medicine. 2001; 155: 1105–1110. Howland, Hoffman, Nelson. 7th Edn. McGraw Hill Medical Publishing 14. Vasvani V, Patil VD, Spectrum of Childhood Poisoning: A Belgaum Division, USA: 2002; pp 1640-1646. Experience. Journal of Forensic Medicine and Toxicology. 1998; 15(1): 6. https://www.pediatriccareonline.org/pco/ub/view/Pediatric-Drug- 50-52. Lookup/153856/0/ Definition_of_Age_Group_Terminology accessed 15. Jan MA, Siddiqui TS, Haq IU, Khan Z. Mushroom Poisoning in Children: on 16th May 2011. Clinical Presentation and Outcome; Journal of Ayub Medical College 7. The World Health Report. World Health Organization, Geneva: 2004. Abottabad. 2008; 20(2): 99-101 8. Injuries in the European Union Statistics summary 2003–2005. 16. White SR. Pediatric Poisonings and Antidotes. In: Neonatal Pediatric Eurosafe, Vienna: 2007. Pharmacology – Therapeutic Principles in Practice. Edited by Yaffe SJ, 9. Reith DM, Pitt WR, Hockey R. Childhood Poisoning in Queensland: An Aranda 1.JV. 2nd Edn. Lippincotts Williams & Wilkins, Philadelphia: Analysis of Presentation and Admission Rates. Journal of Paediatrics 1992; pp 831-835. and Child Health. 2001; 37: 446–450.

Keywords: paediatric, poisoning, gender 72 - Pratik Vijay Tarvadi NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Short Communication MENOPAUSAL TRANSITION AMONG NORTHERN INDIAN WOMEN Vijayalakshmi S.1, Ramesh Chandrababu2 & Eilean Victoria L.3 1 Vice Principal, S.B.S College of Nursing, Shohiankalan, Fatehgarh Churian Road, Amristar, Punjab, India. 2Assistant Professor, Noor College of Nursing, Bengaluru, Karnataka, India, 3 Associate Professor, Sri Ramachandra College of Nursing, Sri Ramachandra University, Porur, Chennai, Tamilnadu, India Correspondence: Eilean Victoria L., Mobile : +91 94451 03841 E-Mail : [email protected] Abstract : According to Indian menopause society research there are about 65 million Indian women over the age of 45. Average age of menopause in around 48 yrs but it strikes Indian women as young as 30-35 years. The main aim of the study is to assess the menopausal transition among women residing at selected rural community, Punjab. The study was conducted from July 2012 to December 2012. The sample from the selected rural community and the research design used for this study was Non experimental design – descriptive survey method. The sample size selected for this study consists of 30 rural women 40-55 years of age from selected rural community at Amritsar. Purposive sampling method was used to select the samples. The tool used in this study was ZEG Berlin menopause rating scale to assess the menopausal transition. The data analysis was done using both descriptive and inferential statistics. The results reported that more prevalent symptoms were feeling tired (92.90%), headache (88.80%), joint and muscular discomfort (76.20%), physical and mental exhaustion (60.09%), sleeplessness (54.40%), depressive mood (37.30%), irritability (36%), dryness of vagina (36%), hot flushes and sweating (35.80%) and anxiety (34.50%). The rural women of Amritsar, Punjab experience high prevalence of menopausal symptoms. The high percentage and scores of MRS were observed in perimenopausal and postmenopausal women. Keywords: Menopausal Transition, Rural Community Women, Northern India

Introduction : women life and is caused by aging of ovaries which leads to Middle age is one of the turning point in one's life as decline in the production of ovarian gonadotrophins, it brings many changes. It roughly starts in the early estrogen and progesterone. The deficiency of these forties, when for most of the people it is the best period in hormones elicits various somatic, vasomotor, sexual and their life when their achievement is at the highest point. psychological symptoms that impair overall quality of life of Midway between the challenges of adulthood and despair women. of old age, comes the compulsory change menopause in Menopause is a difficult process. Women going through women. Middle age in women includes the gradual the menopause transition may experience a variety of winding down of the reproductive system and ending of symptoms ranging from vasomotor symptoms to sleep the child bearing years. disturbance, mood disorders, loss of sexual desire and Access this article online Menopause is permanent vaginal dryness. The symptoms can make it a considerable Quick Response Code cessation of menstruation struggle for those already dealing with their hectic lives. As at the end of reproductive many as two-third of all women report vasomotor life due to loss of ovarian symptoms and over 85% report at least one menopausal f o l l i c u l a r a c t i v i t y . symptom as transition through menopause. The study M e n o p a u s e i s a findings showed that 25% of women whose symptoms physiological event in the were severe, the resulting discomfort greatly diminish the

Keywords: Menopausal Transition, Rural Community Women, 73 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science quality of life (Randolph JF, et. al., 2004). sample size selected for this study consists of 30 rural women 40-55 years of age from selected rural community According to Indian menopause society research there are at Amritsar. Purposive sampling method was used to select about 65 million Indian women over the age of 45. Average the samples. The tool used in this study was background age of menopause in around 48 yrs but it strikes Indian variables and ZEG Berlin menopause rating scale to assess women as young as 30-35 years. Menopausal health the menopausal transition. demand is a higher priority in Indian scenario. The goal of INDIAN MENOPAUSE SOCIETY is to enhance awareness Description of the tool : about menopause and aging through public health and Section-I: It is a structured interview schedule which education activities. The year 2011 of Indian menopause consists of 2 parts. society is dedicated to peri and post menopausal women lPart-A consists Background variables such as age, who had been suffering in silence; the theme is “HELPING marital status, educational status of woman, HER BREEZE THROUGH MENOPAUSE” (Srivastava Saroj, occupational status of woman, type of family, family 2011). socioeconomic status, type of diet and Distance of health care facility from house. Menopause is natural and should not affect a woman's lPart-B consists of Clinical variables such as parity of enjoyment of life. Menopause fills many people with woman, number of health visits per year, suffering from unease. But the best way to deal with it is to understand it. any menopausal symptoms, suffering from any chronic Many women have difficulties in coping with the emotional illness, taking hormone replacement therapy, taking and physical strain of menopause, while others are calcium supplements and doing any exercise. relatively symptom-free. The study will help to identify menopausal symptoms and plan the future research for Section – II educational program. The ZEG Berlin Menopause rating scale (MRS) consists of 11 menopausal symptoms. It includes 5 columns for Materials and methods responses (None, mild, moderate, severe and very severe) Statement of the problem with a score of 0, 1, 2, 3 and 4 respectively. Total score is 44. A descriptive study to assess the menopausal transition For the present study the MRS English version was among women residing at selected rural community at translated into local language Punjabi. Amritsar, Punjab. Menopause symptoms Score Percentage Objectives of the study No symptoms 0 0% Mild symptoms 1-11 1-25% lAssess the menopausal transition among women Moderate symptoms 12-22 26-50% residing at selected rural community. Severe symptoms 23-33 51-75% Very severe symptoms 34-44 76-100% lFind out the association between menopausal transition and selected background variables. Validity and reliability of the tool :

?Hypothesis The validity of the tool was established in consultation with Ho1: There is a statistically significant association between nursing experts. The reliability was established by test- menopausal transition and selected background retest method and the Karl Pearson's correlation co- variables. efficient formula was used to find the stability and consistency of the tool. It is found to be reliable (0.81) at Methodology : the 0.01 level. The research design used for this study was Non experimental design – descriptive survey method. The Method of data collection : The study was conducted at chetanpura rural community,

Keywords: Menopausal Transition, Rural Community Women, 74 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Amritsar. Written permission was obtained from the vagina (40%), sleep problems (36.66%), irritability medical officer and oral consent was obtained from the (36.66%), bladder problems (36.66%), anxiety (30%) and subjects after explaining the purpose of the study. The data hot flush and sweating (26.66%). was collected for a period of 1week from 30 women with Association between variables: 40-55years of age. Descriptive survey was conducted with validated tools. Demographic variables and ZEG Berlin The data presented in table-IV revealed that significant menopause rating scale were used to collect the data for association was found between menopausal transition and assessing menopausal transition among rural women. the following background variables such as menopausal Collected data was coded, tabulated and analyzed by status (X²=15.089, P=0.020), chronic illness status descriptive and inferential statistics. Data was put to (X²=16.560, P=0.035) and monthly family socio economic statistical inferences by using SPSS software package. status (X²=12.473, P=0.052). There is no significant association found between menopausal transition and the Results : following variables such as age, marital status, educational Background variables: status of woman, occupational status of woman, type of Majority of the women were belongs to 46-51years family, type of diet, distance of health care facility from (43.3%), married (80%), illiterate and having primary house, parity of woman, number of health visits per year, education (36.7%), house wife (56.7%) and vegetarian intake of HRT and calcium supplements and doing (83.3%). The data revealed that majority were belongs to exercises. joint family (50%), having 1-3 children (70%) and monthly Discussion : family socio economic status upto 30000 and above The present study revealed that percentages of (43.3%). Most of them were perimenopausal (43.3%), menopausal symptoms were significantly high in suffering from hypertension (33.3%), not taking perimenopausal and postmenopausal women. These HRT(86.7%), not taking calcium supplements(53.3%) and findings are consistent with the findings of Rahman et al not doing any exercise(76.7%). Total 40% of women were (2010), menopausal symptoms assessment among middle taking health checkup 5-6 times per year. Distance of age women in Bangladesh. The results reported that more health care facility from the house was less than 5Km for prevalent symptoms were feeling tired (92.90%), headache most of the women (40%). (Table-I) (88.80%), joint and muscular discomfort (76.20%), physical Menopausal transition: and mental exhaustion (60.09%), sleeplessness (54.40%), Majority of women (66.7%) are having moderate level of depressive mood (37.30%), irritability (36%), dryness of symptoms, 20% are having severe symptoms and few vagina (36%), hot flushes and sweating (35.80%) and (13.3%) are having mild symptoms. The mean value is anxiety (34.50%). 17.87 and SD value is ± 6.279 (Table-II, Fig1). Priya Sharma et al (2011) conducted a study on assessment Table-III revealed that prevalence of menopausal of knowledge on perimenopause, symptoms experienced symptoms among women. The findings shows that most and practices of perimenopausal women. The symptoms severe level of symptoms were sleep problems (26.66%), which were always present were frequent urination bladder problems (26.66%), anxiety (23.33%), irritability (65.40%), backpain (54.80%), weight gain (49%), night (20%) and dryness of vagina (20%). More prevalent sweats (49.2%), tiredness (47.1%), joint pains (44.20%), moderate level of symptoms were heart discomfort mood swings (41.30%) irritability (40.40%), feel tingling in (46.66%), depressive mood (43.33%), joint and muscular hands and feet (40.40%), difficulty in concentrating discomfort (43.3%), sexual problems (40%), dryness of (39.40%), poor memory (36.48%), difficulty in falling asleep

Keywords: Menopausal Transition, Rural Community Women, 75 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

(36.48%), feel depressed (33.60%) and sudden sensation of S.No Background variables Frequency Percentage(%) 5 Type of family heat with flushing (45.12%). 5.1 Nuclear family 12 40 5.2 Joint family 15 50 Conclusion : 5.3 Extended family 3 10 The rural women of Amritsar, Punjab experience high 6 Monthly family socio economic status (in Rs) prevalence of menopausal symptoms. The high percentage 6.1 Up to 5000 10 33.3 6.2 Up to 10000 5 16.7 and scores of MRS were observed in perimenopausal and 6.3 Up to 15000 2 6.7 postmenopausal women. The severity of symptoms were 6.4 Up to 30000 and above 13 43.3 7 Type of diet more distressing in perimenopausal and postmenopausal 7.1 Vegetarian 25 83.3 women than premenopausal women. 7.2 Non vegetarian 5 16.7 8 Distance of health care facility from house Acknowledgement : 8.1 Less than 5km 12 40 8.2 6-10Km 6 20 The author expresses deep sense of gratitude to Research 8.3 11-15Km 7 23.3 guide Prof.Dr. Eilean Victoria, M.Sc(N).,PhD., Reader, Sri 8.4 More than 16Km 5 16.7 Ramachandra University, Porur, Chennai for her endless 9 Parity of women( number of children) 9.1 Nulliparous 1 3.3 guidance, thoughtful comments, invaluable suggestions 9.2 1-3 21 70 and constant encouragement throughout the period of 9.3 4-6 8 26.7 9.4 7 and more 0 0 study; appreciate the cooperation of Medical officer, 10 Number of health visits per year Chetanpura, Amritsar; extend heartfelt thanks to women 10.1 1-2 10 33.3 for their participation; and appreciate the work of 10.2 3-4 6 20 10.3 5-6 12 40 Computer Hut staffs. Author likes to acknowledge all those 10.4 7 and more 2 6.7 who have helped directly and indirectly to make the 11 Do you experience following symptoms 11.1 Pre menopause (mood 5 16.7 fruition of this study possible. swings, anxiety, Table-I: Frequency and percentage distribution of irritability and nausea) background variables of women regarding menopausal 11.2 Perimenopause (Irregular 13 43.3 transition: (n=30) menses, hot flush, sweating and pre S.No Background variables Frequency Percentage(%) menopause symptoms) 1 Age in years 11.3 Post Menopause (Period 12 40 1.1 40-45 years 11 36.7 after Complete stoppage 1.2 46-51 years 13 43.3 of menstruation for one 1.3 <52 years 6 20 complete year) 2 Marital status 12 Are you suffering from any chronic illness 2.1 Unmarried 1 3.3 12.1 Diabetes mellitus 2 6.7 2.2 Married 24 80 12.2 Hypertension 10 33.3 2.3 Widowed 5 16.7 12.3 Diabetes mellitus 0 0 2. Divorced 0 0 and Hypertension 3 Educational status of woman 12.4 Cardio vascular diseases 2 6.7 3.1 Illiterate 11 36.7 12.5 Cancer and osteoporosis 0 0 12.6 Other illness 9 30 3.2 Primary education 11 36.7 12.7 No illness 7 23.3 3.3 Secondary education 1 3.3 13 Are you taking hormone replacement therapy 3.4 Higher secondary 4 13.3 13.1 Yes 4 13.3 3.5 Graduate and above 3 10 13.2 No 26 86.7 4 Occupational status of the woman 14 Are you taking calcium supplements 4.1 Self-employee 2 6.7 14.1 Yes 14 46.7 4.2 Government 2 6.7 14.2 No 16 53.3 4.3 Private employee 3 10 15 Are you doing any exercise 4.4 Daily wage labour 6 20 15.1 Yes 7 23.3 4.5 House wife 17 56.7 15.2 No 23 76.7

Keywords: Menopausal Transition, Rural Community Women, 76 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table-II: Frequency, percentage, mean, median and standard deviation of women regarding menopausal transition (n=30) S.no Symptoms level Frequency Percentage Mean Median Standard deviation 1 Mild symptoms 4 13.3% 2 Moderate symptoms 20 66.7% 17.87 19.00 ± 6.279 3 Severe symptoms 6 20%

Table-III- Menopause rating scale(MRS) Item Menopausal None Mild Moderate Severe Very severe No. Symptoms F % F % F % F % F % 1 Hot flush and sweating 8 26.66 8 26.66 8 26.66 5 16.66 1 3.33 2 Heart discomfort 9 30 6 20 14 46.66 1 3.33 0 0 3 Sleep problems 4 13.33 6 20 11 36.66 8 26.66 1 3.33 4 Depressive mood 1 3.33 11 36.66 13 43.33 3 10 2 6.66 5 Irritability 4 13.33 7 23.33 11 36.66 6 20 2 6.66 6 Anxiety 2 6.66 11 36.66 9 30 7 23.33 1 3.33 7 Physical and mental exhaustion 5 16.66 13 43.33 7 23.33 5 16.66 0 0 8 Sexual problems 4 13.33 12 40 12 40 2 6.66 0 0 9 Bladder problems 6 20 5 16.66 11 36.66 8 26.66 0 0 10 Dryness of vagina 7 23.33 4 13.33 12 40 6 20 1 3.33 11 Joint and muscular discomfort 5 16.66 4 13.33 13 43.33 5 16.66 3 10

Table-IV: Association between menopausal transition of women with their selected background variables: (n=30) S.no Demographic variables Mild Moderate Severe Chi square p-value F % F % F % value 1 Age in years 1.1 40-45 years 3 27.3 7 63.6 1 9.1 1.2 46-51 years 1 7.7 9 69.2 3 23.1 3.991 1.3 <52 years 0 0 4 66.7 2 33.3 NS 0.407 2 Marital status 2.1 Unmarried 0 0 1 100 0 0 2.2 Married 4 16.7 15 62.5 5 20.8 2.3 Widowed 0 0 4 80 1 20 1.571 2.4 Divorced 0 0 20 66.7 6 20 NS 0.814 3 Educational status of woman 3.1 Illiterate 2 18.2 6 54.5 3 27.3 3.2 Primary education 1 9.1 9 81.8 1 9.1 3.3 Secondary education 0 0 0 0 1 100 8.034 0.430 3.4 Higher secondary 1 25 2 50 1 25 NS 3.5 Graduate and above 0 0 3 100 0 0 4 Occupational status of the woman 4.1 Self-employee 0 0 1 50 1 50 4.2 Government 0 0 2 100 0 0 4.3 Private employee 0 0 1 33.3 2 66.7 12.103 0.147 4.4 Daily wage labour 2 33.3 2 33.3 2 33.3 NS 4.5 House wife 2 11.8 14 82.4 1 5.9 5 Type of family 5.1 Nuclear family 1 8.3 7 58.3 4 33.3 4.017 0.404 5.2 Joint family 3 20 11 73.3 1 6.7 NS 5.3 Extended family 0 0 2 66.7 1 33.3

Keywords: Menopausal Transition, Rural Community Women, 77 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

S.no Demographic variables Mild Moderate Severe Chi square p-value F % F % F % value 6 Monthly family socio economic status (in Rs) 6.1 Up to 5000 2 20 5 50 3 30 6.2 Up to 10000 1 20 4 80 0 0 12.473 0.052 6.3 Up to 15000 0 0 0 0 2 100 S 6.4 Up to 30000 and above 1 7.7 11 84.6 1 7.7 7 Type of diet 7.1 Vegetarian 4 16 17 68 4 16 2.040 0.361 7.2 Non vegetarian 0 0 3 60 2 40 NS 8 Distance of health care facility from house 8.1 Less than 5km 3 25 7 58.3 2 16.7 8.2 6-10Km 1 16.7 5 83.3 0 0 6.574 0.362 8.3 11-15Km 0 0 4 57.1 3 42.9 NS 8.4 More than 16Km 0 7 4 80 1 20 9 Parity of women( number of children) 9.1 Nulliparous 0 0 0 0 1 100 9.2 1-3 2 9.5 16 76.2 3 14.3 6.107 0.191 9.3 4-6 2 25 4 50 2 25 NS 9.4 7 and more 0 0 0 0 0 0 10 Number of health visits per year 10.1 1-2 1 10 8 80 1 10 10.2 3-4 2 33.3 2 33.3 2 33.3 5.850 0.440 10.3 5-6 1 8.3 9 75 2 16.7 NS 10.4 7 and more 0 0 1 50 1 50 11 Do you experience following symptoms 11.1 Pre menopause (mood swings, 3 60 2 40 0 0 anxiety, irritability and nausea) 11.2 Perimenopause (Irregular menses, 0 0 9 69.2 4 30.8 15.089 0.020 hot flush, sweating and pre menopause symptoms) 11.3 Post Menopause (Period after 1 8.3 9 75 2 16.7 S Complete stoppage of menstruation for one complete year) 12 Are you suffering from any chronic illness 12.1 Diabetes mellitus 0 0 2 100 0 0 12.2 Hypertension 1 10 7 70 2 20 12.3 Diabetes mellitus and Hypertension 0 0 0 0 0 0 16.560 0.035 12.4 Cardio vascular diseases 0 0 0 0 2 100 S 12.5 Cancer and osteoporosis 0 0 0 0 0 0 12.6 Other illness 3 0 4 77.8 2 22.2 12.7 No illness 0 42.9 4 57.1 0 0 13 Are you taking hormone replacement therapy 13.1 Yes 0 0 2 50 2 50 2.885 0.236 13.2 No 4 15.4 18 69.2 4 15.4 NS 14 Are you taking calcium supplements 14.1 Yes 0 0 11 78.6 3 21.4 4.085 01.30 14.2 No 4 25 9 56.2 3 18.8 NS 15 Are you doing any exercise 15.1 Yes 1 14.3 5 71.4 1 14.3 0.186 0.911 15.2 No 3 13 15 65.2 5 21.7 NS

