ISSN: 2249 4995

NATIONAL JOURNAL OF MEDICAL RESEARCH

Volume 2 Issue 2 April – June 2012 Page: 117 - 242

ISSN: 2249 - 4995 NATIONAL JOURNAL OF MEDICAL RESEARCH

Print ISSN: 2249 4995 Online ISSN: 2277 8810

EDITORIAL BOARD

Chief Editor Dr. Himanshu Rana, MD (Medicine)

Executive Editor Dr. Viren Patel MD (Pathology)

Members

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

All the views expressed in the articles are the personal views of the authors and should not be considered as the official views of the National Journal of Medical Research or the Association.

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ADDRESS FOR CORRESPONDENCE Dr. Viren Patel, Executive Editor, NJMR Email: [email protected] mail.com

PUBLISHER @g

National Journal of Medical Research (Reg. No. 24-022-21-48410) C-43, Umiya Bunglows, Bhadreshwar, Hansol, Ahmedabad – 382475.

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NATIONAL JOURNAL OF MEDICAL RESEARCH : April – June 2012 Volume 2 Issue 2

NATIONAL JOURNAL OF MEDICAL RESEARCH

NATIONAL JOURNAL OF MEDICAL RESEARCH Volume 2 Issue 2 Pages 117 – 242 April - June 2012

TABLE OF CONTENT Page

ORIGINAL ARTICLE Prevalence of Hepatitis D Virus (HDV) in South Gujarat Shah Latika J, Mulla Summaiya A ...... 117 - 120 Study of Congenital Malformations in Central Nervous System & Gastro- Intestinal Tract Saiyad SS, Jadav Hrishikesh R ...... 121 - 123 Etiological Profile and Clinical Presentation of Patients with Atrial Fibrillation from a Rural Area of Bihar Nand Vidya, Gupta AK, Mahmood Syed E, Kulshrestha Malini, Patiyal RK ...... 124 - 127 Types of Talar Articular Facets and Morphometric Measurements of The Human Calcaneus Bone Nagar SK, Malukar Ojaswini, Kubavat Dharati, Gosai SR, Andani RH, Patel Bhaskar ...... 128 - 132 A Histopathological Study of Ophthalmic Lesions at a Teaching Hospital Chauhan Sanjay C, Shah Sejal J, Patel Amul B, Rathod Hitesh K, Surve Sunil D, Nasit Jitendra G ...... 133 - 136 A Profile of Cases of Hemoglobinopathies at a Medical College Shah Sejal J, Chauhan Sanjay C, Rathod Hitesh K, Patel Amul B, Sharma Vaibhavi Y ...... 137 - 140 Occupational Stress and Burnouts as Predictors of Job Satisfaction Amongst Lawyers in District Sangli Patel Kriti A, Rajderkar Shekhar S, Naik Jayashree D ...... 141 - 144 Factors Affecting Treatment Seeking Behaviour of Individuals with Locomotor Disabilities Padhyegurjar Mansi S, Padhyegurjar Shekhar B ...... 145 - 148 Socio Demographic Profile of TB-HIV Co-Infected Patients in Bundelkhand Region, Uttar- Pradesh Jaiswal Rishi K, Srivastav Shalini, Mahajan Harsh ...... 149 - 151 Histopathological Study of 100 Cases of Vasculartumours Kapuriya Dharmesh P, Patel Prashant, Shah Amrish N...... 152 - 155 Antibiotic Resistance Pattern in Pseudomonas Aeruginosa Species Isolated at a Tertiary Care Hospital, Ahmadabad Rajat Rakesh M, Ninama Govind L, Mistry Kalpesh, Parmar Rosy, Patel Kanu, Vegad MM ...... 156 - 159 A Study of Superficial Mycoses with Clinical Mycological Profile in Tertiary Care Hospital in Ahmedabad, Gujarat Bhavsar Hitendra K, Modi Dhara J, Sood Nidhi K, Shah Hetal S ...... 160 - 164 Effect of Different Sitting Postures in Wheelchair on Lung Capacity, Expiratory Flow in Patients of Spinal Cord Injury (SCI) of Spine Institute of Ahmedabad Prajapati Namrata P, Bhise Anjali R ...... 165 - 168 Study of Steroid Induced Rise in Intraocular Pressure Using Non-contact Tonometer After Cataract Surgery in Camp Patients at P.D.U. Medical College Rajkot, Gujarat Dodiya Kamal S, Aggarwal Somesh V, Bareth Kiran, Shah Nirzari ...... 169 - 172 Are Care Takers of Link Worker’s Scheme of HIV/AIDS Knowledgeable Enouth? Assessment Study of Link Workers Scheme in Surat District Parmar Rohit, Desai Binita, Kosambiya JK, Solanky Priti, Prajapati Shailesh, Kantharia SL ...... 173 - 175 Prevalence of Hepatitis B Virus Infection in Health Care Workers of a Tertiary Care Hospital Khakhkhar Vipul M, Thangjam Rubee C, Parchwani Deepak N, Patel Chirag P ...... 176 - 178 Work-Related Musculoskeletal Disorders: a Survey of Physiotherapists in Saurashtra Region Buddhadev Neeti P, Kotecha Ilesh S ...... 179 - 181 Yoga Training with Meditation Ameliorates The Asthmatic Attack by Improving Pulmonary Functions: a Pilot Study B Biju, Geetha N, Sobhakumari.T ...... 182 - 187

Volume 2 Issue 2 April – June 2012 print ISSN: 2249 4995 eISSN: 2277 8810

NATIONAL JOURNAL OF MEDICAL RESEARCH Vitamin A Deficiency Among School Children of Bareilly: Crucial Role of Nutrition Education Khan Swati, Mahmood Syed Esam ...... 188 - 190 Comparative Study of Peak Expiratory Flow Rate and Maximum Voluntary Ventilation Between Smokers and Non-Smokers Karia Ritesh M ...... 191 - 193 Study of Prevalence and Risk Factors of Postpartum Depression Desai Nimisha D, Mehta Ritambhara Y, Ganjiwale Jaishree ...... 194 - 198 Anatomical Study of Variation of Vertebral Artery Entering the Foramen Transversarium of Cervical Vertebrae Rawal Jitendra D, Jadav Hrishikesh R ...... 199 - 201 Frequency and Distribution of Blood Groups in Blood Donors in Western Ahmedabad – A Hospital Based Study Patel Piyush A, Patel Sangeeta P, Shah Jigesh V, Oza Haren V ...... 202 - 206

Study of Angle of Humeral Torsion in Subjects of Gujarat Region of India Patel Shilpa, Kubavat Dharati, Malukar Ojaswini, Nagar SK, Parikh Jyoti, Ganatra Dimple ...... 207 - 210 A Study of Sacralisation of Fifth Lumbar Vertebra in Gujarat Kubavat Dharati, Nagar SK, Malukar Ojaswini, Trivedi Dipali, Shrimankar Paras, Patil Sucheta ...... 211 - 213 Medial Open Wedge High Tibial Osteotomy for Varus Arthritic Knees by Dynamic External Fixator System (Distraction Callotasis) Shah Mukesh N, Amin Richa P, Patel Kunal C, Amin Prakash V, Pandit Jyotindra P ...... 214 - 217 Clinico-Epidemiological Correlates of Hospitalized H1N1 Pneumonitis Cases in A Teaching Hospital of Western India During 2009-2010 Pandemic Patel Bhavin D, Srivastav Vipul S, Patel Ameekumari B, Modi Bhautik P ...... 218 - 222 Susceptibilities of ESBL-Producing Enterobacteriaeceae To Ertapenem, Meropenem and Piperacillin-Tazobactam Shah Kinal, Mulla Summaya A ...... 223 - 225 Choice of Operative Technique for Emergency Cases of Sigmoid Volvulus in a Tertiary Care Hospital of Gujarat Patel Upendra, Bhautik Modi ...... 226 - 228 Prevalence and Associated Factors of Back Pain Among Dentists in South Gujarat Patel Harshid L, Marwadi Mehul R, Rupani Mihir, Patel Priyanka ...... 229 - 231