Keywords: Menopausal Transition, Rural Community Women, 78 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Fig3: Percentage distribution of women regarding level of menopause symptoms Fig1: Percentage distribution of women according References: to their age 1. Syamala TS, Sivakami M. Menopause: An emerging issue in India. Economic and political weekly. 2005 Nov 19; 40. (47): 4923. 2. Shahedur R, Faizus S and Asif I. Menopausal symptoms assessment among middle age women in Kushtia, Bangladesh. BMC Research Notes. 2011; 4(188): 1-4. Available from http://www.biomedcentral. com/1756-0500/4/188. 3. Priya Sharma, Maxie Andrade, Bharathi R Nayak. Assessment of knowledge on perimenopause, symptoms experienced and practices of perimenopausal women. Prism's Nursing Practice. 2012; 7(2-3): 51- 62. 4. Kala Bharthi S, Kalavathi S. Menopausal transition. Nightingle nursing times. 2010; 6. (3): 37-38, 41. 5. Sharda Sidhu, Avneet Kaur, Mandeep Sidhu. Age at menopause in educated women of Amritsar. J. Hum. Ecol. 2005; 18. (1): 49-51. 6. Price SL, Storey S, Lake M. Menopause experiences of women in rural areas. J Adv Nurs. 2008; 61. (5): 503-511. 7. Sengupta A. The emergence of the menopause in India. Climacteric. Fig2: Percentage distribution of women according to 2003; 6: 92-95. their menopausal status 8. Singh A, Arora AK. Profile of menopausal women in rural north India. Climacteric. 2005; 8. (2): 177-184.

Keywords: Menopausal Transition, Rural Community Women, 79 Northern India - Eilean Victoria L. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Short Communication A COMPARATIVE STUDY ON COPING STRATEGIES AND SENSE OF COHERENCE AMONG CAREGIVERS OF MENTALLY AND NEUROLOGICALLY ILL PATIENTS IN KASTURBA HOSPITAL, MANIPAL, KARNATAKA. Rigi George1, Asha Nayak2 & Anjalin D'Souza3 1 M.Sc. (N) Student-2010-12 batch, 2 Assistant Professor, Department of Psychiatric/Mental Health Nursing, 3 Assistant Professor, Department of Childl Health Nursing, Manipal College of Nursing Manipal, Manipal University, Manipal, Udupi, Karnataka - 576 104 Correspondence: Asha Nayak Assistant Professor, Department of Psychiatric/Mental Health Nursing, Manipal College of Nursing Manipal, Manipal University, Manipal, Udupi, Karnataka - 576 104 Mobile : +91 94482 52940 E-mail : [email protected] Abstract : Introduction : Diseases take a toll not only on those affected, but also on the ones around them. Regardless of language, culture or country caregiving has become an everyday part of life for millions of people around the globe. Though differently named on each continent, these millions of 'carers' or 'caregivers' provide care to family members ,partners or friends each year because they are sick, elderly or have a disability. This cross-sectional study was undertaken to assess the coping strategies and sense of coherence among caregivers of patients with mental and neurologic illness. Methods : Comparative, descriptive study design was used. The study was conducted among 40 caregivers of clients who were admitted in psychiatric and neurologic wards of Kasturba Hospital, Manipal. Tools used were demographic proforma, coping scale and sense of coherence-29 scale. Results : Findings showed that there was no significant difference in the coping strategies and sense of coherence of caregivers of mentally and neurologically ill patients (p>0.05). The study also revealed that there was no association between sense of coherence and coping strategies of caregivers of mentally ill patients (p=1). Conclusion : Both the caregivers of mentally and neurologically ill patients used almost same coping strategies such as substance abuse and denial. Both the caregivers of mentally and neurologically ill patients considered caring their relative during illness is meaningful. The study highlights the need for family interventional programs to address the specific concern , related to coping and sense of coherence of caregivers. Keywords : Caregivers, Coping , Sense of Coherence, Mentally and Neurologically ill patients.

Introduction: objectives, purpose to be mentioned they are sick, elderly or have a disability. The care they Diseases take a toll not only on those affected, but also on provide is unpaid or often unrecongnized and the ones around them1. Regardless of language, culture or undersupported. In most countries, family care is the country caregiving has become an everyday part of life for primary means of caregiving with immediate or extended millions of people around family rather than institutions2. The objectives of the study Access this article online t h e g l o b e . T h o u g h is to assess the sense of coherence and coping strategies of Quick Response Code differently named on each caregivers of clients with mentally ill and neurologically ill continent, these millions of and to compare the coping strategies and sense of 'carers' or 'caregivers' coherence of caregivers of mentally and neurologically ill provide care to family patients members ,partners or Materials and methods: friends each year because After obtaining the administrative permission from the

Keywords: Caregivers, Coping, Sense of Coherence, Mentally 80 and Neurologically ill patients. - Asha Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science authority ethical clearance was obtained . Consent was Coping Scale is a self reported rating scale comprised of taken from participants of the study twenty six questions. The maximum score was 130 and minimum score was 26. Based on the total scores obtained, Fourty caregivers of patients diagnosed as paranoid the subjects were classified into three categories- Low schizophrenia, severe depression with or without coping: 26-60, moderate coping: 61-95, High coping: 96- psychotic symptoms, recurrent depressive disorder, 130. dysthymia, psychosis and bipolar affective disorder according to ICD 10 criteria were selected from psychiatric Sense Of Coherence Scale is a standardized tool of 29 items ward and fourty caregivers of patients diagnosed as stoke which is scored in a seven point rating scale. The maximum were selected from neurologic wards of KH, Manipal. score was 203 and minimum score was 29. The language Caregivers were above 20 years , living with the patient for validity was determined by giving the translated Kannada atleast one year and taking care of the patients at home and Malayalam version of tools to language experts and and hospital was included in the study. Caregivers having translated back to English.. Descriptive statistics (mean, chronic physical illness, past/current psychiatric illness, mean percentage, Standard deviation ) and inferential unwilling to participate in the study and those who were statistics (Independent sample t-test, chi-square) were illiterate were excluded from the study. used for the analysis. Results: Tables Table 1: Frequency and percentage distribution of sample characteristics of caregivers of mentally and neurologically ill patients n = 40+40=80

Sample characteristics Caregivers of Caregivers of mentally ill neurologically patients ill patients f % f % Age in years 20-30 11 27.5 13 32 31-40 11 27.5 11 27.5 41-50 7 17.5 9 22.5 51-60 8 20 4 10 61 and above 3 7.5 3 7.5

Gender Male 22 55 21 52.5 Female 18 45 19 47.5

Marital status Married 28 70 27 67.5 Single 9 22.5 12 30 Divorced 1 2.5 0 0 Widowed 2 5 1 2.5

Religion Hindu 38 95 38 95 Christian 1 2.5 0 0 Muslim 1 2.5 2 5

Keywords: Caregivers, Coping, Sense of Coherence, Mentally 81 and Neurologically ill patients. - Asha Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Sample characteristics Caregivers of Caregivers of mentally ill neurologically patients ill patients f % f % Educational level Illiterate 1 2.5 0 0 Primary 2 5 2 5 Middle school 8 20 5 12.5 High school 14 35 17 42.5 Secondary school 6 15 5 12.5 Diploma 9 22.5 9 22.5 Graduate 0 0 2 9

Occupation Unemployed 15 37 13 32.5 Unskilled worker 17 42.5 13 32.5 Office worker 7 17.5 8 20 Professional 1 2.5 6 15

Monthly family income in Rs. < 2000 20 30 15 37.5 2000- 5000 10 25 9 22.5 5001- 8000 4 10 3 7.5 8001-11,000 4 10 4 10 11,000 2 5 9 22.5

Relationship with the client Parents 14 35 19 47.5 Son/Daughter 4 10 5 12.5 Siblings 9 22.5 12 22.5 Spouse 7 17.5 1 30 Others 6 15 3 7.5

Type of family Joint 28 70 24 60 Nuclear 12 30 15 37.5 Extended 0 0 1 2.5

Place of living Urban 33 32.5 28 70 Rural 7 17.5 12 30

Keywords: Caregivers, Coping, Sense of Coherence, Mentally 82 and Neurologically ill patients. - Asha Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 2: Frequency and percentage distribution of sample characteristics of mentally and neurologically ill patients n =40+40=80 Sample characteristics Mentally ill Neurologically patients ill patients f % f % Age in years 20-30 14 35 4 10 31-40 9 22.5 3 7.5 41-50 3 7.5 9 22.5 51-60 8 20 13 32.5 61 and above 6 15 11 27.5

Duration of illness in years Less than 2 20 50 21 52.5 > 2-5 20 50 19 47.5

Duration of present hospitalization in weeks Less than 2 33 82.5 33 82.5 >2-4 7 17.5 7 17.5 Number of hospitalizations One 11 27.5 15 37.5 Two 12 30 12 30 Three 9 22.5 6 15 More than three 8 20 7 17.5

Table 3: Mean percentage and standard deviation of domains of coping strategies among caregivers of mentally and neurologically ill patients n=40+40=80 Domains No.of Maximum Caregivers of Caregivers of Items possible mentally ill neurologically score patients ill patients f % f % Active coping 3 15 10.47 3.02 10.47 3.02 Venting 3 15 9.20 2.37 9.67 2.30 Self distraction 3 15 9.45 3.54 8.77 2.36 Denial 3 15 10.95 2.55 10.57 2.44 Emotional support 3 15 9.07 3.53 8.90 2.79 Substance abuse 2 10 17.85 4.20 17.25 3.94 Spiritual support 2 10 6.97 2.45 6.77 2.22 Planning 2 10 6.55 2.87 6.52 2.45 Positive reframing 3 15 9.85 2.90 9.50 2.39 Self blame 2 10 6.57 2.25 6.67 1.52 Total 96.93 95.07

Keywords: Caregivers, Coping, Sense of Coherence, Mentally 83 and Neurologically ill patients. - Asha Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Table 4: Mean percentage and standard deviation of domains of sense of coherence among caregivers of mentally ill and neurologic patients n=40+40=80 Domains No.of Maximum Caregivers of Caregivers of Items possible mentally ill neurologically score patients ill patients Mean SD Mean SD Comprehensibility 11 77 57.23 12.88 58.44 12.43 Manageability 10 70 63.07 12.46 67.60 10.97 Meaningfulness 8 56 65.80 9.46 70.21 10.08 Total 96.93 95.07

Table 5: Comparison of coping and sense of coherence between caregivers of mentally and neurologically ill patients n=40+40=80 Variables df 't' value 'p' value Coping 78 0.392 0.696 Sense of coherence 78 1.005 0.318 *significant at p < 0.05 level

Discussion : appeared to be low concerning meaningfulness, which The present study findings are supported by the previous probably makes coping with hardship still harder. Findings study conducted by Eaton (2011) to examine the coping suggested that individuals with low Sense of Coherence strategies of family members of hospitalized psychiatric scores had certain difficulties in coping with their patients showed that the common coping strategies used situation7. by family members were substance abuse, avoidance, and Now a days, the treatment is pointed out not only to the spirituality5. client, but the whole family. Sense of Coherence scale can Binil V (2008) conducted a correlative study to assess be used as a baseline measurement for detecting the burden and coping strategies among the caregivers of diseases or illness which may threaten the individual. So patients with affective disorders in Kasturba Hospital and the nurses can use this tool as a daily basis both in the A.V Baliga Hospital, Karnataka which contradicts the hospital and in the community settings. findings of the present study . Out of 100 caregivers, 32 % of Nurses who are caring for mentally ill and stroke clients to caregivers were found to be using medium coping and 68 % be sensitive to family caregivers needs and should give were using high coping. Mean percentage score was timely advice to the caregivers. The concepts of caregiving highest ie 86% in the area of planning. Lowest mean and effects of long term illness to the family members percentage score ie 34% was in humour, substance use and should incorporate into the nursing curriculum. Hence it behavioural disengagement 6. helps the students to administer self reported Nilsson , Axelsson ,Gustafson , Lundman , Norberg (2001) questionnaires to the client and family and to identify them conducted a study on well-being, sense of coherence, and very earlier and to sensitize future professionals in this burnout in stroke victims and spouses during the first few area. months after stroke in Sweden which contradicts the The nurse administrators of mental health services should findings of the present study. Findings showed that the be aware of the needs of the carers of patients having long scores of the components composing the Sense of term illness and formulate policies which enforces mental Coherence showed that four stroke victims and one spouse

Keywords: Caregivers, Coping, Sense of Coherence, Mentally 84 and Neurologically ill patients. - Asha Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science health professionals to include psychosocial interventions Conclusion : in their day to-day interventional activities with the In summary, the present study has shown that there was no patients and caregivers , both in hospital and in the significant difference between sense of coherence and community settings. They can also include coping scale and coping experienced by caregivers of patients with mental Sense Of Coherence scale mandatory for client and neurological illness. Future studies can be replicated by assessment, so the client has a better prognosis in terms of random sampling method ,on different groups of mentally holistic care. ill patients and longitudinal studies can also be conducted to find out the pattern of coping and sense of coherence Nurses can expand the studies in the area of sense of over time. coherence and see how it can be used in better quality care of the client and helpful for the early identification of We acknowledge all the subjects who participated in the illness. study willingly.

References : 1. Emotional support is the most important form of care [Internet]. Times Of India. 2011 Jul 24. Available from:http://articles. timesofindia.indiatimes.com › Collections. 2. Caring for the caregiver: Why your mental health matters when you care for others. World Federation For Mental Health. [Internet]. 2010 [updated Oct 18;cited Nov 10].Retreived from url:http:// www.wfmh.org. 3. Creado DA, Parkar SR ,Kamath RM .Burden and coping of caregivers in relation to the level of functioning in patients with chronic schizophrenia. Indian J Psychiatry.2006 Jan;48(1):27-33. 4. Van M, Hinojosa MS, Rittman MR. Influence of sense of coherence on caregiver burden and depressive symptoms at 12 months post- stroke,2008 May-Jun;15(3):272-82. Available from: http:// web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid =15&hid=112 &sid=ffc8d14b-e981-40dd-8762-6f958ffe0172% 5. Eaton PM, Davis BL, Hammond PV, Condon EH, McGee ZT. Coping Strategies of Family Members of Hospitalized Psychiatric Patients. Nursing Res and Pract. 2011 .Available from: www.hindawi.com/ journals /nrp/2011/ 392705/ 6. Binil V .A correlative study of burden and coping strategies among the caregivers of patients with affective disorders in selected hospitals of Udupi district, Karnataka.[M.Sc thesis].August 2008.Manipal:Manipal University. 7. Nilsson I, Axelsson K, Gustafson Y, Lundman B, Norberg A. Well-being, sense of coherence, and burnout in stroke victims and spouses during the first few months after stroke.[Internet].Scand J Caring Sci.[updated 2001;cited 2002]Available from:http:// web.ebscohost.com.sweden

Keywords: Caregivers, Coping, Sense of Coherence, Mentally 85 and Neurologically ill patients. - Asha Nayak NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Short Communication NURSING ASPECTS IN CARE OF PATIENTS WITH DEMENTIA Linu Sara George1 & Asha K. Nayak2 Access this article online 1Professor, 2Assistant Professor, Department of Psychiatric Nursing, Quick Response Code Manipal College of Nursing, Manipal University, Manipal - 576 104, India. Correspondence: Linu Sara George, Phone: +91 820 22462(0), Mobile : +91 98456 02400. E-mail : [email protected] Abstract : Dementia is one of the major disorders existing in our population. The nurse is responsible to plan the activities which will help to improve the behavior of clients and thereby reduce the complications. Nurses working with dementia clients should perform an analysis of client's ability to perform activities of daily living (ADL Keywords: Dementia, nursing care, assessment

Introduction: encouraged to undertake the activity on his/her own and Nursing is often involved in the development and help given when necessary. Assessment of activities of implementation of therapeutic activities. For people with daily living includes: dementia, activities are designed to prevent behaviour lPersonal ADL: Activities concerning self care. For eg problems, to provide some meaningful purpose of the day :feeding, dressing and Bathing to maintain and restore holistic health and function, lInstrumental ADL Activities concerning home promote socialization, pleasure and a positive sense of self. management. eg: cooking, cleaning, shopping Nurses working with dementia clients should perform an lProfessional ADL: Ability to perform his /her analysis of client's ability to perform activities of daily professional work to his /her customary ability living(ADL). After careful assessment of the sufferers, ADL lLeisure ADL: Ability to participate in the usual leisure help should be given to the sufferer where there is activities of the religious places. handicap. At all times the demented client should be

Problems/Needs Nursing Management A. Physical problems : 1. Urinary incontinence or inappropriate urination Other possible causes of lAvoid giving the dementia patients fluids after 6.00 p.m. at night and then the patient be incontinence should be identified toileted prior to being taken to bed. before contributing the problems lIf nocturnal incontinence continues to be a problem, it might be necessary to toilet to dementia. half way through the night. lIf cold cause recurrent urinary tract infection and that in itself could lead to other problems with regard to the patients care. The only solution which could give some relief to this distressing condition is regular toileting lLocate bed near a bathroom when possible.Take patient to the toilet at regular intervals. lEstablish bladder /bowel training programme lPromote patient participation to level of ability. 2. Faecal smearing: This is due to constipation and lProvide the patient with laxative improper evacuation of his or lArrange for regular toileting. Regular bowel evacuation does indeed relieve this condition her bowel to a fair extent. l Maintain personal hygiene. lAdequate bowel elimination is essential for physiologic functioning and daily comfort of older clients.