SHORT COMMUNICATION Comparison of Efficacy of Dial Flow Microdrip Sets for Hyperviscous Fluids Shiraboina Madanmohan , Ramachandran Gopinath ...... 232 - 233

CASE REPORT Transient Appearance of Blasts in Peripheral Smear in Paediatric Patient with Acute Aleukemic Leukemia Vaghasiya Viren L, Parikh Hina S, Patel Divyesh V, Taviad Dilip S ...... 234 - 235 A Rare Case of Aberrant Migration of Primordial Germ Cells – Yolk Sac Tumor of Uterus Tandon Rakesh, Chugh Ashima, Patel Harsh, Aggarwal Deepti ...... 236 - 237 An Unusual Case of Unilateral Atlanto-Occipital Assimilation with Skull Asymmetry Rajani Sangeeta J, Suttarwala Ila M, Rajani Jitendra K ...... 238 - 240 A Case Report on Carcinoma of Jejunum Patel Upendra, Shrimali Gaurishankar ...... 241 - 242

INSTRUCTION TO AUTHOR

Volume 2 Issue 2 April – June 2012 print ISSN: 2249 4995 eISSN: 2277 8810

NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

PREVALENCE OF HEPATITIS D VIRUS (HDV) IN SOUTH GUJARAT

Shah Latika J1, Mulla Summaiya A2

1Assistant Professor, 2Professor & Head, Department of Microbiology, Government Medical College, Surat,

Correspondence: Dr. Latika Shah 51, Aagam Heritage, Near Someswara Enclave, Opp.Landmark Honda, Vesu, Surat – 395 007 E mail: [email protected]

ABSTRACT

Aim: Hepatitis D Virus (HDV) infects only patients that are already infected by hepatitis B virus (HBV).There is lack of data on the impact of Hepatitis D Virus (HDV) in patients with hepatitis B virus (HBV) in south Gujarat. This study was aimed at determining the seroprevalence of Hepatitis D Virus (HDV) in south Gujarat and does epidemiological studies on HDV among chronic Hepatitis B patients. Methods: This study was carried out at tertiary hospital (New Civil Hospital, Surat).This study was done from March 2010 to April 2011.Total 141 consecutive HbsAg positive patients were included in this study. Results: Out of 141 HbsAg positive patients 12 patients were positive for anti-HDV ELISA. High prevalence rate was found in middle aged man. HBV- HDV infection togather cause more severe liver damage.HDV infection was more associated with blood tranfusion. Conclusion: The HDV infection is not uncomman.Coexistent infection with Hepatitis B aggravates the course of liver disease.One of the common route of HDV transmission is haematologic, suggesting the need for blood screening for HDV particularly in groups with numerous blood transfusions.

Keywords: Viral hepatitis, HbsAg, anti HD antibody, liver cirrhosis, hepatocellular carcinoma

INTRODUCTION HBV and HDV viruses causes more severe acute liver disease and is a higher risk for the development of Hepatitis Delta virus (HDV) infection is present fulminant hepatitis compared to only HBV infected globally and infects human being already infected by patients 5. Moreover, response to therapy is different Hepatitis B virus (HBV). HDV was first discovered by and less satisfactory in patients with hepatitis delta virus Rizzetto in the patients that were already infected by (HDV) infection than hepatitis B virus (HBV) HBV in year 1980 1. Hepatitis delta virus (HDV) is a monoinfection. satellite RNA virus that depends on the envelope protein of the hepatitis B virus (HBV) to enter the Co-infections of hepatitis B with multiple hepatitis hepatocytes and assemble new HDV particles. The viruses are associated with diverse patterns of reciprocal particle size of HDV is about 36-nm that require inhibition of viral replication. Delta hepatitis occurs due hepatitis B surface antigen (HBsAg) for their enveloped to co-infection of HBsAg positive patients with and transmission 2. The HDV genome is a circular, hepatitis delta virus. There are inconsistent reports on negative sense, single-strand RNA, which is the role of each virus in the pathogenicity of approximately 1700 nucleotides in length 3. HBV/HDV infection. Some reports suggest that the activity of liver disease is mainly due to HDV while Worldwide, more than 350 million people are others implicate hepatitis B virus, regardless of the considered to have chronic HBV infection. It has been levels of HBV DNA, in the aggressive nature and estimated that approximately 5% of HBV carriers are progression of disease. In studies from Europe, HDV co-infected with HDV4, leading to an estimated 15-20 has frequently been shown to suppress HBV million persons infected with HDV. The dual infection replication, and 70-90% of patients with hepatitis D are of HBV and HDV occurs in the form of co-infection hepatitis B e antigen (HBeAg) negative, with low serum or as a superinfection.The Super infection of HDV levels of HBV DNA. However, despite this influence with HBV causeda progressive chronic liver disease up of HDV on HBV, 15- 30% of patients with hepatitis D to (80%), which further enhances liver cirrhosis and are HBeAg and/or HBV DNA positive.6-12 hepatocellular carcinoma (HCC). Co-infection by both