Keywords: Dementia, nursing care, assessment - Linu Sara George 86 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

lEncourage adequate fluid intake during the day, diet high in fiber and fruit juices lProvide good skin care lRecord frequency of voiding/bowel movements 3. Lack of personal hygiene lHelp him to brush and take bath. lGive back massage to prevent bed sore. lChange position. lObserve skin for injuries, bruises or abrasion. 4. Nutritional Problems Changing in eating pattern is very lAssess patients/families knowledge of nutritional needs important to deal during the care lAsk likes & dislikes. of dementia patients. This change lDon't make the patient to hurry up. Provide enough time for eating may lead to weight loss or lEnsure adequate hydration. Hence the patient can be given with diluted juices because weight gain. The dementia they are palatable and provide needed calories. suffers can indulge in lProvide roughage and green leafy vegetables inappropriate feeding habits such l Provide finger foods as stuffing their mouth with hot lObserve swallowing ability, monitor oral activity food resulting in burns or choking. They often suffer from dehydration because they cannot recognize the discomfort of thirst or remember when they had their last drink 5. Impaired sleep: lDiscourage day time sleep lKeep him busy with activities / exercises lEncourage warm bath at night lKeep the room calm. lAllow to do some interested activities like reading books etc. lIncrease interaction time between patient and family/staff during day lAvoid use of continuous restraints lEvaluate level of stress/orientation as day progresses lAdhere to regular bed time schedule lReduce fluid intake in the evening B. Emotional problems Encourage the family members to be with the patient. lListen to the patient's feelings. lGive reassurance to the client. 1. Anxiety 2. Wandering : Wandering is defined as moving The nurses observe patients carefully to identify situations that contribute to wandering about in an apparently aimless or behaviour. The various points to deal the wandering behaviours are: disoriented manner. Wandering is lProvide familiar objects, signs and pictures a behaviour that causes great lThe elderly person must always be secured and protected under some ones observation concern to care givers. and protected to prevent wandering away from home. lDecrease excessive stimulation lDecrease stress in the environment especially during the night. lProvide meaningful activity. lSafe areas can be provided where patients can move freely. lThe physical environment can provide safety and security and promote a degree of orientation than can help lessen anxiety and agitation and promote functions confused elders. C. Cognitive impairment 1. Confusion lAssess degree of cognitive impairment lMaintain a pleasant ,quiet environment lApproach in a slow, calm manner lAddress patient by name lFace the individual when conversing

Keywords: Dementia, nursing care, assessment - Linu Sara George 87 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

lGive simple directions, one at a time, step by step instructions, using short words and simple sentences lFocus on appropriate behaviour, give verbal feedback, positive reinforcement lIdentify potential dangers to client in environment. lPlace identification bracelet on clients lAvoid unfamiliar situation lDecrease noise levels by call light lGive one simple direction at a time lUse symbols rather than written signs to assist clients to locate room, bathroom 2. Ineffective communication lPleasant ,calm, supportive tone of voice should be used lVerbal communication should be clear, concise & unhurried lNonverbal techniques especially touch may be reassuring to the patient lPictures & symbols can be used for locating bathrooms, bedrooms or other areas in the setting lEnvironmental clues can prevent unwanted behaviour. Creative use of environmental cue is putting a stop sign on an exit door. lMaintain eye contact lGive time for comprehension lRepeat key words & phrases lUse gestures, pictures & facial expression to convey more meaning lListening carefully can help decipher a patients words substitution & generally understand what the patient is trying to say. lUse short small sentences lRepeat sentences as often as needed & periodically summarize what has been said lContinuous praise & encouragement promote successful communication with Alzhiemer's disease patients. lTo question, ask one specific question at a time requiring yes or no or multiple choice answer. lUse soft voice while conversing lMusic therapy is a very effective method to enable communication for patients in third stage because it helps to preserve quality of life lSimplify the verbal message using more than five or six words at a time . lAccompany words with touch & visual clues to decrease confusion & increase clarity of message Identify hearing & vision lMaintain eye contact-Determine in which language the client can communicate more impairments effectively by asking family ; & use interpreter if necessary l Approach from the front, make eye contact, address the person by name, and speak in a calm voice. lTalk first; pause ; touch second, reducing the person's threat. lAvoid verbal testing or questioning beyond the client's capacity lDo not argue or insist that the client accept your reality. lBe aware of memory impairments in addition to communication difficulties. lAssessment of specific receptive & expressive language abilities helps in understanding the client's communication difficulties & facilitate communication. Lubinski 1991 discusses the following needs for improved communication 1. To develop & maintain a sense of identity to permit elderly patients to be participants in their care 2. To vent anxieties 3. To relieve loneliness 4. To diminish depression 5. To exercise some power or influence 6. To meet basic desire & need 3. Reduce disorientation lAssess patient's level of disorientation /confusion to determine specific requirement for safety lOrient to him to time, place & persons with the help of a clock, calendar & physical setup lRemove dangerous articles like lighter, matches, cigarettes & sharp objects lProvide padded side rails

Keywords: Dementia, nursing care, assessment - Linu Sara George 88 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

lCall him by name lOrient patient to reality and surroundings at frequent times 4. Memory: lRepeat the routine activity lSpeak slowly, clearly in simple sentences lConvey warmth & concern lEncourage him to speak clearly lCreate comfortable environment lProvide opportunities to recall past events lEncourage to use written cues such as calender, lists or a notebook lKeep environment changes to a necessary minimum lProvide single step instructions for the client when instructions are needed 5. Spiritual needs lMake them understand that change is due to disease lTell relatives not to get irritated if the patient forgets to inform important message lGive appreciation for complete work 6. Support to families lAllow patient to attend regular prayers lDon't get irritated with extra time spent by patient for prayers lProvide guidance & counseling lThe nursing professionals should help & advice the caregivers to cope with their emotional problems. lA very important aspect is to promote communication between caregivers & individuals with dementia. lNote physical /mental condition ,therapeutic regimen of care receiver lIdentify strength of care giver and care receiver lProvide information or demonstrate techniques for teaching with acting out disoriented behaviour lDiscuss care giver's view and concerns about situation lDetermine available supports and resources currently used 7. Therapeutic needs lGive medicines as prescribed lHelp he patient to express his physical complaints lProvide reassurance 8. Prevention from injuries lProvide adequate furniture in the room lElectricity connection should be covered lProvide bell within reach of the client lAdequate light should be provided lPleasant & quiet environment should be provided 9. Impaired social interaction lDo not allow the client to embarrass himself/herself I in front of others lIntervene as soon as you observe embarrassing behaviour lPraise the client for appropriate behaviour lDetermine the client's interests, hobbies and favorite activities before hospitalization lAssess the client's current capability of engaging in former hobbies or activities. Make these activities available as much as possible lApproach the client with a calm, positive attitude lBegin with small, short term activities, initially one-one staff, and gradually progress to small groups lEncourage small group activities or discussion of an activity with clients who share similar interests lAllow the client to ventilate feelings of despair and hopelessness

Conclusion : any change in behaviour since they are with the patient for Like any other disease, patients with dementia also have 24 hours. Family members should understand that problems that nurses have to take care. Nurses can observe dementia is not a sign & symptom of aging but a problem in itself.

Keywords: Dementia, nursing care, assessment - Linu Sara George 89 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Witzke J,Rebecca A (2008). Music for Alzheimer's dementia. J O G N 51(1):45-49. Online; 34 (10):45-52. 8. Rawlins R P, Williams SR, Beck CK.(1993). Mental Health Psychiatric 2. Rasin J.( 2008 ).Knowing the resident with dementia perspectives of Nursing – A holistic lifestyle approach. St. Louis: Mosby Year Book; 649- assisted living facility care givers. J O G N online; 33 (9):30-36. 670. 3. Hepburnn K, Lewis M. (2007) .Transportable dementia caregiver 9. Fortinash KM, Holoday PA .Psychiatric Mental Health Nursing .St. psychoeducation programme. J O G N Online.; 33(3):30-36. Louis: Mosby 4. Sorell JA, Sorell JM.( 2008 ) Music for older adults. Journal of 10. Lilly ML, Richards BS, Buckwalter KC.(2003)Friends and social support Psychosocial Nursing. March; 46(3):21-24. in dementia caregiving – Assessment and Intervention. Journal of 5. Tompkins C J,Sorell JM. (2008). Older adults with Alzheimer's disease Gerontological Nursing; 29 (1). in a faith community. Journal of Psychosocial Nursing; 46 (1):22-25. 11. Roper JM, Shapira J, Beck A (2001).Nurse caregiver feelings about 6. Kar N (2009) Behavioural and psychosocial symptoms of dementia agitation in Alzheimer's disease. Journal of Gerontological Nursing; 27 and their management .Indian Journal of Psychiatry. Vol. 51 (12): 33-38. Supplement; 577-586. 12. Lorentz MM. (2000) Effective nursing interventions for the 7. Shaji KS, George RK, Prince JM, Jacob KS . (2009). Behavioral symptoms management of Alzheimer's disease. Journal of Neuroscience and care givers burden in dementia. Indian Journal of Psychiatry; Nursing; 32(3):153-156.

Keywords: Dementia, nursing care, assessment - Linu Sara George 90 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Case Report FABRICATION OF SINGLE PIECE HOLLOW BULB INTERIM OBTURATOR WITH PALATAL RAMP FOR TREATMENT OF HEMIMAXILLECTOMY AND HEMIMANDIBULECTOMY - A CASE REPORT Anupama Prasad D.1, Krishna Prasad D.2 & Chethan Hegde.3 1Lecturer, 2Professor and H.O.D., 3 Professor Department of Prosthodontics and Crown & Bridge, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte , Mangalore - 575 018 Correspondence: Anupama Prasad D. Lecturer, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte , Mangalore - 575 018 E-mail : [email protected] Abstract : A male patient aged 45 years reported with squamous cell carcinoma of palate. Patient was seen presurgically and an immediate surgical obturator provided followed by an interim maxillary obturator by a novel method wherein hollowing the obturator bulb was planned which also had a palatal ramp to correct jaw relation lost due to hemimandibulectomy .The treatment was done in sequential order to correct the deviation of mandible to provide aesthetics to the subject and also for a comfortable social life with improved mastication and appearance. Keywords: obturator, palatal ramp, maxillectomy, mandibulectomy, prosthodontic rehabilitation, aesthetic rehabilitation, functional efficiency, prosthesis

Introduction : he will be desolated. These victims have oronasal Patients with hemimandibulectomy are affected by many separation making intake of liquid and solid food difficult, debilitating problems. There is usually a decreased loss of resonation for production of sound and loss of capacity of the masticatory cycle.¹ Most of such subjects support to facial structures. They have to be treated as are compounded with facial disfigurements causing to feel soon as possible to restore esthetics and oral functions like dismay in public appearance. There is usually a limitation of speech and feeding .⁴ speech production and drooling of saliva which are seen as A male patient aged 45 years reported with squamous cell a result of lack of support and loss of innervations to , carcinoma of the palate requiring an immediate surgical certain areas as a consequence of surgical intervention.²³ obturator. Patient gave history of hemimandibulectomy Prosthetic management in patients who have undergone (Curtis and Cantor class III) done one year back. The hemimandibulectomy and commando procedures due to mandibulectomy defect was left aloof without any radical cancer surgery is frustrating because it involves prosthetic rehabilitation which had disfigured the patient's loss of tissue as well as face and had deviated the jaw to the side of defect. The Access this article online f u n c t i o n . E v e n t h e Quick Response Code patient was to undergo hemimaxillectomy (Aramany class reconstructive surgical I) and had reported presurgically . p r o c e d u r e s c a n n o t i m p r o v e p r o s t h e t i c Primary impressions of maxilla and mandible were made potential.³ If the same with irreversible hydrocolloid as the impression material patient has to undergo (NEOCOLLOID,ZERMACK CLINICAL,ITALY ),during hemimaxillectomy as well,

Keywords : obturator, palatal ramp, maxillectomy, mandibulectomy, 91 prosthodontic rehabilitation, aesthetic rehabilitation, functional efficiency, prosthesis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Figure 1: Presurgical cast altered and Figure 2: Immediate Figure 3: Immediate surgical clasps designed for immediate obturator. surgical obturator obturator in patient's mouth

Figure 4: Post surgical cast for Figure 5: Waxed up trial partial Figure 6: Acrylised interim fabrication of interim obturator denture obturator with impression obturator with clear acrylic

Figure 7: Hollow obturator after Figure 8: Deviation of jaw before Figure 9: Improved position of removal of condensation silicone and treatment with palatal ramp mandible in relation to maxilla after before closure with autopolymerising treatment with palatal ramp obturator.

impression procedure ,patient was made to sit in an material (TREVELON DENTSPLY,GURGAON,INDIA ) upright position so that soft palate assumed relatively fabricated like a denture base with no replacement teeth normal and relaxed position. Casts were poured with on the resection side (fig 2). The obturator thus prepared dental stone. was immersed in disinfectant solution an afternoon prior to surgery. The principle advantage of immediate surgical The planned area of surgery was marked on the cast and obturators is support and retention of the surgical packing, the cast was scored to an arbitrary depth to construct an reduces oral contamination of wound during immediate immediate surgical obturator. The obturator required to be post surgical period and decreases local infection. Permits stable so clasps of wrought wire were planned, an I- Bar on deglutition and eliminates need of nasogastric tube, the maxillary right central incisor and a Continuous clasp on lessens psychological impact of surgery and reassures the right first premolar and an Adams clasp to embrace the patient on beginning of rehabilitation. Enables the patient right second and third molars were planned(fig1) to speak effectively in the postoperative period if normal The cast was then invested and immediate surgical palatal contours are reproduced and palatal defects obturator was made with heat polymerizing acrylic resin covered .5

Keywords : obturator, palatal ramp, maxillectomy, mandibulectomy, 92 prosthodontic rehabilitation, aesthetic rehabilitation, functional efficiency, prosthesis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Immediately following surgery the obturator was coated packed with 2mm thickness of veined acrylic such that it with a tissue conditioning material and inserted into the took the shape of the defect, in between these two layers maxilla (fig 3) and patient was recalled after two weeks for of acrylic we placed a small ball of condensation silicon fabrication of interim obturator. with very little catalyst added and the flask was closed and acrylic cured. Once deflasking was done we got a dual Patient reported back after 15 days for interim obturator, coloured obturator where the palatal ramp was clear and impression of the defect was made and cast was obtained hence aesthetic to the patient, and the rest of the (fig 4). The major challenge now was the correction of obturator was veined, pink acrylic (fig 6). deviated jaw due to mandibulectomy and reduction of weight of maxillary interim obturator. Periodic addition of The bulb part of the obturator was given a small opening interim lining materials increases the bulk and weight of using no.10 round bur until the condensation silicon putty the surgical prosthesis, temporary materials tend to material was reached. The material was retrieved through become rough and unhygienic with time, addition of the tiny opening with the help of the rear end of a lackrons anterior and posterior teeth to the obturator is a great carver, the opening (fig 7) was then closed with the help of psychological benefit. So an interim prosthesis has to be autopolymerising acrylic resin material. made for a period of three to six months until the wound Patient was recalled once in every week after fit and completely heals. It can also serve as backup prosthesis insertion of the hollow bulb interim obturator with palatal when definitive prosthesis needs repair, relining or ramp and clear autopolymerising acrylic material was used rebasing .5 to adjust the ramp gradually and correct the jaw deviation. Occlusal plane was established and an impression There was gradual improvement seen with palatal ramp compound palatal ramp made to guide the mandible. (fig 8 &9). Teeth were included in the prosthesis for esthetics. Trial of Discussion : waxed up removable partial denture with palatal ramp was In treating patients with surgical defects, factors of denture made. Retention was with wrought wire clasps similar to retention are compromised .7 The maxillofacial appearance the surgical obturator (fig 5). is marred. Patient is compromised anatomically, Cleanliness, simplicity of construction and light weight are physiologically and psychologically. Public denigration important considerations in construction of obturators.⁴, keeps them away from socialization, post operative 6In the present case it was not only the weight of the bulb swallowing is temporarily impaired. Speech is disturbed but the obturator would have a palatal ramp as well which due to denervation or limited tongue mobility as well as would double up the weight and decrease the retention due to oronasal communication which leads to absence or factor. decreased resonance. Speech becomes hollow and flat.³Occlusal components such as temporomandibular A new technique was followed here to hollow the bulb. The joints and masticatory muscles are involved which leads to trial base with monoplane teeth and impression dawdling of the treatment progress. Heavy extensions like compound palatal ramp was invested in the flask, dewaxing solid bulb obturators compromise retention by was done ,separating media applied and the palatal ramp cantilevering the prosthesis. A hollow obturator is better in area was packed with clear heat polymerising acrylic resin so many aspects like improved resonance, decreased (TREVELON, DENTSPLY, GURGAON, INDIA),over which weight and improved retention. A closed hollow obturator v e i n e d h e a t p o l y m e r i s i n g a c r y l i c prevents collection of fluid and air space.8 Frank R Lauciello resin(TREVELONDENTSPLY,GURGAON,INDIA) was placed et al., ? used 0.16 inch flexible vinyl resin mouth guard to a thickness of 2mm ,counter flask with defect was also material with which number of obturators could be

Keywords : obturator, palatal ramp, maxillectomy, mandibulectomy, 93 prosthodontic rehabilitation, aesthetic rehabilitation, functional efficiency, prosthesis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science fabricated as it stains and distorts easily. Chalian6 has given ultimately the will of the patient, prognosis of surgery, the a design of making single piece hollow obturator where area available for support and retention, size and curvature obturator surrounded a hollow shim of self cure acrylic. of the dental arch after surgery and maintenance of The method adapted by us was comparatively easy, time hygiene by patient that would make a treatment saving and the condensation silicone could be completely successful. Ultimately we have to realize that there is no and easily retrieved from the obturator. shortcut for success.