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NATIONAL JOURNAL OF MEDICAL RESEARCH Different rates of HDV infection among HBsAg- RESULTS positive patients have been reported from worldwide. Total 141 HbsAg positive patients were enrolled in the The infection was endemic in the 1970s throughout study. Out of the 141 patients, 12 were found to be Southern Europe, and was responsible for a substantial reactive for anti-delta antibodies, yielding an overall proportion of cases of HBsAg- positive liver HDV seroprevalence of 8.5%. disorders13,14. However, the prevalence of HDV had substantially declined in Italy from 23% in 1987 to 8.3% in 1997 as reported by Stroffolini et al 15. A similar decline was noted in Taiwan, with prevalence Table-1 Comparison of positive cases of anti HD decreasing from 23.7%in 1983 to 4.2% in 1996 16, as antibody in different age well as in Spain and Turkey 17. This decline in Age M.V.Murhekar,SC Present study prevalence of HDV infection was achieved by group(years) Sehgal et al(20) enhancing awareness among the general public and by 0-10 0 0 measures taken for vaccination against hepatitis B in 11-20 1 0 these countries. Recently, a comprehensive report on 21-30 0 2 the epidemiology of hepatitis delta in the Asia-Pacific 31-40 5 5 region was published by Abbas et al 18. According to 41-50 2 3 this report, prevalence from different parts of Asia is >50 0 2 variable, and ranges from 3-10% in India, 2-20% in Total 8 12 Iran, 18% in Afghanistan and 3-8% in Saudi Arabia. Eight phylogenetically distinct genotypes of HDV have Table No: 1 shows the age wise distribution. From the been reported. Various genotypesare reported to be table we observed positive cases of anti HD antibody associated with different long term outcomes of are among the adult and old age. Higher prevalence rate infection 19. Genotype1 is the most frequent and found for anti HD antibody observe in >30yrs. in Europe,Middle East,North America and North Africa; Genotype 2 is seen in the Far East;Genotype 3 was reported in the Amazonian region of South Table 2: Distribution of anti-HD antibody America; Genotype 4was isolated in Taiwan and Japan; according to sex,clinical groups and risk groups. and Genotype 5 to 8have been identified in Africans. Characteristic Cases Positive(%) There is lack of data on the characteristics and impact Sex Male 111 10 (9.0) of hepatitis delta virus on hepatitis B virus infection Female 30 02 (6.6) and its spectrum of diseases from South Asia. The aim Clinical Fulminant Hepatitis 53 08 (15.09) of this study was to investigate the virological and groups Non-Fulminant Hepatitis 78 4 (5.12) clinical characteristics of patients infected with Jaundice without s/s of 10 00 (00) HBV/HDV infection. Hepatitis Risk Blood Tranfusion 60 06 (10) groups Surgery 30 01 (3.33) METHODS Multiple Exposure 29 01 (4.16) Other 22 04 (18.18) This study was carried out at tertiary hospital (New Civil Hospital, Surat).This was one year long study Looking at the sexual preponderance, out of 141 carried out between March 2010 to April 2011. A total enrolled patients, 78.7 %( n=111) were male and 21.2 of 141 consecutive HbsAg positive serum sample by %( n=30) were females. Among HDV positive patients enzyme linked immunosorbant assay (ELISA) were 10 were males and 2 were females. included in the study. As shown in above table, prevalence rate amongst cases Demographics and physical findings were recorded in of fulminant hepatitis was as high as 15.09%,while in all patients. Serum samples of all patients were tested case of non-fulminant hepatitis, only 5.12 (%)cases for biochemical parameters including complete blood were found positive for antibody and both the cases count, total bilirubin, ALT, alkaline phosphatase, were of chronic active hepatitis. This difference is creatinine, and prothrombin time (PT) by standard satisfactory significant as p value is 0.01, p<0.05. laboratory methods. Serological test carried out were Fulminant hepatitis is more common in HDV HbsAg and anti HD antibody by ELISA. infection. Statistical Analysis Above table shows that rate of positive cases was All the data were analyzed and the summary statastic higher in cases with past history of blood transfusion, was carried out.Variables are given in the form of rates which was 10% and in cases with history of multiple (%).The chi -square test was used for categorical exposure and surgery, it was 4.16 and 3.33% variables. Values of less than 0.05 were considered respectively. significant.