Summary and Conclusion : Whatever may be the effort put by the clinician, it is

References: 1. Atkinson HF, Shepherd RW. The masticatory movements of patients 6. Chalian VA, Barnett MO.A new technique for constructing a one- piece after major oral surgery. J Prosthet Dent 1969; 21: 86-91. hollow obturator after partial maxillectomy. J Prosthet Dent 1972; 28: 2. Cantor R, Curtis TA, Shipp T, Beumer J 3rd, Vogel BS. Maxillary speech 448-53. prostheses for mandibular surgical defects. J Prosthet Dent 1969; 22: 7. Cantor R, Curtis TA. Prosthetic management of edentulous 253-60. mandibulectomy patients. II. Clinical procedures. J Prosthet Dent 3. Cantor R, Curtis TA. Prosthetic management of edentulous 1971; 25; 546-55. mandibulectomy patients. I. Anatomic, physiologic and psychologic 8. Phankosol P, Martin JW. Hollow obturator with removable lid. J considerations. J Prosthet Dent 1971; 25(4): 446-57. Prosthet Dent 1985; 54:98-100. 4. Oral K, Aramany MA, McWilliams BJ. Speech intelligibility with buccal 9. Lauciello FR, Casey DM, Crowther DS. Flexible temporary obturators flange obturator. J Prosthet Dent 1979; 41: 323-8. for patients with severely limited jaw opening. J Prosthet Dent. 1983 5. Beumer J 3rd , Curtis TA, Marunick MT. Maxillo Facial Rehabilitation – Apr; 49:523-6. Prosthodontic and surgical consideration : Ishiyaku Euro America, Inc;1996

Keywords : obturator, palatal ramp, maxillectomy, mandibulectomy, 94 prosthodontic rehabilitation, aesthetic rehabilitation, functional efficiency, prosthesis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Case Report LIGHT WEIGHT HOLLOW DENTURE – A CASE SERIES Laxman Singh Kaira1, Krishan Singh Negi2, Shalini Parihaar3, Rahul Bisht4 1Assistant Professor, 2Associate Professor, 4Senior Resident, Department of Dentistry, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar Garhwal, Uttarakhand, 3Private Practitioner, Lucknow, Uttar Pradesh Correspondence: Laxman Singh Kaira, Faculty Residence, Flat No. 4,Type 2, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar Garhwal, Uttarakhand Mobile : +91 87559 02525 E-mail : [email protected] Abstract : It is the prosthodontist's responsibility to fabricate a prosthesis incorporating stability, retention and support which ultimately provide satisfaction to the patient. But in the certain conditions such as long lip length or severely resorbed ridges with increased inter ridge distance, the weight of a maxillary denture is often a dislodging factor. Hence, a light weight denture is required for better retention. This article describes 2 case reports of completely edentulous patient successfully rehabilitated with a hollow denture where a simplified technique of fabricating a light weight maxillary denture was used. Keywords: Dental education, dental health, dental health promotion, tooth loss

Introduction : obvious that in large maxillofacial defects and in severe Physiological, esthetic and functional variables are resorption of the edentulous ridges, there is a decreased associated with successful conventional complete denture denture bearing area for support, retention and stability. therapy. Despite the development of dentures supported Increased interridge space compounds this problem. To by osseointegrated implants; rehabilitation of resorbed decrease the leverage, reduction in the weight of the residual ridges is still a challenge. Conventional restoration prosthesis was recommended and was also found to be of the severely atrophied mandibular ridge has sparked a beneficial. Reducing the weight of a maxillary prosthesis number of designs to accommodate patients who have has been shown to be beneficial when constructing an difficulty wearing a mandibular denture.The success of a obturator for the restoration of a large maxillofacial defect complete denture relies on the principles of retention, 1,2 . It has also been proved that prosthesis weight can be stability and support. The prosthodontist's skill lies in reduced by making the denture base hollow. Different applying these principles efficiently in critical situations. approaches like using a solid 3-dimensional spacer, Severely resorbed maxillary edentulous ridges that are including dental stone1-6 , silicone putty7,8 , modelling clay9,10 narrow and constricted with increased inter ridge space , or cellophane wrapped asbestos 11 have been used provide decreased support, retention and stability. The during laboratory processing to exclude denture base consequent weight of the processed denture only material from the planned hollow cavity of the prosthesis. compromises them further. This article describes a case Holt7 processed a shim of acrylic resin over the residual report of an edentulous ridge and used a spacer (Insta-mold; Nobilium, Albany, NY). Access this article online patient with resorbed Quick Response Code The resin was indexed and the second half of the denture ridges where a simplified processed against the spacer and shim. The spacer was technique of fabricating a then removed and the 2 halves luted with autopolymerized light weight maxillary acrylic resin using the indices to facilitate positioning. The complete denture was primary disadvantage of such techniques is that the used for preservation of junction between the 2 previously polymerized portions of denture bearing areas. It is

Keywords : Dental education, dental health, dental health 95 promotion, tooth loss - Laxman Singh Kaira NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science the denture occurs at the borders of the denture. This is a dimension of occlusion (VDO) and vertical dimension at long junction with an increased risk of seepage of fluid into rest (VDR) were more than average . The previous denture the denture cavity increasing the risk of leakage. Fattore et of the patient was heavy with attrited teeth and was under al 12 used a variation of a double flask technique for extended. Hence, it was decided to fabricate a new set of obturator fabrication by adding heat polymerizing acrylic denture for the patient. resin over the definitive cast and processing a minimal The treatment options for complete denture available to thickness of acrylic resin around the teeth using a different the patient were: drag. Both portions of resin were then attached using heat- a. Implant supported complete denture polymerized resin. b. Conventional Complete denture O'Sullivan et al.13 described a modified method for c. Hollow maxillary complete denture and conventional fabricating a hollow maxillary denture. A clear matrix of mandibular complete denture. trail denture base was made. The trail denture base was After analysing each available option, it was decided to then invested in the conventional manner till the wax fabricate hollow maxillary complete denture.The patient elimination. A 2 mm heat polymerized acrylic resin shim also approved of the treatment modality as it was light in was made on the master cast using a second flask. Silicone weight, inexpensive and non-surgical procedure. putty was placed over the shim and its thickness was estimated using the clear template. The original flask with Technique: the teeth was then placed over the putty and shim and the Preliminary and final impressions were made in processing was done. The putty was later removed from conventional manner. At the time of jaw relation due the distal end of the denture and the opening was sealed consideration was given to adjust maxillary occlusal rims with autopolymerizing resin. Though this technique was properly as to provide proper aesthetics to the patient with useful in estimation of the spacer thickness, but removal of long upper lip. Teeth were selected and arranged in putty was found to be difficult especially from the anterior balanced occlusion and try-in was done first for anterior portion of the denture. Moreover, the openings made from teeth and then for posterior teeth. All the procedures were the distal end had to be sufficiently large to retrieve the carried out by conventional method till the dewaxing hard putty. In this case reports, two edentulous male stage. After dewaxing patients with severely resorbed ridges and increased inter- Half of the heat cure PMMA (Trevalon, Dentsply India Pvt. ridge distances were treated with a hollow maxillary Ltd., Gurgaon, India) in dough stage was positioned denture, using common salt and putty as spacer has been accurately over the dewaxed mould and then salt crystals described. were placed over it. Case Report 1 : ( Figure 2 &3) A 55-year-old patient walked into the outpatient department of prosthodoontics with a chief complaint of Above that, the remaining heat cure resin was packed and replacing missing teeth. He had been edentulous for 10 cured at 74 degree C for 7-8 hours Cured denture was years and had been wearing dentures for 7 years. On retrieved and 3 holes were made in the thickest palatal area examination, he had severely resorbed ridges, the upper ( Figure 4) . All the residual salt crystals were removed by being narrow and constricted and with an interridge space flushing water with the high pressure syringe through the of 32 mm .Both maxillary and mandibular ridges were holes. After making sure that all the salt crystals have been severely resorbed ( Figure 1). His upper lip was long, the removed, the escape holes were closed with inter-ridge distance was more than normal and vertical autopolymerizing resin (Trevalon, Dentsply India Pvt. Ltd.,

Keywords : Dental education, dental health, dental health 96 promotion, tooth loss - Laxman Singh Kaira NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Gurgaon, India). The hollow cavity seal was verified by patients with systemic illness, economic constrains, immersing the denture in water, if no air bubbles are possess reluctance for a long. duration treatment evident, an adequate seal is confirmed ( Figure 5). The procedure and unwillingness for any kind of surgical dentures were inserted in the patient's mouth and procedure. Hence, the best way is to rehabilitate them with instructions regarding care, hygiene and maintainance the conventional way. Apart, from modifying the were given ( Figure 6). impression technique to get maximum denture bearing area, modifying the type of denture may also be better Case report 2 : accepted by the patient.In general, a conventional (heavy) A 65-year-old patient walked into the department of denture whether maxillary or mandibular is likely to cause prosthodontics with a chief complaint of chronic stomach poor denture bearing ability. Extensive volume of the upset due to inability to eat properly. Patient was taking denture base material in prosthesis provided to patients antacids for the same. He had been edentulous for 3 years with large maxillofacial defects or severe residual ridge and had been wearing dentures for 2 years. Artificial teeth resorption is always a challenge to prosthodontists. To were severely attrited. The lower denture was broken & increase the retention and stability of heavy prosthesis, was repaired. Intraoral examination revealed a severely many methods have been tried like utilising the undercuts, resorbed upper ridge ( Figure 7). So as an alternative the modifying the impression technique, use of magnets, use patient was treated with a hollow complete maxillary of implants, etc.14 denture. Till the dewaxing stage all steps were same as in conventional denture. After dewaxing Half of the heat cure The first technique has advantages over the second PMMA (Trevalon, Dentsply India Pvt. Ltd., Gurgaon, India) technique. The salt crystals being heat labile melt during in dough stage was positioned accurately over the dewaxed the curing procedure and thorough flushing after curing mould and then polyvinylsiloxane is mixed and were placed results in no crystals remaining in the denture thereby over it ( Figure 8) . Above that, the remaining heat cure maintaining the integrity of the denture, avoiding the resin was packed and cured at 74 degree C for 7-8 hours. tedious effort to remove the spacer material from the Two small openings were made with a bur into the denture denture. This technique of lost salt technique is simple to base distal to most posterior teeth to remove the spacer ( execute and utilizes a very cheap and easily available Figure 9 & 10 ). The polyvinylsiloxane was then removed by spacer material. scraping with a sharp instrument. The cavity was cleaned The technique 2 described has advantages for hollow and disinfected. Later, these openings were closed with the denture fabrication. Leakage and difficulty in gauging resin autopolymerizing resin (Trevalon,Dentsply,Gurgaon) in thickness are problems inherent in. The procedures dough stage. The dentures were then polished in usual described in this article overcome these problems. Heat- manner. The sealing of the cavity was then verified by polymerizing portion of the denture against polymerized placing it in water and checked for any bubbles ( Figure 11). resin may reduce leakage at the junction of the portions of The dentures were inserted in the patient's mouth and the denture. The small window in the cameo surface instructions were given ( Figure 12). facilitates recovery of the spacer in an area that is not Discussion : commonly adjusted after denture insertion and has a small Rehabilitation of patient with severely resorbed ridges and margin along which leakage could occur. The Silicone putty long lip length is a challenge to the dentist. Even though, is used as a spacer advantages, including its stability, its the choice for rehabilitation can be implant supported ability to be carved, and the fact that it does not adhere to overdenture, and ridge augmentation but many a times the acrylic resin. The cyanoacrylate bond between the resin patient who come with such a problem are geriatric and the putty may be easily removed.

Keywords : Dental education, dental health, dental health 97 promotion, tooth loss - Laxman Singh Kaira NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Figure 1 Preoperative photograph Figure 2 heat cure packing Figure 3 salt placement over heat cure

Figure 4 holes were madr in Figure 5 Hollow denture Figure 6 Postoperative photograph polished surface

Figure 7 Preoperative view Figure 8 Putty placement Figure 9 Cured denture

Figure 10 Holes were made Figure 11 Hollow denture Figure 12 Happy patient in posterior region Summary : patients with many systemic illness. Hence, the best way is Rehabilitation of severely resorbed ridges is a challenge to to rehabilitate them with conventional complete dentures. the prosthodontist. Even though, the choice of Apart, from modifying the impression technique to get rehabilitation can be overdentures, implant retained over- maximum denture bearing area, modifying the type of dentures, ridge augmentation, etc., many a times the denture also may be better accepted by patients. Hence, patients who comes with such a problem are geriatric less denture weight provides for healthy and comfortable living.

Keywords : Dental education, dental health, dental health 98 promotion, tooth loss - Laxman Singh Kaira NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References 1. El Mahdy AS.Processing a hollow obturator. J Prosthet Dent 8. Jhanji A, Stevens ST. Fabrication of one-piece hollow obturators. J 1969;22:682-6. Prosthet Dent 1991; 66:136-8. 2. Brown KE. Fabrication of a hollow bulb obturator. J Prosthet Dent 9. DaBreo EL. A light-cured interim obturator prosthesis. A clinical report. 1969;21:97-103. J Prosthet Dent 1990; 63:371-3. 3. Ackerman AJ. Prosthetic management of oral and facial defects 10. Elliott DJ. The hollow bulb obturator: its fabrication using one denture following cancer surgery. J Prosthet Dent 1955;5:413-32. flask. Quintessence Dent Technol 1983; 7:13-4. 4. Nidiffer TJ, Shipman TH. Hollow bulb obturator for acquired palatal 11. Worley JL, Kniejski ME. A method for controlling the thickness of openings. J Prosthet Dent 1957;7:126-34. hollow obturator prostheses. J Prosthet Dent 1983; 50:227-9. 5. Rahn AO, Boucher LJ. Maxillofacial prosthetics: principals and 12. Fattore LD, Fine L, Edmonds DC. The hollow denture: an alternative concepts.St. Louis.Elsevier;1970, p.95 treatment for atrophic maxillae. J Prosthet Dent 1988; 59:514-6. 6. Chalian VA, Barnett MO. A new technique for constructing a one-piece 13. O'Sullivan M. The hollow maxillary complete denture: A modified hollow obturator after partial maxillectomy. J Prosthet Dent 1972; 28: technique. J Prosthet Dent 2004;91:591-94. 448-53. 14. Kalavathy N, Shetty MM, Premnath, Pawashe K, Patel RKV: Hollow 7. Holt RA Jr. A hollow complete lower denture. J Prosthet Dent 1981; mandibular complete denture - A case report. SRM University Journal 45:452-4 of Dental Sciences, 2010;1(3): 243-246.

Keywords : Dental education, dental health, dental health 99 promotion, tooth loss - Laxman Singh Kaira NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Case Report CAVITY IN THE LUNG: A RARE CASE OF BURKHOLDERIA CEPACIA INFECTION Suresh G.1, Rama Prakasha S.2, Giridhar B.H.3 & Shama Prakash K.4 1Associate Professor, 2Assistant Professor, 4Assistant Professor, Department of Medicine, 3Assistant Professor, Department of Respiratory Medicine, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, Karnataka Correspondemce: Suresh G., Associate Professor, Department of Medicine, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, Karnataka E-mail : [email protected] Abstract: An elderly patient was evaluated for fever and cough of three weeks duration. Chest X-ray revealed a thin walled cavity in the right parahilar region. Sputum Acid Fast Bacilli was negative and sputum culture has grown multidrug resistant Burkholderia Cepacia sensitive to carbapenams only. This is a rare case report of community acquired B. Cepacia infection in an individual wherein the clinical presentation was mimicking smear negative pulmonary tuberculosis, but the patient has shown a complete clinical and radiological response to imipenam. Keywords : Berkholderia cepacia, Immunocompetent, Pneumonia

Introduction : relieved with sweating. There was history of weight loss of B. cepacia is a lung pathogen usually in patients with cystic 3 kg in last three weeks. There was no other significant past fibrosis. [1, 2] It is also described as an important cause of medical history. He was non-alcoholic and had history of multi-drug resistant nosocomial infection, but infections in smoking of 30 pack years. On examination he was immunocompetent patients are extremely rare. Reported emaciated with BMI of 19/m2. Respiratory system cases of B. Cepacia lung infection in immunocompetent exa m i n at i o n reve a l e d b a r re l s h a p e d c h e st individuals include pneumonia and pyopneumothorax. [3-5] (emphysematous). There was bilateral wheeze with Rare cases of acute non-pulmonary B. cepacia infection crackles in right infra- clavicular area. Examination of other have also been described in immunocompetent patients.[6] systems was unremarkable. This report is about a patient with no underlying lung Investigations revealed total leucocyte count of disease or systemic illness diagnosed as community- 17,600cells/mm3, ESR of 55mm in one hr. Blood urea was acquired B. cepacia pneumonia mimicking tuberculosis or 54mg/dl and creatinine was 1.6mg/dl on admission, chest malignancy, which resolved completely with carbapenem X-ray showed a cavitatory lesion along hilar area on right treatment. side. [Figure 1] Sputum smear was negative for acid-fast bacilli Case report : (AFB). He was initially treated with ceftriaxone, A 63 year old male agriculturist was admitted to hospital azithromycin and amikacin in view of leucocytosis and toxic with complaints of high condition, and there was no clinical response. Sputum Access this article online grade intermittent fever culture grew Burkholderia cepacia (heavy growth) and was Quick Response Code a n d c o u g h w i t h sensitive only to carbapenemes – meropenam and expectoration of three imepenam. He was treated with imepenam and responded weeks duration. His fever clinically in three to four days with resolution of toxaemia was associated with chills and subsidence of fever. His follow-up chest roentogram and occurred mostly after four weeks showed resolution of lung lesion, [Figure 1] and during evenings, and

Keywords : Berkholderia cepacia, Immunocompetent, Pneumonia 100 - Suresh G. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science a complete radiological resonse at the end of six weeks. routinely used, and was susceptible only to carbapenems; to which patient showed a complete clinical and Discussion : radiological response. Because of its inherent resistance to B. Cepacia is a complex group of aerobic gram negative many antibiotics the organism can be difficult to treat. It bacilli and infection is commonly described in patients with has been shown that the organism has a remarkable cystic fibrosis or chronic granulomatous disease with fatal potential as an agent for both biodegradation and outcome.[1, 2] It is very rarely known to cause community biocontrol, thus it is being considered as a plantgrowth- acquired infections in immunocompetent individuals. It is promoting rhizobacterium. [10] Used as a pesticide and also implicated in nosocomial infections, [7] and exhibits biofertilizer in agriculture, B. cepacia can be transmitted to high intrinsic antibiotic resistance to most of the available humans via contaminated agricultural products. Its antibiotics. [8, 9] Firstly Waterer et al. described a development in out-of-hospital settings and community-acquired pneumonia caused by B. cepacia in immunocompetent cases may possibly be attributed to healthy adult. [5] environmental exposure, probably from agricultural The patient in question had fever with productive cough of produce, like in this case. Otherwise, in non-cystic fibrosis three weeks duration with a well defined cavity in the right patients B cepacia pneumonia is characteristically a lung. His ESR was elevated and sputum AFB was negative. hospital acquired infection in the intubated or The sub-acute course of illness with productive cough, immunocompromised patients. evening rise of temperature, sweating, weight loss, The unusual reporting of such case highlights the presence elevated ESR and the radiological picture of cavity was of rare organism as a cause of lung infection, which was pointing towards a diagnosis of smear negative pulmonary previously considered as merely an opportunistic infection tuberculosis. Due to negative sputum smears for AFB, factor, and this is a point of concern. A high index of cavitating lung lesion along with his smoking history and suspicion and prompt treatment with appropriate advanced age, malignancy was also strongly considered in antibiotic as per culture and sensitivity is needed to the differential diagnosis. However, sputum culture grew B. prevent mortality. Cepacia and the organism was resistant to all antibiotics

immunocompetent host. Clin Infect Dis 1992;15:887-8. 4. Suman SK, Hariharan R, Kiran C, Mukhyaprana P. A rare case of community acquired Burkholderia cepacia infection presenting as pyopneumothorax in an immunocompetent individual. Asian Pacific Journal of Tropical Biomedicine 2012;166-8. 5. Waterer GW, Jones CB, Wunderink RB. Bacteremic community- acquired pneumonia in an immunocompetent adult due to Burkholderia cepacia. Chest 1999;116:1842-3. 6. Hobson R, Gould J, Govan J. Burkholderia (Pseudomonas) cepacia as a cause of brain abscess secondary to chronic supperative otitis externa. Eur J Clin Microbiol Infect Dis 1995;14:908–11. 7. Bressler AM, Kaye KS, LiPuma JJ, Alexander BD, Moore CM, Reller LB, et Figure 1: A- Chest X-ray PA view showing cavitatory lesion al. Risk factors for Burkholderia cepacia complex bacteremia among along the parahilar region on the right side. B- Partial intensive care unit patients without cystic fibrosis: a case-control resolution of the lesion on the right side after four weeks of study. Infect Control Hosp Epidemiol 2007;28:951-8. 8. Slama TG. Gram-negative antibiotic resistance: there is a price to pay. antibiotic therapy. Crit Care 2008;12 Suppl 4. 9. Araque-Calderon Y, Miranda-Contreras L, Rodriguez-Lemoine V, References : Palacios-Pru EL. Antibiotic resistance patterns and SDS-PAGE protein 1. Lynch JP. Burkholderia cepacia complex: impact on the cystic fibrosis profiles of Burkholderia cepacia complex isolates from nosocomial lung lesion. Semin Respir Crit Care Med 2009;30:596-610. and environmental sources in Venezuela. Med Sci Monit 2008;14:49- 2. Coutinho HD. Burkholderia cepacia complex: virulence characteristics, 55. importance and relationship with cystic fibrosis. Indian J Med Sci 10. Govan JRW, Hughes JE, Vandamme P. Burkholderia cepacia:medical, 2007;61:422-9. taxonomic and ecological issues. J Med Microbiol 1996;45:395-407. 3. Pujol, M, Corbell, X, Carratala, J, Gudiol F. Community-acquired bacteremic Pseudomonas cepacia pneumonia in an