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NATIONAL JOURNAL OF MEDICAL RESEARCH Table 3: Comparison study for prevalence rate in different risk groups. Risk Group Angeles castro et al Velorie Kelly et al Present study Cases +ve (%) Cases +ve (%) Cases +ve (%) Blood Transfusion 15 02 (13.33) 24 00 (00) 60 06 (10) Sexual 02 00 (00) 108 02 (1.85) 29 01 (4.16) Others 158 32 (20.25)274 18 (6.56) 107 05 (4.67) Total 175 34 (19.42) 406 20 (4.92) 196 12 (6.12)

DISCUSSION India. Composition and risk factor distribution within the respective study groups may account for the In this study mean age of HDV positive patients was apparent inter-study differences. Additionally, 40+/-10. If we compare our study with the study of epidemiological differences due ethnicor geographical M.V.Murhekar, S.C.Sehgal et al20, the cases of anti HD factors, study methodology, etc., can not be ruled out. antibody positivity is more with adults and older age which correlates well with us. Another study done in Our studies suggest that HDV is more commonly Pakistan by Asad U Khan also has high prevalence in associated with fulminant hepatitis. The study done by older (31.7%). Gupta P, Kar Pet al 23 also shows that Hepatic Encephalopathy was seen in 75% of delta infected

patients as compare to 13.88% of delta negative Table 4: Prevalence of Anti-D antibody in HbsAg patients. There is a lot variation in the clinical course. positive More positivity of anti HD antibody in case having severe liver disease. There appeared to be a large Study HbsAg +ve Anti-D +ve (%) variation in the reported HDV seroprevalence in L.Matthyssen et al. 173 7 (4.04) Fulminant hepatic failure (12.6 to 63%) 6, 7, 10, 11 Gupta P,KarP et al 40 4 (10) from India, and the small number subjects evaluated in Al-Traifl,Ali A et al 780 67 (8.6) different studies (including the present study) limited M.V.Murhekar et al 223 8 (3.58) the overall interpretation. In non fulminant hepatitis Asad U khan et al 190 53 (28) anti-HDV antibodies were found in 5.12 per cent. In Present study 141 12 (8.5) contrast, higher seroprevalence of 21.4 and 19 per cent have been reported from Chandigarh and Mumbai, According to L.Matthyssen et al21, prevalence of anti- respectively. A high frequency of dual HBV/HDV HD antibody was 4.04% amongst 173 cases of HBsAg infection has been described in patients of HCC and it reactive patients. Study conducted by Gupta Y et al 22 has been suggested that florid replication of both HBV among the HBV related cirrhosis of Liver shows that and HDV and the resulting severe necro-inflammation 10% were reactive for anti-delta antibodies. Our study may be an additional factor for promotion of HCC. No can be well correlated with the study of Al-TraifI, Ali A comparison could be made with earlier studies due to et al 24and Gupta P, et al.One study conducted in lack of subjects in the HCC subgroup in our study. Pakistan by Asad U Khan et al.25 shows very high prevalance (28%). We can infer that the prevalence rate Above studies shows that variation in rate of positivity varies widely as per geographic distribution. Some for anti HDV in different risk groups in different countries have witnessed a declining trend in the community. In Spain, HDV infection more common in prevalence of HDV infection.HDV had been found to blood transfusion which correlates with our study, be responsible for a high proportion of cases of HBV- while in London it was nil. In present study, there was related acute and chronic liver disorders in Southern no case of drug addiction. The Group others include Europe during the 1970s. However, by the 1990s, its the cases with non specific history. seroprevalence had substantially declined In Italy, the There is difference in life style as well as risk factor in prevalence of anti-HDV among HbsAg carriers with different area, so one must know the prevalence liver diseases decreased from 25 per cent in 1983 to 14 incidence in their region. per cent in 1992. A multi-center Italian study conducted in 1997 has reported HDV positivity of only 8.3 per cent in HBsAg-positive patients – a figure much lower CONCLUSION than those observed in the previous two multi-center surveys performed in 1987 and 1992 (23 and 14%, The prevalence rate of Hepatitis D virus infection was respectively). A similar decrease (from 15.1% in 1983 to 8.5% amongst HbsAg positive patients at tertiary 7.1% in 1992) has also been reported from Spain and hospital of South Gujarat. Prevalence of HDV Taiwan. The reduction in HDV seroprevalence has infection was more common in middle aged male. been postulated to result from a variety of factors such Blood tranfusion is the commenest mode of as active preventive measures directed against sexually transmission. The HDV infection is not uncomman. transmitted diseases, promotion of disposable needles Coexistent infection with Hepatitis B aggravates the and better control of HBV infection itself. A similar course of liver disease. One of the common route of epidemiological change may possibly be happen in HDV transmission is haematologic, suggesting the need