Keywords : Berkholderia cepacia, Immunocompetent, Pneumonia 101 - Suresh G. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Case Report CHICKENPOX- CUSTOMS, BELIEFS AND TRADITIONAL PRACTICES IN UDUPI DISTRICT: A CASE STUDY Asha K. Nayak1 & Shalini2 1& 2Assistant Professors, Department of Psychiatric Nursing, Manipal College of Nursing, Manipal University, Manipal - 576 104, India Correspondence: Asha K. Nayak E-mail : [email protected] Abstract: Cultural beliefs regarding causes of diseases and practices related to treatment vary from one area to another area, one community to another community. Ms X, 10 years female child was suffering from chicken pox. They strongly believed that chickenpox can be cured with home remedies only and their child has to be treated at home and child was treated at home. The nurse must be aware of these beliefs while providing care. Keywords : Chicken pox, trans-culture, culture

Introduction : gender, caste. There are many communicable diseases which are A case report : prevalent in India. Cultural beliefs regarding causes of Ms X, 10 years female child was suffering from the diseases and practices related to treatment vary from one following chills, malaise, pain in both eyes for 2days.On area to another area, one community to another examination, her body temperature was found to be 99·F. community. She had 3 small papules on posterior trunk and one on Culture is that complex whole which includes knowledge, abdomen. The parents came to know that the child is belief, art, morals, law, custom & any other capabilities infected with chickenpox. They strongly believed that acquired by man as a member of society chickenpox can be cured with home remedies only and their child has to be treated at home. They believed the Culture is combination of custom and practice which are superstitions that chickenpox was due to their past evils influenced by standard of living, occupation, literacy, faith against the spirit of Devi .Since the deity is the guardian of and reverence towards deity, manifesting healing power the locality, this disease can be cured by Goddess only. by divine inspiration and contemplate and content with divine blessings and so on. The child was not sent to school, but was not isolated at home. In home they stopped cooking and consuming non- Culture pattern are formed when traits and complexes vegetarian food. They have stopped using oil for seasoning become related to each other subconsciously in functional the food and Stopped application of oil to the body. role. Bathing was wit held, child was not allowed to move out of Transculture is a process Access this article online the home. She was provided with boiled ragi juice and Quick Response Code which involves exchange boiled green gram with little salt on first day. of cultural items when two different cultures come On 2ndday, papules were seen in clusters widely dispersed into continuous contact all over the body including on palm, soles except scalp. with one another. It Chills and malaise were present. The child was served with transcends the barriers of rice congee and pickle. Tea and coffee were withheld. Milk

Keywords : Chicken pox, trans-culture, culture - Asha K. Nayak 102 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science and warm water with cookies were provided. items were kept in that place.

On 3rdday, Child had throat pain, difficulty in swallowing. Child was provided with rice, special rice roti and Papules were found in hard palate. Redness in pharynx was horsegram rasam. Same diet was continued for 4 days. seen. The child also had body pain and chills. She was given Horse gram rasam was prepared with pepper, salt and only liquid and semi solid diet with milk and warm water. tamarind. The macules seen on first day turned into vesicles. The child Neem juice was prepared and 3 teaspoons of neem juice was unable to tolerate bright objects. Macules, papules was provided twice a day for 7 days. and vesicles spread all over the body including scalp and posterior pinna of the ears. On 15thday, other vegetables were used without oil or coconut. Scabs were found to be dried She was sent to On 4th day, child had severe head ache and itching on the school on 21st day. bod . She was provided with congee, semi liquid food and biscuits. This was a personal experience. No other remedial measures or treatment was taken. On 5-7th day, solid diet conjee with pickle given. Food prepared with oil was avoided. Rice pundi, cucumber with It is very important to know the cultural beliefs and practice salt, bottle guard, yam, tomato curry was served. No bath when we take care of clients with different backgrounds. was given but dresses were changed every day. Nurses play an important role in identifying such customs and practices. On 7th day, bath was given according to the traditional practice. Adathodavasika (Aadusoge), neem leaves, tender 1. Nurse must have knowledge on ethno heritage & ethno coconut husk, Strichnusnuxvomica (Karaskara) were put in history of the patient water and boiled continuously for an hour till the color of 2. Nurse should collects the bio cultural history of the client the water changes to red or brown. Green turmeric stem (Carcumalongarhizome), NizalumSativum (Karijeerige) 3. The nurse should know about the social organization of were grinded with the above boiled water to make it like a the society paste and applied on to the body and left for an hour. Later 4. The nurse should consider the religious & spiritual bath was given with the same boiled water without mixing beliefs of the client and their family cold water. After the bath, boiled rice, rice special roti was kept ready in spathe of arecanut. Water, lime and turmeric 5. The nurse should know about the communication powder was mixed and special type of liquid was prepared pattern of the client and kept in a tumbler. 6. The nurse must have knowledge on the caring beliefs & Child was made to sit on a wooden-seater outside the practices home and food was served on a banana leaf. Fresh water from well was brought and kept in a tumbler. 2 stick lamps 7. The nurse must understand about the cultural (stick twisted with oiled string of cloth at the top lit on fire) misconceptions regarding health were made and water was sprinkled in front of her to Conclusion : reduce phobia. It was believed that fear is subsiding by The health professionals to understand that for no fault of doing this ritual, it will ward off suffering caused by evil eye. the child, it had to undergo the trauma for 21 days. This will Later the child was asked to go home without looking back. not only reduce her immunity but also causes inferiority Thereafter, the water, food items were taken to a place complex. In such circumstances, to respect the good where cross road were join. Lemon was cut and above

Keywords : Chicken pox, trans-culture, culture - Asha K. Nayak 103 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science habits of the practices such as avoiding non vegetarian mental agony of the child and persuade them to follow food and spicy and oily food. Besides, the health scientific diagnosis along with respecting their cultural professionals may appreciate the parents the physical and practices.

References : 1. Clement IA. Sociological implications in nursing in Nursing .Hyderabad: Frontline publishers; 2007. 2. Park K. A text book of preventive and social medicine. Jabalpur, Banarsidas Bhanot publishers;2008.

Keywords : Chicken pox, trans-culture, culture - Asha K. Nayak 104 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Review Article ENHANCING STABILITY : A REVIEW OF VARIOUS OCCLUSAL SCHEMES IN COMPLETE DENTURE PROSTHESIS Krishna Prasad D.1, B. Rajendra Prasad2, Anshul Bardia3 & Anupama Prasad D.4 1 Professor and H.O.D, 2 Principal/Dean and Research Guide, 3 Post Graduate student, 4 Lecturer Department of Prosthodontics and Crown & Bridge, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte, Mangalore - 575 018 Correspondence: Krishna Prasad D., Professor and H.O.D, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte, Mangalore - 575 018 E-mail : [email protected] Abstract : A practical approach to rehabilitate the edentulous patients to optimal occlusion is not an easy task. Complete denture prosthesis when compared to natural teeth have relatively unstable bases and have no proprioception comparable to the periodontal ligament of the natural tooth and acts as the single unit instead of an individual tooth. To enhance the stability of the complete dentures, the philosophy of the balanced occlusion has been proposed. Balanced occlusion in dentures implies occlusal contacts that contribute to equilibrium of the denture bases on their respective ridges. The search for the ideal occlusal scheme, one which provides stability, comfort, function and esthetics is still underway. While there is little research to support one occlusal scheme over the other, it is known that the prosthesis is less efficient than natural teeth and the ability to chew with it varies with the individual, regardless of the occlusal schemes. Poor oral awareness makes it more difficult for a patient to adapt to the function with the prosthesis especially one with a complicated occlusal scheme. This article reviews several occlusal schemes, their characteristics, recommendations for usage along with their advantages and disadvantages. Keywords : Occlusal schemes, neutrocentric occlusion, lingualized occlusion, balanced occlusion, monoplane occlusion.

Introduction : to be giving various occlusal schemes considering only There has been search for the ideal denture occlusion in an relevant data. The key words used for the search were effort to find out the tooth forms which provides esthetic, occlusal schemes, neutrocentric occlusion, lingualized stability, and masticatory efficiency without compromising occlusion, balanced occlusion, monoplane occlusion. the health of underlying hard and soft tissues of the Numerous concepts, techniques and philosophies have edentulous arch. The main aim of clinician is to fulfill these been documented concerning about complete denture objectives, regardless of posterior tooth form selected 1,2. occlusal schemes. There are several schools of thoughts on This article reviews literature published from 1930 to 2011 occlusal schemes in complete denture and some clinician with various approaches in the occlusal schemes to believe there should be cusps on the teeth and must be in enhance the stability of complete denture prosthesis complete harmony with the stomatognathic system. Some designs. A search in the National Library of Medicine's believe that cuspless teeth create minimum horizontal PubMed database, Google force to unseat denture. Many investigations on a scientific Access this article online search and Science Direct level have not proved that which occlusal schemes is Quick Response Code was performed to include superior in function or that best meet the requirements of all reviews on various biologic and physiologic concepts for each patient3.There occlusal schemes. A total are many studies states that the merits of a given concept of 35 articles were or pointing out the deficiencies of another4. included for discussion in Occlusal scheme is defined as the form and the the review found by search

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 105 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science arrangement of the occlusal contacts in natural and • Pitch or inclination or tilt artificial dentition. The pattern of occlusal contacts • There was no compensating curve and no incisal between opposing teeth during centric relation and guidance. functional movement of the mandible will be determined • This positioning directed forces perpendicular to the by the occlusal schemes. The quantity and the intensity of mean osseous foundation plane. these contacts determine the amount and the direction of lForm: the forces that are transmitted through the bases of the • Flat teeth with no deflecting inclines•R e d u c e d denture to the residual ridges. That is why the occlusal destructive lateral forces and helped to keep scheme is an important factor in the design of complete masticatory forces perpendicular to the support. denture prosthesis. • Reduced destructive lateral forces and helped to keep masticatory forces perpendicular to the Occlusal schemes have been classified into: support. lNeutrocentric occlusion lNumber: lLingualized occlusion • The posterior teeth were reduced in number from lNon anatomic occlusion (Monoplane occlusion with eight to six. balance) • This decreased the magnitude of the occlusal force lLinear occlusion and centralized it to the second premolar and first lBalanced occlusion molar area. Neutrocentric occlusion : Advantages : Neutrocentric occlusion is at the far right of the occlusal lTechnique is simple and requires less precise records. spectrum and the exact opposite of the anatomic lIdeal for a patient who have resorbed friable ridges. occlusion, was developed by De van. lBy removing inclines, the lateral forces, which are very De Van coined the term neutrocentric to embody the two destructive to the residual ridges, are reduced. key objectives of his occlusal scheme, lBecause the neutrocentric technique provides an area 1. The neutralization of inclines. of closure and does not lock the mandible into a single 2. The centralization of forces which act on the basal seat position. Ideal for Geriatric patient with limited oral when the mandible is in centric relation to the maxillae. dexterity. lIt is especially good for Class II (retrognathic), Class III There are five elements in this occlusal scheme: (prognathic) and crossbite cases. lPosition: • Positioned the posterior teeth over the posterior Disadvantages residual ridge as far lingually as the tongue would lIt is the least esthetic of the five basic occlusal schemes. allow, so that forces would be perpendicular to the lMoving the teeth lingually and altering their vertical support areas. position may not be compatible with the tongue, lip and lProportion: cheek function. • Reduction of tooth width upto 40%. lImpair mastication because of poor bolus penetration. 5 • Reduced vertical stress on the ridge by narrowing the lThis flat type of occlusion cannot be balanced . occlusal table. When using this concept of occlusion the patient is • Forces were centralized without encroachment on instructed not to incise the bolus, with this tooth the tongue space. arrangement Devan noted that “the patient will become a lPitch: chopper, not a chewer or a grinder”6.

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 106 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

1 Lingualized occlusion lCan be used in Class II, Class III & cross-bite situations . Concept was introduced by Alfred Gysi in 1927 Disadvantages : S.H. Payne (1941): 'cusp-to-fossa occlusion' lWear of maxillary lingual cusp or mandibular fossa Pound: 'lingualized occlusion' rapidly results in buccal and lingual contact of equal Lingualized occlusion can be defined as, the form of intensity results in negotiation of centralization of forces denture occlusion that where the maxillary lingual cusps on the mandibular posterior teeth and increase the like articulate with the mandibular occlusal surfaces in centric hood of lateral displacement. working and non-working mandibular positions7. Monoplane occlusion : Lingualized occlusion should not be confused with Sear introduced monoplane occlusion with balancing placement of the mandibular teeth lingual to the ridge ramps or tooth at the distal part of the mandibular arch crest8-12. which comes in contact only in eccentric excursions13.

Indications : De Van has used the same principle without the balancing lWhen patient places high priority on esthetics but oral ramp5. conditions indicate a non-anatomic occlusal scheme According to this concept teeth which are flat mesiodistally such as: and buccolingually are used, oriented as close as possible • Severe alveolar resorption parallel to the maxillary and mandibular mean foundation • Class II jaw relationship plane. • Displaceable supporting tissues. lWhen a complete denture opposes a removable partial Indication : denture. lAbnormal closure imbalance, pathosis, trauma, lWhen a more favorable stress distribution is desired in neuromuscular disturbances. patients with parafunctional habits. lPosterior displaceable mucosa. lMultilated, tortuous ridges with an excessive denture Advantages : space14. lLingualized occlusal concept is a simple technique lRidges are flat or knife edge, rendering dentures more requiring less precise records than fully balanced suspectible to horizontal force. occlusion and is similar in requirements to non- lWhen chewing pattern is milling type with broad anatomic teeth set on a curve. excursions. lMost of the advantages attributed to both anatomic & lMaximum of vertical force and a minimum of horizontal non-anatomic forms are retained. stress is desired15. lCusp form is more natural in appearance compared to The amount of horizontal overlap is determined by jaw non-anatomic tooth form. relation, ranges from 0mm (edge to edge) Class III lGood penetration of food bolus is possible. This may 17 reduce the lateral chewing component. relation to as much as 12mm for severe class II relation . lVertical forces are centralized on mandibular teeth & it Usually the mandibular second molar will be placed on the provides an area of closure, allowing easier molar slope area, called 'skid row'. accommodation to unpredictable basal seat changes. lWith lingualized occlusion, additional stability is In this the occlusal surface of the maxillary second molar imparted to the denture during parafunctional set parallel to the occlusal surface of the mandibular movements when balanced occlusion is used. second molar but 2 mm above the occlusal plane, well out of occlusion.

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 107 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

Monoplane occlusion can be balanced by following reducing unfavourable occlusal forces18. methods: Linear occlusion is a one dimensional contact between two Incline the mandibular second molar to provide contact opposing posterior teeth. The contact occurs only in one with the maxillary denture in all excursions, the maxillary dimension which is the length of the contacting blade (not second molars are similarly inclined but left out of centric surface). This blade, being always in the form of a straight contact. The use of customized balancing ramp placed line, geometrically constitutes “length” without either distal to the mandibular second molar. Ramp provides “width” or “depth” of occlusal contacts. tripodal effect of contacts of denture bases.In eccentric relation, there is smooth contact anteriorly on teeth and Linear occlusion consists of following basic parameters posteriorly on the balancing ramp. Balancing ramp Zero degree (flat plane) teeth are opposed by bladed (line improves horizontal stability of the denture. contact) teeth in which the blade is in a precisely straight line over the crest of the ridge. Advantages : One arch is set to a flat (monoplane occlusal plane). lThey are more adaptable to the unusual jaw relation There is no anterior interference to protrusive and lateral such as class II and class III relations, used easily in cases movements19. of variations in the width of maxillary and mandibular lPlane of occlusion jaws, cross bite. The plane is set steeper. lThese impart a sense of freedom to the patients, do not Esthetics and phonetics determine the maxillary lock mandible in one position. anterior tooth position lThey eliminate horizontal forces, more damaging than lStabilization of mandibular denture vertical forces. Mandibular dentures are almost always less stable than lBecause the monoplane teeth occlude in more than one maxillary dentures, the linear ridge is usually placed on relationship, so centric relation developed to an area the lower ridge. instead of a point. lEsthetics lMonoplane teeth permit the use of a simplified and less For esthetic purpose anatomic teeth are used in time consuming technique and offer greater comfort maxillary posterior region, which occlude with non- and efficiency for a longer period. anatomic mandibular teeth20, 21. lThey accommodate better to the negative changes in the ridge height that occur with aging17. Balanced occlusion : The bilateral, simultaneous, anterior and posterior occlusal Disadvantages : contact of teeth in centric and eccentric positions7. lNo vertical component to aid in shearing during It is not seen in natural dentition. mastication. lPatients may complain of lack of positive intercuspation Characteristic requirements of balanced occlusion: position. • All the teeth of the working side (central incisor to lEsthetically limited. second molar) should glide evenly against the lOcclude only in two dimensions, but the mandible has a opposing teeth. 3D movement due to its condylar behavior. • No single tooth should produce any interference or disocclusion of the other teeth. Linear occlusion : • There should be contacts in the balancing side, but This concept advocates a straight line of points or knife they should not interfere with the smooth gliding edge contacts on artificial teeth in one arch occluding with movements of the working side. flat non-anatomic teeth in the opposing arch, thereby

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 108 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

• There should be simultaneous contact during helps to improve stability of the denture during centric, protrusion. eccentric or parafunctional movements.

Importance of balanced occlusion : For minimal occlusal balance, there should be at least three Balanced occlusion is one of the most important factors points of contact on the occlusal plane. More the number that affect denture stability, absence of occlusal balance of contacts, better the balance. Bilateral balanced will result in leverage of the denture during mandibular occlusion can be protrusive or lateral balance. movement. Protrusive balanced occlusion : Sheppard stated that, “Enter bolus, Exit balance” according This type of balanced occlusion is present when mandible to this statement, the balancing contact is absent when moves in a forward direction and the occlusal contacts are food enters the oral cavity. This makes us think that smooth and simultaneous anteriorly and posteriorly. There balanced occlusion has no function during mastication; should be at least three points of contact in the occlusal hence, it is not essential in a complete denture, but this is plane. Two of these should be located posteriorly and one not true. should be located in the anterior region. This is absent in natural dentition. On an average, a normal individual makes masticatory tooth contact only for 10 minutes in one full day compared Lateral balanced occlusion : to 4 hours of total tooth contact during other functions. So, In lateral balanced there will be a minimal simultaneous for these 4 hours of tooth contact, balanced occlusion is three point contact (one anterior, two posterior) present important to maintain the stability of the denture. during lateral moment of the mandible.