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NATIONAL JOURNAL OF MEDICAL RESEARCH for blood screening for HDV particularly in groups 12. Coppola N, Scolastico C, et al: Virologic and clinical with numerous blood transfusions. Clinician dealing expressions of reciprocal inhibitory effect of hepatitis B, C, and delta viruses in patients with chronic hepatitis. Hepatology with the Liver Disease should be made aware of the 2000, 32:1106-1110. danger of twin infection with HBV and HDV. 13. Rizzetto M, Purcell RH, Gerin JL: Epidemiology of HBV associated deltaagent: geographical distribution of antidelta and prevalence in polytransfused HBsAg carriers. Lancet 1980, REFERENCE 1:1215- 1. Rizzeto M, Canese MG, Gerin JL: Transmission of the 14. Cotrina M, Buti M, Jardi R, et al: Hepatitis delta genotypes in hepatitisB virus associated delta antigen to chimpanzees.J infect chronic deltainfection in the northeast of Spain (Catalonia). J Dis 1980, 141:590-602 Hepatol 1998, 28:971-7. 2. Gerin JL, Cassey JL, Purcell RH: Hepatitis delta virus. In Viral 15. Stroffolini T, Ferrigno L, Chialdea L, et al: Incidence and risk Hepatitis. Edited by: Hollinger FB, Purcell RH, Gerin JL. factors of acute delta hepatitis in Italy: results from a national Philadelphia: Lippincott Williams and Wilkins; 2002:169-182. surveillance system. J Hepatol 1994, 21:1123-6. 3. Radjef N, Gordien E, Ivaniushina V, Gault E, Anais P, Drugan 16. Gaeta GB, Stroffolini T, Chiaramonte M, et al: Chronic T: Molecular Phylogenetic analyses indicate a wide and ancient hepatitis D: a vanishing disease? An Italian multicenter study. radiation African hepatitis delta virus, suggesting a deltavirus Hepatology 2000, 32:824-7. genus of at least seven major clades. J Virol 2004, 78:2537-2544. 17. Degertekin H, Yalcin K, Yakut M: The prevalence of hepatitis 4. Cramer DA: Hepatitis D.Gale Encylopedia of Medicine (the delta virus infection in acute and chronic liver diseases in Gale Group) 2002 Turkey: an analysis of clinical studies. Turk J Gastroenterol 2006, 17:25-34. 5. Yamaguchi Y, Deléhouzée S, Handa H: HIV and hepatitis delta virus: evolution takes different paths to relieve blocks in 18. Abbas Z, Jafri W, Raza S: Hepatitis D: Scenario in the Asia- transcriptional elongation. Microb Infect 2002, 4:1169-1175. Pacific region. World J Gastroenterol 2010, 16(5):554-562. 