Hence, balanced occlusion is more critical during Lateral balanced occlusion is absent in normal dentition. parafunctional movements. Advantages of Bilateral Occlusal Balance Types of Balanced occlusion lBilateral simultaneous contact help to seat the denture Occlusal balance or balanced occlusion can be classified as in a stable position during mastication, swallowing and follows maintain retention and stability of the denture and the • Unilateral balanced occlusion health of the oral tissues. • Bilateral balanced occlusion lDue to cross-arch balance, as the bolus is chewed on one • Protrusive balanced occlusion side, the balancing cusps will come close or will contact • Lateral balanced occlusion on the other. lDenture bases are stable even during bruxing activity. Unilateral balanced occlusion: This is a type of occlusion seen on occlusal surfaces of teeth Disadvantages of Balanced Occlusion : on one side when they occlude simultaneously with a lIt is difficult to achieve in mouths where an increased smooth, uninterrupted glide. This is not followed during vertical incisor overlap is present. complete denture construction. It is more pertained to lIt may tend to encourage lateral and protrusive grinding fixed partial dentures. habits. lA semi adjustable or fully adjustable articulator is Bilateral balanced occlusion : required3. This is a type of occlusion that is seen when simultaneous contact occurs on both sides in centric and eccentric Occlusal schemes in class II jaw relation : positions. Bilateral balanced occlusion helps to distribute Arrangement of anterior teeth in class II ridge relations: the occlusal load evenly across the arch and therefore lSelect lower anterior teeth of a narrower mesiodistal

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 109 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

width and try to achieve the normal canine relationship. Discussion : lIf esthetics permit, a little crowding of the lower anterior Numerous studies have been done which evaluate and teeth compare occlusal concepts based on various parameters. lSlight spaces between the upper anterior teeth to attain In a study by Heydecke et al it was found that patient ratings normal canine relation. of the prosthesis were not significantly different for a lLower first premolar must be eliminated from dental lingualized scheme as compared to a simple scheme with arch, if discrepancy is more. anatomic teeth28. Participants provided with complete Arrangement of posterior teeth in class II ridge relations: dentures having lingualized or anatomic posterior occlusal lUpper posterior teeth can be placed slightly palatally to forms exhibited significantly higher levels of self-perceived provide a working occlusal contact with the lower teeth. satisfaction compared to those with 0-degree posterior lThe lower posterior teeth are placed over crest of the occlusal forms25. ridge. The upper teeth are then set so that they occlude Effect of occlusal scheme on vertical dimension at with the lower teeth. Then the buccal surface are built occlusion, results shown that increase in vertical on the upper posterior teeth in wax is replaced by tooth- dimension is similar to set in conventional balanced colored acrylic resin to fulfill esthetic requirements and occlusion and lingualized balanced occlusion29. Chewing to provide support for the cheek22, 23. efficiency of monoplane occlusion versus lingualized Occlusal schemes in class III jaw relation occlusion and found that 67% of the patients preferred Arrangement of anterior teeth in class III ridge relations: lingualized articulation26. lIf the ridges are in an edge-to-edge relation, the incisal In a study by Ohguri to estimate which occlusion scheme edges of the upper and lower incisors and canines will shows best conditions of pressure distribution on also meet in edge-to-edge relationship. supporting structures in a complete denture prosthesis it lIn case of extreme protrusion of the mandible, a was found that lingualized occlusion and fully balanced negative or reverse horizontal labial overlap must be occlusion a great occlusal force was not required for used. crushing hard food, and the stress to the supporting tissues lSelect a larger lower tooth mould, to compensate for is smaller than with monoplane occlusion30. wider lower arch width. lCrowding in upper anterior teeth, if esthetically In a study by Matsmaru , he evaluated the influence of acceptable. mandibular residual ridge resorption on masticatory lAn extra lower incisor should be included to avoid the measures of lingualized and fully bilateral balanced spaces between the lower anterior teeth so that denture articulation and he found that lingualized denture appears esthetically better. occlusion is the preferred occlusal scheme for patients with severe RRR32. Arrangement of posterior teeth in class III ridge relations: lUpper posterior teeth can be placed slightly buccal to However on the contrary it was found in a study by Kimoto the crest of the upper ridge. et al that among patient's provided with complete lCuspless teeth may be used to allow freedom of dentures with lingualized occlusion and bilateral balanced buccolingual placement and provide occlusal contact in occlusion. Those with lingualized occlusion displayed upper and lower teeth. greater satisfaction with their denture retention33. lIn case of wider lower arch, an interchange can be done by using upper teeth on the lower denture and lower In another study by Heydecke et al, they found that teeth on the upper denture24. comprehensive methods used for fabrication of complete

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 110 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science dentures including semi-anatomical lingualized teeth and a Total stability is not possible because of the yielding nature full registration did not greatly influence patients perceived of the supporting structures, but control of the physical chewing ability, when compared with more simple factors that apply to the relationship of the teeth to each procedures. Anatomical teeth showed better patient other and that apply to the position of the teeth in the satisfaction with chewing ability for tough foods34. denture base as related to the ridge must be understood. Anatomic denture teeth made up of all ceramic show high Conclusion : average pressure transmission compared to zero degree Differing ideas about occlusion relative to centrics, non anatomic teeth31. gnathology, occlusal adjustment have led to controversial Using Linear occlusal scheme in combination syndrome in the literature. In resorbed ridges, the chances for arch showed that it is esthetically pleasing, no problem in relationship discrepancies are increased due to greater phonetics and ability to chew better35. Effect of occlusal horizontal overlap and lack of specific interdigitation make scheme on muscular activity shown that least activity for all neutrocentric occlusal scheme ideal. With Lingualized occlusal schemes and external pterygoid muscle activity occlusal scheme, additional stability is imparted to the was found to relatively constant for all occlusal schemes27 denture during parafunctional movements when balanced occlusion is used. Monoplane occlusal scheme are more When forces act on a body in such a way that no motion adaptable to the unusual jaw relation such as class II and results, there is balance or equilibrium. This should be a class III malocclusions and cross bite cases. Linear occlusal primary consideration of the dentist when considering the scheme stabilizes the denture bases by minimizing lateral forces that act on the teeth and the denture bases with occlusal forces. their resultant effect on the movement of the base. A stable base is the ultimate goal.

References: 15. Robert Rapp. The Occlusion And Occlusal Patterns Of Artificial 1. Becker CM , Swoope CC, Guckes AD .Lingualized occlusion for Posterior Teeth,J Prosth. Dent 1954;4:461-480. removable prosthodontics. J Prosthet Dent 1977;38:601-608. 16. Chastain G Porter. The Cuspless Centralized Occlusal Pattern,J Prosth 2. Boucher CO, Hickey JC, Zarb GA .Prosthodontic Treatment For Dent 1955;5:313-318. Edentulous Patients, ed 10.St Louis.CV Mosby,1990. 17. Levin, B. Monoplane Teeth. JADA 1972;85: 781-783. 3. Harold R Ortman, Complete Denture Occlusion In: Sheldon Winkler . 18. Frush, J. P.: Linear Occlusion, Glendale, Calif., 1967, Swissedent Essentials of Complete Denture Prosthodontics .2nd ed. India Corporation. 2. Myerson, R. L.. :A.I.T.B.S.Publishers 2009 : 217-249. 19. Myerson RL. The Use of Porcelain and Plastic Teeth in Opposing 4. Bernard Levin : A Review Of Artificial Posterior Tooth Forms Including A Complete Dentures, J. Prosthet. Dent. 1957;7 625-633. Preliminary Report On A New Posterior Tooth. J Prosthet Dent 1977 ; 20. Koran A, Craig RG, Tillitson EW. Coefficient of Friction of Prosthetic 38:3-15. Tooth Materials, J. Prosthet. Dent.1972;27: 269-274. 5. DeVan, M.M. Concept of Neutro-centric occlusion. JADA 48:165-169, 21. Donald GG, Charles JS. Lineal Occlusion Concepts For Complete 1954. Dentures,J Prosth Dent.1974;32:122-129. 6. De Van, M M : Synopsis, Stablilty In Full Denture Construction, 22. Hardy IR, Passamonti GA. Method of arranging artificial teeth for class Penn,Dent.J.22:8,1955 II jaw relations. J. Prosthet Dent 13:606-610, 1963. 7. The glossary of prosthodontic terms. J Prosthet Dent.2005;94:49–81. 23. Goyal BK, Bhargava K : Arrangement of artificial teeth in abnormal jaw 8. Winter CM., Woelfel JB, Igarashi T. Five Year Changes in the Edentulous relations: maxillary protrusion and wider upper arch. J Prosthet Mandible as Determined on Oblique Cephalometric Radiographs. J Dent.1974;32:107. Dent Res. 53: 1455-1467, 1974. 24. Goyal BK, Bhargava K : Arrangement of artificial teeth in abnormal jaw 9. Boswell JV. Practical Occlusion in Relation to Complete Dentures, J relations: mandibular protrusion and wider lower arch. J Prosthet Prosthet Dent.1: 307-321, 1951. Dent.1974;32:458. 10. Sears VH. Specifications for Artificial Posterior Teeth, J Prosthet Dent. 25. AF Sutton, JF McCord : A randomized clinical trial comparing anatomic, 2: 353-361, 1952. lingualized, and zero-degree posterior occlusal forms for complete 11. Porter CG. The Cuspless Centralized Occlusal Pattern, J Prosthet Dent. dentures. J Prosthet Dent 2007;97:292-298 5: 313-318, 1955. 26. Clough HE, Knodle JM, Leeper SH, Pudwill ML, Taylor DT.A comparison 12. McMillian HW. Unilateral vs Bilateral Balanced Occlusion. JADA. of lingualized occlusion and monoplane occlusion in complete 17:1207-1221, 1930. dentures. J Prosthet Dent. 1983;50:176-179. 13. Seras VH : Principles And Technique Of Complete Denture 27. Judson C. Hickey, James A. Kreider, Carl O. Boucher, Otto Storz : A Construction.St Louis,CV Mosby,1949. method of studying the influence of occlusal schemes on muscular 14. Sameul Friedman. A Comparative Analysis Of Conflicting Factors In activity. J Prosthet Dent. 1959;9:498-505. The Selection Of The Occlusal Pattern For Edentulous Patients,J 28. Heydecke G, Vogeler M, Wolkewitz M, Türp JC, Strub JR. Simplified Prosth. Dent 1964;14:31-44. versu comprehensive fabrication of complete dentures: patient

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 111 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

ratings of denture satisfaction from a randomized crossover trial. 32. Matsumaru Y. Influence of mandibular residual ridge resorption on Quintessence Int. 2008 Feb;39(2):107-16 objective masticatory measures of lingualized and fully bilateral 29. Michael Frederico Manzolli Basso,a Sergio Sualdini Nogueira, Joao balanced denture articulation. J Prosthodont Res. 2010 Jul;54(3):112- Neudenir Arioli-Filho: Comparison of the occlusal vertical dimension 8. Epub 2010 Jan 19. after processing complete dentures made with lingualized balanced 33. Kimoto S, Gunji A, Yamakawa A, Ajiro H, Kanno K, Shinomiya M, Kawai occlusion and conventional balanced occlusion J Prosthet Dent Y, Kawara M, Kobayashi K. Prospective clinical trial comparing 2006;96:200-4. lingualized occlusion to bilateral balanced occlusion in complete 30. Ohguri T, , Ichikawa T, Matsumoto N. Influence of occlusal scheme on dentures: a pilot study. Int J Prosthodont. 2006 Jan-Feb;19(1):103-9. the pressure distribution under a complete denture. Int J Prosthodont. 34. Heydecke G, Akkad AS, Wolkewitz M, Vogeler M, , Strub JR.Patient 1999 Jul-Aug;12(4):353-8. ratings of chewing ability from a randomised crossover trial: 31. Mansuang Arksornnukit,Thitima Phunthikaphadr, and Hidekazu lingualised vs. first premolar/canine-guided occlusionfor complete Takahashi: Pressure transmission and distribution under denture dentures. Gerodontology. 2007 Jun;24(2):77-86. bases using denture teeth with different materials and cuspal 35. William S Jameson:The Use Of Linear Occlusion To Treat A Patient With angulations.J Prosthet Dent 2011;105:127-13. Combination Syndrome : A Case Report.J Prosth Dent 2001;85:15-19.

Keywords : Occlusal schemes, neutrocentric occlusion, lingualized 112 occlusion, balanced occlusion, monoplane occlusion. - Krishna Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science Review Article BIOFILMS PRODUCED BY CANDIDA YEASTS AND ITS CONSEQUENCES: A REVIEW

Anupama Prasad D.1, B. Rajendra Prasad², Veena Shetty³ & C.S. Shastry⁴ ¹ Lecturer, Department of Prosthodontics, ² Dean, Professor, Post graduate guide, A. B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte, Mangalore, Karnataka, India - 575 018. ³ Assoc. Professor, Department of Microbiology, K.S. Hegde Medical Academy, Nitte University , Deralakatte, Mangalore - 575 018. ⁴ Principal, NGSM Institute of Pharmceutical Sciences, Nitte University Paneer, Deralakatte, Mangalore - 575018 Correspondence: Anupama Prasad D. Lecturer, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Deralakatte , Mangalore - 575 018 E-mail : [email protected] Abstract: This paper aimed to gather information regarding mechanism of biofilm formation and development of resistance of the fungi mainly the candida species to antifungal therapy from literature through 1996-2012. We have carried out a detailed search in the National Library of Medicine's PubMed database, Google search and Science Direct to include all studies and reviews published in English language. The key words used for the search were biofilm, Candida, antimicrobial resistance, denture stomatitis and Candidiasis. This paper tries to explain the mechanism of biofilm formation, factors which initiate and propagate biofilm production and certain special features like thigmotropism and quorum sensing which are responsible for development of resistance in these yeasts. Keywords : Biofilms by Candida, quorum sensing, thigmotropism, antifungal resistance, candidal colonisation, denture stomatitis

Introduction : Candida species to antifungal therapy from 1996-2012. We Infections due to fungal biofilms are usually refractory in have carried out a detailed search in the National Library of nature and do not show positive response to antimicrobial Medicine's PubMed database, Google search and Science therapy as they have developed resistance to conventional Direct to include all original studies and reviews. The key antifungals¹'². A biofilm is defined as a structured words used for the search were biofilm, Candida, community of micro-organisms surrounded by a self antimicrobial resistance, denture stomatitis and produced polymeric matrix and is adherent to an inert or Candidiasis. living surface³. It is seen that a biofilm is a resilient group of Denture stomatitis and candida biofilm : microbes in an organized form, in which properties such as The fitting surface of the maxillary denture and soft lining drug resistance is acquired by individual cells. We have materials are the main reservoirs of Candida albicans and seen that many fungal species are capable of forming related Candida species. Soft denture liners are used to aggregates in the form of flocs, mats, biofilms, etc., but C. provide comfort to complete denture wearers where albicans is one of very few fungal species which is efficient retention is compromised and cannot tolerate dentures enough to form biofilms in due to irregular alveolar bone and thin fragile mucosal Access this article online a healthy mammalian Quick Response Code covering. Colonization by Candida and subsequent host⁴. This paper aimed to formation of biofilm on denture materials leads to g a t h e r i n f o r m a t i o n development of denture stomatitis5. The surface of the regarding mechanism of acrylic denture has a biofilm of mixed species formed biofilm formation and which contains large numbers of bacteria, and yeasts 6.It is development of resistance seen that candidal colonisation is common in immune of the fungi mainly the

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 113 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science compromised individuals, denture prosthesis and soft with C. glabrata when compared to C. albicans. Candida liners provide refuge to Candida fungi rapidly and lead to growth was higher on the polyamide resin than on the formation of either single species or multispecies biofilms. PMMA material. Complexity and phenotypic Also it is seen that Candida yeast species can adhere very heterogeneity explains the difference in adherence strongly to denture materials7. capacity. Heterogenicity is a result of variation in surface hydrophobicity, formation of hyphae, presence or absence Candidiasis a superficial form denture stomatitis affects of extracellular protienases or thigmotropism, all of which 65% of edentulous individuals, the development of which influence adhesion of Candida to plastic surfaces¹². i s a n o u t c o m e o f b i o f i l m f o r m a t i o n . Environmental factors which contribute to the initial Polymethylmethacrylate, which is used in construction of surface attachment flow of the surrounding medium dentures, and silicone elastomers were the main bio (urine, blood, saliva, and mucus), pH, temperature, prosthetic materials where biofilm formation is seen and osmolarity, bacteria, presence of antimicrobial agents, and infection becomes re-established after treatment. Biofilms host immune factors¹³. Fungal colonisation on denture g r o w n o n t h e i r r e g u l a r s u r f a c e o f lining materials may also be promoted by salivary and polymethylmethacrylate(PMMA) have a biphasic structure serum pellicles, mainly mucinous glycoprotein of human compared to, those grown on flat hydrophobic surfaces saliva by sugar-specific interactions¹⁴. such as silicone elastomer .This is composed of an adherent blastospore layer covered by sparser hyphal elements Mechanism of biofilm formation and its function: embedded in a deep layer of extracellular material8 When 'planktonic' bacteria which are unattached .Insufficient oral hygiene and stress factors leads to fungal individual cells adhere to a surface, there is beginning of proliferation and biofilm formation with respect to soft biofilm development. Mechanism of adherence varies denture liners mainly in the maxillary denture bases?. depending on the surface to be attached and microbes, physiological adaptations are induced as adherent cells Van der Waals forces facilitate adherence of Candida grow and divide in proximity to the surface, including albicans . Absence of ionic surface on PMMA minimizes the secretion of exopolysaccharides which creates a protective adsorption of defence molecules on denture surfaces. matrix enclosing the cells¹5. Sophisticated intercellular Edentulous patients mostly wear dentures during the night communication systems are utilized for formation of a which is a significant factor for development of denture biofilm, it also involves extracellular polymeric matrix stomatitis. Risk of general health complications and formation and depends on adhesion both to substrates, denture wearing increases with age. Reduced saliva ,the adhesion from cell to cell, and can be composed of multiple natural protectors of oral cavity along with poor oral cell types. Biofilms by microbes represent the first step in hygiene are directly related to higher Candida colonization the evolution of multicellularity in higher eukaryotes¹6. on dentures due to increased medications in such patients Biofilm is defined as a community of microorganisms ¹°. attached to a surface, forming three-dimensional Immediately after inserting into the oral cavity, the denture structures containing exopolymeric matrix and cells that surface will be coated by salivary components which exhibit distinctive phenotypic properties¹7 change the physicochemical property of the surface, Biofilm formation follows certain characteristic phases, adding specific receptors for microbial adhesion and hence beginning with initial adherence of individual or single cells influences fungal adhesion. With an increase in mucin to the substratum. Later there is formation and growth of thickness the density of adhering C. Albicans is also seen to micro colonies in the form of trabeculated monolayer increase, mucin thus has an important role in rigidity of the which grows confluent. There is a network formed biofilm¹¹. Superior adhesion to acrylic resin surfaces is seen

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 114 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science consisting of hyphae, yeast cells and pseudohyphae which candidiasis. Limited oxygen at base of substratum causes become enclosed by extracellular matrix¹8.Initial expression of gene SUN 41, which augments biofilm colonization is in the form of yeast cells, this is followed by attachment to substratum²² formation of germ tubes 3-6 hrs later. The basal layer is C. albicans, has the ability to switch between different formed by adhering yeast cells which is responsible for firm morphological forms. It can grow as blastospore or pseudo attachment of basal layer to the substratum. Subsequent hyphae or hyphae, it is therefore considered a pleomorphic germination brings about bulk of biofilm. Biofilm which is or polymorphic organism. The blastospores are converted mature contains mycelia, yeast and pseudo mycelia and are to mycelial or filamentous forms by production of germ seen after 48 hrs. Yeasts form only basal layer therefore tubes. Yeast cells growing by budding elongate and do not form a thin bio film, mycelia forms a loose adherent detach from adjacent cell but undergo polarised cell attachment to the surface¹7'¹?. In C. albicans biofilm division to form pseudo hyphae. Round, retractile spores formation, cells adhere to the substratum resulting in with a thick cell wall called chlamydospores are formation of basal layer which further divide and produce transformationforms of Candida in non optimal growth compartmentalized hyphae. Intertwining in the upper conditions. Various such transformation capacity of region of the biofilm is brought about by these long tubular Candida permits it to adapt to different biological projections¹6. The strongly adherent yeasts can cause niches¹'²³. cavitations on the surface of substratum mainly the mucosal and epithelial surfaces. Tip growing hyphae also SEM studies have shown the emergence of germ tube arise from yeast cells, grooves ridges and pores of the appendages which produce adhesins for plastic surfaces. substratum guide the direction of hyphal growth, this type They also possess binding sites for serum protein of contact guidance is called thigmotropism and holds the components like fibrinogen, fibronectin and complement responsibility of hyphal invasion in areas of weak surface or factor. Greatest blastospore-substrate adhesion was seen membrane integrity ²°. on the serum-coated specimens indicating presence of adhesin receptor- like mechanisms in the presence of Biofilms with characteristic three-dimensional structures is serum. Fibronectin and Con-A binding material were formed by C. albicans cells on solid surfaces. For a involved in Candida biofilm development with saliva and successful biofilm formation, appropriate cell surface serum. Therefore biofilm formation is a complex molecules for adhesion should be expressed. Also genes phenomenon which involves mannan-binding protein, responsible for protein synthesis in high levels should be fibronectin, glycoproteins and IgG or IgM¹⁴. expressed. Biofilm formation by adherence of Candida glabrata is mediated in part by a cell surface protein Profuse biofilm was produced by C. albicans when Epa6p¹7. Efg1p another cell surface protein promotes compared to C. parapsilosis and C. Krusei. Compared to C. formation of biofilm and a protein Czf1p antagonizes bio albicans, biofilms of C. parapsilosis and C. Krusei were of film formation. C. albicans cells must sense more than one reduced thickness, less profuse, and devoid of hyphal feature on the surface of substratum to produce a correct elements while C. albicans biofilms showed development response such as invasive filamentation or biofilm of a dense mass stacked in a palisadic manner devoid of formation ,which are distinct processes occurring on intracellular spaces. C. tropicalis strain produced a biofilm different types of surfaces²¹. Cell wall protein Hwp1 is without a basal blastospore layer. C. glabrata isolates required for the formation of biofilm in case of C. Albicans produced scant population of blastospores 24,25. both in vitro and in vivo. SUN41, a cell wall-related gene has Extracellular matrix of polymeric substances should be a major role to play in formation of biofilm, integrity of cell released by cells in the developing biofilm , adhesion plays wall and virulence in oropharyngeal and disseminated a major role in development of biofilm. Adhesion must first

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 115 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science bind cell to one another and to the substratum. As a second between hyphal cells to facilitate the diffusion of nutrients step, the hyphae must be bound to each other to stabilize from the environment through the biomass and from there the maturing biofilm¹6. These hyphae are essential to the bottom layers, it also permit waste disposal, elements which give structural integrity to fully mature resistance of physical and chemical stress, a community- biofilm. Hyphal formation in C. albicans occurs as a based regulation of gene expression, forms micro-niches in response to distinct environmental stimuli. The hyphal the bio film, and host oxygen radical and protease defences formation is controlled by complex regulatory networks. and potential for dispersion via detachment ¹³'²6'²?'³°. Filamentation also is critical in the development of the Mature bio films are elaborate structures which appear as spatially organized architecture of a mature biofilm ²6. pillars rising up from mats of jumbled cells, fluid-filled micro channels for permeation. They are dynamic Population in a biofilm can be developed from a single communities which can spread across surfaces, they can species or multiple microbial species forming a community. also incorporate particulates and other microbes from the Protection from the environment, new genetic traits surrounding and continue to shed new planktonic cells. On acquisition, availability of nutrient source and metabolic dentures formation of bio film is a result of complex cooperation are the ecologic advantages for the microbes interactions among yeast, bacteria, nutrients, and saliva or in a biofilm. Early (0–11 h), intermediate (12–30 h), and even serum proteins¹5. mature (38–72 h) are three distinct developmental phases of a biofilm¹'²7. Biofilms form a protective reservoir or safe Constitution of biofilm and factors influencing its sanctuary for oral microbes³'¹³. Performing special cellular formation: functions and production of specific extracellular materials Universal, complex, interdependent communities of is the characteristic nature of a true biofilm. C. albicans are surface-associated microorganisms enclosed in an capable of biofilm formation both in yeast and hyphal exopolysaccharide matrix are called biofilms and can occur forms, hence biofilm growth is not morphology specific³. on any surface¹.The cells embedded in extracellular Adherence and dimorphic transition are major steps in polymeric material which showed an amorphous granular initiation of biofilm development²8. appearance .On close examination the structures in the biofilm showed coaggregating C. albicans cells³. Recently Stages in formation of biofilm Based on in vitro studies carried out (Baillie and Douglas, 1999; biofilm network in C. albicans has undergone relatively an Chandra et al., 2001; Douglas, 2003; Hawser and Douglas, 1994; extensive evolutionary changes where ''old'' genes are Nobile et al., 2009; Uppuluri et al., 2010a, 2010b)⁴ underrepresented and ''young'' genes are enriched in the 1. Attachment and colonization of yeast-form (nearly spherical) cells to a surface biofilm circuit⁴. Extracellular polymeric material of the 2. Growth and proliferation of yeast-form cells to allow planktonik as well as from bio films showed presence of formation of a basal layer of anchoring micro colonies carbohydrate, protein, phosphorus, hexosamine, glucose 3. Growth of pseudo hyphae (ellipsoid cells joined end to end) and extensive hyphae (chains of cylindrical cells) in a proportion higher than mannose, galactose, concomitant with the production of extracellular matrix extracellular DNA and uronic acid6'¹³'³¹. material 4. Dispersal of yeast-form cells from the biofilm to seed new Candida cells in the bio film show heterogeneity, which sites. may be a response to environmental conditions, like differences in pH, oxygen availability, and redox potential. A typical bio film formed on flat, hydrophobic surfaces, like A bio film has been described as “heterogeneous mosaic silicone elastomer and polyvinyl chloride, has a biphasic model”, since it contains extracellular polymeric distribution of components: A blastospore layer, adherent substances that hold stacks of bacterial micro colonies to substrate which in turn is covered by a sparse layer of together. A layer of cells (5 mm thick) underlie and attach to hyphal elements embedded in EPS. Water channels exist

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 116 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science the substratum below these stacks8. Morphogenesis of multilayer biofilm with clusters of blastospores under cells in the bio film is dependent on factors such as carbon aerobic dynamic condition and an extensive hyphal source, substratum, and species. Maturation of Candida network under anaerobic conditions³². Candida is able to bio films formed in in-vivo models is faster and of greater grow either aerobically or anaerobically²?. Positive impact thickness than the ones grown in in-vitro models. of dynamic conditions on microbial biofilm growth is a Substratum, nutrient, presence of saliva, availability of result of better perfusion of oxygen and nutrients into the oxygen, EPS and Candida species are factors which innermost part of the biofilm³². Cell type, growth influence Candida bio film formation²?. conditions, and the abiotic surface properties affect the tenacity of biofilm adherence ¹8. Substratum used in in-vitro model systems are acrylic, silicone elastomeric catheter disks , cellulose cylindrical Variation in biofilms of different species is observed, more filters, polymethylmethacrylate, plastic, Biotic surfaces, confluent biofilms are seen with C. albicans, C. such as those in an engineered human oral mucosa model dubliniensis, and C. krusei. Wild-type Candida strains and glass²?. Surface properties of materials, surface produce healthy and confluent biofilm. Greater biofilm- roughness, hydrophilicity, physiochemical properties, forming ability is seen with non-albicans species than for surface topography and chemical properties also play a albicans species ²?. C. parapsilosis formed less thicker critical role in varied bio film formation¹¹'²?. biofilm that showed distinct clumping and consisted of irregular groupings of blastospores devoid of extracellular Glucose, fructose, galactose and lactose favour C. albicans matrix material and hyphae, complex biofilms are formed bio film formation compared to sucrose and maltose. Bio by C. albicans which consists of confluent basal blastospore film formation is also linked to the (over)expression and layer covered by a thick matrix composed of extracellular polysaccharide matrix production by adhesins¹¹. material and hyphal elements ²5. C. krusei, C. tropicalis, C. The surface turns hydrophilic once it is coated with saliva, parapsilosis, C. kefyr and C. guilliermondii showed higher which causes reduced adhesion of hydrophobic strains at biofilm growth under anaerobic conditions in a static the same time enhances hydrophilic strains. Mucin among environment, only C. krusei species formed less biofilm in salivary components acts as a receptor for Candida anaerobic atmosphere. Low oxygen and nutrient adhesion and subsequent biofilm formation. Increased starvation promotes the hyphal growth hence nature of yeast counts and risk of candidosis is associated with dry gaseous environment is responsible for the phase mouth²?. transition in the dimorphic fungus C. albicans³².

Temperature changes, ionic stress, changes in osmolarity, Slowly growing or nongrowing microorganisms are the and oxidative stress are a range of some physiological contents of a biofilm and are protected by their inactivity. stresses. Various receptors sense these stresses and elicit The biofilm mode of growth is characterised by slow responses via signalling pathways. One such reponse is growth and limited nutrition.microbes in the biofilm are mitogen-activated protein kinase (MAPK) Mck1p, which is killed slowly compared to their planktonic varieties, the activated by contact stress, is involved in biofilm rate of killing decreases with increase in the thickness of development¹³. the biofilm.³³ Tyrosol and Farnesol which are quorum sensing molecules promotes hyphal formation during the Low levels of oxygen near the central core area favors early and intermediate stages of biofilm development ,they biofilm architecture. biofilm growth under dynamic also stimulate yeast cells to be released from the biofilm conditions were higher than static conditions after 48 h and permit spread of the microbe to colonize new irrespective of the environmental oxygen content in surfaces³⁴ . Composition of medium, substratum, flow isolates of C. albicans which produced a dense, compact,

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 117 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science conditions, and quorum sensing cause different plasticity Resistance to azole and polyene-derived antifungal agents in biofilm structure suggesting different locations within can be explained based on the alteration of ergosterols in the host calls for different properties of biofilms ¹7. biofilm membranes¹³. There is a significant decrease in the ergosterol levels and diminished levels of ergosterol Factors responsible for development of resistance in biosynthetic gene expression of intermediate and mature biofilm : phases of biofilm , this diminished levels of ergosterol in Candida associated with biofilm often show resistance to sessile C. albicans reflects a physiological state that is more conventional antifungal agents like amphotericin B, conducive to resistance in these cells³5'³7. Cells in biofilms nystatin, chlorhexidine, and fluconazole ¹’³'6'¹³'³5’³7. also have shown to express higher levels of genes involved Resistance of biofilm cells may due to their anaerobic in amino acid and nucleotide metabolism, protein growth conditions, mainly as seen with tooth decay and synthesis, other metabolic functions, and subcellular periodontal disease and these anaerobic cells lead to localization¹7. “persister” cells, which remain viable in biofilms even after being treated with antimicrobial agents ²°. C. krusei, C. Bacterial matrix material may restrict penetration of drugs glabrata, C. lusitaniae, and the newest Candida species, C. by acting as a barrier to fluconazole penetration in mixed Dubliniensis are a few species of Candida which are less species biofilms of C. albicans and S. epidermidis 6, susceptible to commonly used antifungals. Clinical substantially more matrix material are produced in biofilms resistance is defined as persistence or progression of an subjected to a liquid flow than the ones incubated infection despite appropriate antimicrobial therapy. If the statically. C. Tropicalis in contrast with C. albicans organism shows drug resistance before exposure to the synthesize large amounts of extracellular material under drug then it is called as primary resistance, whilst static conditions, with many cells hidden by the enveloping resistance shown by the microbial community is a result of matrix³¹. The matrix which envelops sessile communities of exposure to drug, it is termed as secondary resistance¹. cells, formed by merging of initial founder microcolonies Biofilms have cells with reduced ergosterol content in are composed mainly of slowly growing cells act as a barrier comparison to cells of liquid culture. Also major expression to the diffusion of antimicrobials and/or as an ion- of efflux pumps like adenosine triphosphate–binding exchange resin to bind charged antimicrobial molecules. cassette (ABC) transporters encoded genes encoding drug Drug resistance develops over time, coincident with efflux determinants or multidrug resistance (MDR) biofilm maturation ³5'³7. Cell density, membrane sterols transporters CDR1 and CDR2 are expressed by cells in and cell wall glucans may also be the reason behind this biofilm with transient expression of MDR1 by the adherent resistance development¹?'³6. PH, temperature, oxygen cells¹'²'³'6'8'¹7'³5'³7. Overexpression of genes encoding efflux availability, and many such factors like environmental pumps are regulated differentially during development stresses will lead to alter the architecture of the biofilm, as and exposure to antifungal agents and are employed in well as antifungal sensitivity¹³. nutrient uptake and cellular detoxification¹³'³5. They are Phenotypic changes or phenotypic switching resulting important in maintaining homeostasis within complex from a decreased growth rate or nutrient limitation,cellular environments and confer self protection against acute heterogeneity and reduction of growth rates under toxicity. During early to intermediate phases of biofilm different environmental pressures can benefit the biofilm. development these efflux pumps are used but are Fungal biofilm resistance is an inducible phenotype which conceded as ECM achieves maturity and are then used to is a part of a highly evolved series of molecular pathways “soak” and consume antifungal agents¹³.Non-efflux pump responsible of regulating development and homeostasis of confers drug resistance to mature biofilms ². biofilm¹'³ '¹³'¹7'³¹. Thigmotropism, the directional response

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 118 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science of a cell or tissue to touch, or physical contact with a solid identified as a second quorum-sensing molecule in C. object¹7 reorients the direction of hyphal growth in albicans. Tyrosol accelerates the formation of germ tubes³⁴. response to contact with features of the physical Calcineurin, a Ca2+-calmodulin-activated serine/ environment. On a solid surface, activation of the cell threonine-specific protein phosphatise has also been integrity pathway contributes to biofilm structure and implicated in mediating resistance to the azoles in both in expression of the drug resistant phenotype²¹. vitro and in vivo models of biofilm formation. Beta-1,3, Quorum sensing ,which is a cell-density dependent glucan is responsible for sequestering azoles,by acting as a communication and coordination of microbial behaviour “drug sponge” toconfer resistance on C. albicans biofilms, via signalling molecules relies on production of they are also responsible for sequestering echinocandins, acylhomoserine lactone (AHL) signal molecules which pyrimidines, and polyenes¹³. Quiescence (state of stillness freely diffuse across cell membranes¹5'¹7.It is the or inactivity) is thought to be a factor in drug resistance, but fundamental to microbial biofilm formation because it the majority of cells in C. albicans biofilms are seen to be benefits the biofilms' well being by preventing unnecessary metabolically active³7'8. Biofilms of C. albicans which were overpopulation .It also controls the competition for grown under glucose and iron limited conditions were nutrients and has important implications in the infectious highly resistant to amphotericin B and those biofilms process, particularly for dissemination and for the grown under anaerobic conditions also showed that C. establishment of distal sites of infection³5. The fungal albicans biofilms were resistant to the high levels of pathogen Candida albicans was the first eukaryotic amphotericin B and different azole antifungals¹³. microorganism shown to exhibit quorum sensing³⁴ . Discussion : Farnesol, a quorum sensing molecule is produced by A biofilm is defined as a structured community of micro- continuously growing cells of Candida albicans and organisms surrounded by a self produced polymeric matrix accumulates to a level similar to cell number and inhibits and is adherent to an inert or living surface. It is universal, the filamentation of yeast cells thereby inhibiting its complex, interdependent communities of surface- growth. It is also seen that incubation of cells in the a s s o c i ate d m i c ro o rga n i s m s e n c l o s e d i n a n presence of farnesol leads to reduced formation of biofilms exopolysaccharide matrix. Immuno compromised patients and mature biofilms are affected by the presence of these such as those with cancer or HIV infection are often the molecules. Therefore the formation and stability of the most susceptible ones. Biofilms are most notorious and biofilm is regulated by farnesol¹7'³5. difficult to be eliminated and are often source of A small number of drug-tolerant or “persister” cells which recalcitrant infections. Increased use of azole antifungals usually account for 0.1 to 1% of the biofilm population can which are fungistatic has resulted in the development of remain viable even at high concentrations of antimicrobial resistance to these drugs¹. agents¹?'³5'³6. C. albicans persisters are phenotypic variants Biofilm formation and development of resistance to of the wild type that arise in a clonal population of antimicrobials are closely associated. Mature C. albicans genetically identical cells³7. Biofilm exopolymer is an biofilms show a complex three-dimensional architecture important component of recalcitrance of persister cells with extensive spatial heterogeneity, and consist of a dense because of restricted penetration of drugs through it²8. network of yeast, hyphae and pseudo hyphae encased Biofilms of C. krusei and C. Parapsilosis appear to harbor within a matrix of exopolymeric material. Candida persister cells, while biofilms of C. glabrata and C. tropicalis associated denture stomatitis is a result of adherence of are devoid of such cells¹?'³6. Tyrosol (2-[4-hydroxyphenyl] Candida directly or via an intermediary layer of plaque- ethanol), a derivative of tyrosine, was subsequently f o r m i n g b a c t e r i a t o d e n t u r e a c r y l i c

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 119 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

(polymethylmethacrylate). Complex biofilm in the form of Conclusion : denture plaque serve as a protected reservoir of C. Reduced manual dexterity, hyposalivation, Xerostomia, albicans. The most important factor in the pathogenesis of increased medications, immune compromised situations, denture stomatitis is growth of large numbers of Candida poor oral hygiene, all these are factors which predispose on the fitting surface of the appliance and acid production the elderly population to the risk of biofilm formation and by grown yeasts. This leads to direct cytotoxicity and development of denture stomatitis. Development of activation of acid proteinase. Production of phospholipase resistance due to biofilm formation is a serious problem to by these yeasts promotes adhesion of Candida and be combated. Several studies have been carried out to use successful colonization5. Close fitting removable maxillary herbal products or combination of various antimicrobials complete dentures are most commonly colonized by to overcome the resistance developed by the fungi. Candida due to large surface area available. Characteristic features like dimorphism, Quorum sensing, Nonspecific interactions like hydrophobic and electrostatic thigmotropism, metabolic quiescence all put together interactions, and specific interactions like like adhesin or result in formation of a biofilm which is stubborn and integrin-receptor interactions, serum proteins and salivary prevents the penetration of antifungal drugs and thus a factors regulate co-adhesion and adherence which results resistant form of the yeast in the biofilm, well protected in colonisation and subsequent formation of biofilm. from the host defence mechanism as well as the treatment Thigmotropism and fungal biofilm formation are also rendered. It is a field open for further research to find closely related where the yeast growth follows surface mechanisms of preventing these causative factors and to irregularities¹7. Pathogen is protected by virtue of biofilms discover or invent formulations targeting these areas from host defences and antibiotics, biofilms also provide which are responsible for developing resistance in the pathogen spatial stability and autonomy in controlling its yeast cells. own microenvironment. As a mechanism to protect cell propagation in a hostile environment, C. albicans biofilm formation has preceded host colonization in the evolution of the organism¹6.

Over expression of phenotypic changes Genes encoding for resulting from nutrient metabolic Quiescence drug efflux pumps limitation

Alteration of restricted penetration quorum-sensing ergosterols in biofilm of drugs through the molecules membranes biofilm matrix

changes in both the cell Nutrient limitation and Medium and condition membrane and cell wall slow growth of yeast growth

Calcineurin a Ca2+- calmodulin-activated PH, temperature, Persister cells serine/ threonine- oxygen availability specific protein (stress)

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 120 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Jabra-Rizk MA, Falkler WA, Meiller TF. Fungal Biofilms and Drug Fungi: Farnesol and Beyond. Appl Environ Microbiol. 2006; Resistance. Emerg Infect Dis. 2004; 10(1):14-9. 72(6):3805-13. 2. Bruzual I, Riggle P, Hadley S, Kumamoto CA. Biofilm formation by 20. Watts HJ, Véry AA, Perera TH, Davies JM, Gow NA. Thigmotropism and fluconazole-resistant Candida albicans strains is inhibited by stretch-activated channels in the pathogenic fungus Candida albicans. fluconazole. J Antimicrob Chemother. 2007; 59(3):441-50. Microbiology 1998; 144:689-95. 3. Chandra J, Mukherjee PK, Leidich SD, Faddoul FF, Hoyer LL, Douglas LJ, 21. Kumamoto CA. A contact-activated kinase signals Candida albicans Ghannoum MA. Antifungal Resistance of Candidal Biofilms Formed on invasive growth and biofilm development. Proc Natl Acad Sci U S A. Denture Acrylic in vitro. J Dent Res. 2001; 80(3):903-8. 2005; 102(15):5576-81. 4. Nobile CJ, Fox EP, Nett JE, Sorrells TR, Mitrovich QM, Hernday AD, Tuch 22. Norice CT, Smith FJ Jr, Solis N, Filler SG, Mitchell AP. Requirement for BB, Andes DR, Johnson AD. A Recently Evolved Transcriptional Candida albicans Sun41 in Biofilm Formation and Virulence. Eukaryot Network Controls Biofilm Development in Candida albicans. Cell. Cell. 2007; 6(11):2046-55. 2012; 148(1-2):126-38. 23. Biswas S, Van Dijck P, Datta A. Environmental Sensing and Signal 5. Nikawa H, Jin C, Makihira S, Egusa H, Hamada T, Kumagai H. Biofilm Transduction Pathways Regulating Morphopathogenic Determinants formation of Candida albicans on the surfaces of deteriorated soft of Candida albicans. Microbiol Mol Biol Rev. 2007; 71(2):348-76. denture lining materials caused by denture cleansers in vitro. J Oral 24. Samaranayake YH, Ye J, Yau JY, Cheung BP, Samaranayake LP. In Vitro Rehabil. 2003; 30(3):243-50. Method to Study Antifungal Perfusion in Candida Biofilms. J Clin 6. Douglas LJ. Medical importance of biofilms in Candida infections. Rev Microbiol. 2005; 43(2):818-25. Iberoam Micol.2002; 19(3):139-43. 25. Kuhn DM, Chandra J, Mukherjee PK and Ghannoum MA. Comparison 7. Pathak AK, Sharma S, Shrivastva P. Multispecies biofilm of Candida of Biofilms Formed by Candida albicans and Candida parapsilosis on albicans and non-Candida albicans Candida species on acrylic Bioprosthetic Surfaces. Infect Immun. 2002; 70(2):878-88. substrate. J Appl Oral Sci. 2012; 20(1):70-5. 26. López-Ribot JL. Candida albicans Biofilms: More Than Filamentation. 8. Chandra J, Kuhn DM, Mukherjee PK, Hoyer LL, McCormick T, Curr Biol. 2005; 15(12):R453-5. Ghannoum MA. Biofilm Formation by the Fungal Pathogen Candida 27. Mohandas V, Ballal M. Distribution of Candida Species in different albicans: Development, Architecture, and Drug Resistance J Bacteriol. clinical samples and their virulence: biofilm formation, proteinase and 2001; 183(18):5385-94. phospholipase production: a study on hospitalized patients in 9. Boscato N, Radavelli A, Faccio D, Loguercio AD. Biofilm formation of Southern India. J Glob Infect Dis. 2011; 3(1):4-8. Candida albicans on the surface of a soft denture-lining material. 28. Khan MSA, Ahmad I. Biofilm inhibition by Cymbopogon citratus and Gerodontology. 2009; 26(3):210-3. Syzygium aromaticum essential oils in the strains of Candida albicans. 10. Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral J Ethnopharmacol. 2012; 140(2):416-23. mucosal lesions in U.S. adults: data from the Third National Health and 29. Seneviratne CJ, Jin L, Samaranayake LP. Biofilm lifestyle of Candida: a Nutrition Examination Survey,1988-1994. J Am Dent Assoc. mini review. Oral Dis.2008; 14(7):582-90. 2004;135(9):1279-1286 30. Shirtliff ME, Mader JT, Camper AK. Molecular Interactions in Biofilms. 11. Li J, Hirota K, Goto T, Yumoto H, Miyake Y, Ichikawa T. Biofilm formation Chemistry & Biology 2002, 9(8):859-871. of Candida albicans on implant overdenture materials and its removal. 31. Al-Fattani MA, Douglas LJ. Biofilm matrix of Candida albicans and J Dent. 2012; 40(8):686-92. Candida tropicalis: chemical composition and role in drug resistance. J 12. de Freitas Fernandes FS, Pereira-Cenci T, da Silva WJ, Filho AP, Straioto Med Microbiol. 2006; 55:999-1008. FG, Del Bel Cury AA. Efficacy of denture cleansers on Candida spp. 32. Thein ZM, Samaranayake YH, Samaranayake LP. In vitro biofilm biofilm formed on polyamide and polymethyl methacrylate resins. J formation of Candida albicans and non-albicans Candida species Prosthet Dent 2010; 105: 51-8. under dynamic and anaerobic conditions. Arch Oral Biol. 2007; 13. Ramage G, Rajendran R, Sherry L, Williams C. Fungal Biofilm 52(8):761-7. Resistance. Int J Microbiol. 2012; 2012:528521. 33. Roberts ME and Stewart PS. Modeling Antibiotic Tolerance in Biofilms 14. Nikawa H, Nishimura H, YamamotoT, HamadaT and Samaranayake LP. by Accounting for Nutrient Limitation. Antimicrob Agents Chemother. The Role of Saliva and Serum in Candida albicans Biofilm Formation on 2004; 48(1):48-52. Denture Acrylic Surfaces. Microbial Ecology in Health and Disease 34. Alem MA, Oteef MD, Flowers TH, Douglas LJ. Production of Tyrosol by 1996; 9: 35-48. Candida albicans Biofilms and Its Role in Quorum Sensing and Biofilm 15. Stephens C. Microbiology: Breaking Down Biofilms. Curr Biol. 2002; Development. Eukaryot Cell. 2006;5(10):1770-9 12(4):R132-4. 35. Ramage G, Saville SP, Thomas DP, López-Ribot JL. Candida Biofilms: an 16. Soll DR. Candida Biofilms: Is Adhesion Sexy? .Current Biology Update. Eukaryot Cell. 2005; 4(4):633-8. 2008;18(16): R717-R720. 36. Al-Dhaheri RS, Douglas LJ. Absence of Amphotericin B-Tolerant 17. Kumamoto CA, Vinces MD. Alternative Candida albicans Lifestyles: Persister Cells in Biofilms of Some Candida Species. Antimicrob Agents Growth on Surfaces. Annu Rev Microbiol. 2005; 59:113-33. Chemother. 2008; 52(5):1884-7. 18. Murillo LA, Newport G, Lan CY, Habelitz S, Dungan J, Agabian NM. 37. LaFleur MD, Kumamoto CA, Lewis K.Candida albicans Biofilms Produce Genome-Wide Transcription Profiling of the Early Phase of Biofilm Antifungal-Tolerant Persister Cells. Antimicrob Agents Chemother. Formation by Candida albicans. Eukaryot Cell. 2005; 4(9):1562-73. 2006; 50(11):3839-46. 19. Nickerson KW, Atkin AL ,Hornby JM. Quorum Sensing in Dimorphic

Keywords : Biofilms by Candida, quorum sensing, thigmotropism, 121 antifungal resistance, candidal colonisation, denture stomatitis - Anupama Prasad D. NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

INSTRUCTIONS TO AUTHORS The Nitte University Journal of Health Science (ISSN 2249-7110) is should be given on the title page. The e-mail ID of the a peer-reviewed, indexed research publication printed every corresponding author or the contact e-mail ID must also be three months. The NUJHS invites ethically-cleared, original provided. research articles in any area related to advancement of Abstract and key words: It must start on a new page carrying the knowledge in health sciences. The complete contents of each following information: (a) Title (without authors names or issue of Nitte University Journal of Health Science are also affiliations), (b) Abstract, (c) Key words, (d) Running title. It should available for open access on the university website link. not exceed 250 words excluding the title and the key words. The http://nitte.edu.in/journal/?page_id=86. E-mail manuscript/s as abstract must be concise, clear and informative rather than attachment/s to [email protected]. Send one hard copy indicative. of submissions to Dr. Arunachalam Kumar, Editor NUJHS, Journal The abstract must be in a structured form and explain briefly what Office, K.S. Hegde Medical Academy, Mangalore 575018, India was intended, done, observed and concluded. The conclusions Submission format and recommendations not found in the text of the article should (A) Review Articles: not be given in the abstract. • Reviews are written by researchers of considerable Keywords: Provides 3-5 keywords which will help readers or experience in the field concerned. The authors should indexing agencies in cross-indexing the study. The words found in review the recent trends or advances in that field in the title need not be given as key words. Use terms from the latest light of their own work. Medical Subject Headings (MeSH) list of Index Medicus. A more • The major portion of the above articles should deal with general term may be used if a suitable MeSH term is not available. the up-to-date developments in the field in the 3 – 5 years. Authors are advised to search Medline and other databases Introduction: It should start on a new page. Essentially this on the internet, apartment from collecting information section must introduce the subject and briefly say how the idea using conventional methods. for this research topic originated. Give a concise background of • These articles besides should contain a covering letter, title the study. Do not review literature extensively but provide the page, summary and keywords. The articles should be most recent work that has a direct bearing if any on the subject. written under appropriate sub-headings. The authors are Justification for research aims and objectives must be clearly encouraged to use flow charts, boxes, cartoons, tables, mentioned without any ambiguity. The purpose of the study photographs of good resolution and figures for better should be stated at the end. presentation. Some of the other details are given below: Materials and Methods: This section should deal with the (B) Original Research Articles: materials used and the methodology (how the work was carried These may either be a full length research article or a short out). The procedure adopted should be described in sufficient communication. These papers should be arranged into the detail to allow the experiment to be interpreted and repeated by following sections: the readers, if desired. The number of subjects, the number of 1. Title page with authors name and affiliations groups, the study design, sources of drugs with dosage regimen or 2. Abstract and key words instruments used, statistical methods and ethical aspects must be 3. Introduction mentioned under the section. The data collection procedure must 4. Materials and Methods be described. If a procedure is a commonly used, giving a 5. Results previously published reference would suffice. If a method is not 6. Discussion well known (though previously published) it is better to describe it 7. Conclusion briefly with due acknowledgement. Give explicit descriptions of 8. Acknowledgement modifications or new methods so that the readers can judge their 9. References 10. Tables with captions separately accuracy, reproducibility and reliability. 11. Figures with legends separately The nomenclature, the source of material and equipment used, Title page: It should be paginated as page 1 of the paper. It should with details of the manufacturer in parentheses, should be clearly include the title, authors names and affiliations, running title, mentioned. Drugs and chemicals should be precisely identified address for correspondence including e-mail address and also the using their non-proprietary names or generic names. If necessary, total number of pages, figures and tables. Title: Must be the proprietary or commercial name may be inserted once in informative, specific, unambiguous and short. It should not parentheses. The first letter of the drug name should be small for exceed 150 characters. generic name (e.g., dipyridamole, propranolol) but capitalized for proprietary names (e.g., Persantin, Inderal). New or uncommon Authors and affiliations: The names of authors and their drug should be identified by the chemical name and structural affiliations should be given. It should be made clear which address formula. relates to which author. The does of drugs should be given as unit weight per kilogram Address for correspondence: The corresponding authors address body weight e.g., mg/kg and the concentrations should be given

INSTRUCTIONS TO AUTHORS 122 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science in terms of molarity e.g., nm or mM. The routes of administration an increased risk for pancreatobiliary disease. Ann Intern Med m ay b e a b b r e v i a t e d , e . g . , i n t ra - a r t e r i a l ( i . a ) , 1996; 124: 980-3. intracerebroventricular (i.c.v.), intra-gastric gavage (i.g.), More than six authors: Parkin DM, Clayton D, Black RJ, Masuyer E, intramuscular (i.m.), intraperitoneal (i.p.), intravenous (i.v.), per Friedl HP, Ivanov E, et al. Childhood leukaemia in Europe after os (p.o.), subcutaneous (s.c.), transdermal (t.d.)etc. Chernobyl: 5 year follow-up. Br J Cancer 1996;73:1006-12. Statistical Methods: The variation of data should be expressed in Books: Entwistle N. In, Excellence in higher education. (De Corte terms of the standard error of mean (SEM) or the standard E., ed), 2003; pp. 83-99, Portland Press, London. deviation (SD), along with the number of observations (n). The Bowden A fundamentals of enzyme kinetics, 3rd edn. 2004; details of statistical tests used and the level of significance should Portland Press, London. be stated. If more than one test is used it is important to indicate Web references: As a minimum, the full URL should be given and which groups and parameters have been subjected to which test the date when the reference was last accessed. Any further and why. information, if known (author names, dates, reference to a source Results: The results should be stated concisely without publication, etc.), should also be given. Web references can be comments. They should be presented in logical sequence in the listed separately (e.g., after the reference list) under a different text with appropriate reference to tables and / or figures. The data heading if desired or can be included in the reference list. given in tables or figures should not be repeated in the text. The Check list for Tables same data should not be presented in both tabular and graphic • Serially numbered in Arabic numerals? forms. Simple data may be given in the text itself instead of figures • Short self explanatory heading given? or tables. Avoid discussions and conclusions in the results section. • Columns have headings? Discussion: This section should deal with the interpretation, • Units of data given? rather than recapitulation of results. It is important to discuss the • “n” mentioned? • Mean ± SD or Mean ± SEM given? new and significant observations in the light of previous work. • Statistical significance of groups indicated by asterisks or Discuss also the weaknesses or pitfalls in the study. New other markers? hypotheses or recommendations can be put forth. Avoid • P values given? unqualified statement and conclusions not completely supported • Rows and columns properly aligned? by the data. Repetition of information given under Introduction • Appropriate position in the text indicated? and Results should be avoided. Figures: Each figure must be numbered and a short descriptive Conclusions: It must be drawn considering the strengths and caption must be provided. A computer drawn figure with good weaknesses of the study. Make sure conclusions drawn should contrast is acceptable. Sometimes, raw data for graphs may be agree with the objectives stated under Introduction. required in Excel sheet when the article is accepted for Acknowledgements: These should be typed on a new page. publication. Graphic files for diagrams and figures may be Acknowledge only those who have contributed to the scientific converted to *.pcx, *.tiff,*.jpg format. These files should not content or provided technical support. Sources of financial exceed 2 MB in size. support may be mentioned. Check list for Figures References: It should begin on a new page. The number of • Serially numbered? Self explanatory caption given? references should normally be restricted to a maximum of 25 for a • X and Y axes graduated? full paper. Majority of them should preferably be of articles • X and Y axes titled (legend)? published in the last 5 years. • Units mentioned (if necessary)? Papers which have been submitted and accepted but not yet • Different symbols/markers for different groups given? published may be included in the list of references with the name • SD or SEM represented (graphically)? of the journal and indicated as “In press”. Avoid using abstracts as • Statistical significance indicated? references. The “unpublished observations” and “personal • Approximate position in the text marked? communications” should not be used as references. (D) Short/Brief communications: While other things remain the References are to be cited in the text by superscribed number and same as described above, these papers should be considerably should be in the order in which they appear. References cited only briefer than Original Articles. in tables or in legends to figures should be numbered in (E) Letter to Editor / Correspondence: This may either be a small accordance with a sequence established by the first identification research communication or a commentary on a contemporary in the text of the particular table or illustration. As far as possible issue or remarks/queries on a recently published article in NUJHS mentioning names of author(s) for reference should be avoided in the text. (F) Case Reports: Interesting clinical cases (with pharmacologic significance) may be considered for publication. Those with Please note the following examples for a journal article, a chapter photographs stand a better chance. The case reports should have in multi-authored book, and a single-authored book respectively. an unstructured abstract, introduction, case history and a brief Vega KJ, Pina I, Krevsky B. Heart transplantation is associated with discussion.

INSTRUCTIONS TO AUTHORS 123 NUJHS Vol. 3, No.2, June 2013, ISSN 2249-7110 Nitte University Journal of Health Science

NUJHS DECLARATION AND RIGHT TRANSFER FORM (To be signed by all authors)

I/We, the undersigned author(s) of the manuscript

entitled______

hereby declare that the above manuscript which is submitted for publication in NUJHS is NOT under consideration elsewhere.

The manuscript is not published already in part or whole except in the form of abstract in any journal or magazine for private or public circulation. We have read instructions to authors No part of this manuscript referenced or otherwise has been copied verbatim any source.

I/We give consent for publication in the NUJHS in any media (print, electronic or any other) and transfer copyright to the NUJHS in the event of its publication in the NUJHS.

I/we do not have any conflict of interest (financial or other) other than those declared.

I/We have read the final version of the manuscript and am/are responsible for the contents.

The work described in the manuscript is my/our own and my/our individual contribution to this work is significant enough to qualify for authorship.

No one who has contributed significantly to the work has been denied authorship and those who helped have been duly acknowledged.

I / we also agree to the authorship of the article in the following sequence:

Authors Name(s) Signatures

1

2

3

4

5

COPYRIGHT TRANSFER FORM 124