6. Mumtaz K, Hamid S, Ahmed S, et al: A study of genotypes, 19. Shakil AO,Hadziyannis S,Hoofnagle JH,et al(1997) Geographic mutants and nucleotide sequence of hepatitis B virus in distribution and genetic variability of hepatitis delta virus Pakistan. Hepatitis Monthly 2011, 11(1):25-29. genitype .Virology 234:160-167 7. Sakugawa H, Nakasone H, Nakayoshi T, et al: Hepatitis B virus 20. M.V.Murhekar, K.M.Murhekar, V.A.Arankalle, S.C.Sehgal. Concentrations in serum determined by sensitive quantitative Hepatitis delta virus infection among the tribes of the Andaman assays in patients with established chronic hepatitis delta virus and Nicobar Islands, India. Transaction of the Royal Society of infection. J Med Virol 2001, 65:478-484. Tropical Medicine and Hygine(2005) 99.483-484 8. Yamashiro T, Nagayama K, Enomoto N, et al: Quantification 21. Matthyssen L.et al,Organon Scientific Development Group, of the level of hepatitis delta virus RNA in serum, by real-time Netherlands, Viral Hepatitis and Liver Disease,1988,Pg.409- polymerase chain reaction - and its possible correlation with the 411. clinical stage of liver disease. J Infect Dis 2004, 189:1151-1157. 22. Gupta P,Biswas D,Shukla I,Bal A.Need for routine screening of 9. Hadziyannis SJ, Sherman M, Liberman HM, et al: Liver disease HBV and HDV in patients with Cirrhosis of the liver. Indian activity and hepatitis B virus replication in chronic hepatitis Journal of Medical Microbiology.2005,vol-23,2,141-142. delta antigen-positive hepatitis B virus carriers. Hepatology 23. Gupta P, Kar P, Chakravarty A,Jain A Delta virus infection in 1985, 5:544-547. cirrhotics in a north India hospital. . J Assoc Physicians India. 10. Su CW, Huang YH, Huo TI, et al: Genotypes and viremia of 1993 Aug;41(8):503-504 hepatitis B and D viruses are associated with outcomes of 24. Al-Traifi,Ali A,DaffalaM et al.Prevalence of Hepatitis Delta chronic hepatitis D patients. Gastroenterology 2006, 130:1625- Antibody among HBsAg carriers in Saudi Arabia.Ann Saudi 1635. Med.2004 Sept-Oct;24(5):343-344. 11. Rodriguez F, Buti M, et al: Role of hepatitis B, C, and D viruses 25. Asad U Khan, Muhammad Waqar, Madiha Akram, Khan et al. in dual and triple infection: influence of viral genotypes and True prevalence of twin HDV-HBV infection in Pakistan: a hepatitis B precore and basal core promoter mutations on viral molecular approach Virology Journal 2011, 8:420. replicative interference. Hepatology 2001, 34:404-410.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

STUDY OF CONGENITAL MALFORMATIONS IN CENTRAL NERVOUS SYSTEM & GASTRO- INTESTINAL TRACT

Saiyad SS1, Jadav Hrishikesh R2

1Professor & Head, Department of Anatomy, GMERS Medical college, Gandhinagar 2Professor & Head, Department of Anatomy, GMERS Medical college, Sola , Ahmedabad, Gujarat

Correspondence: Dr. H. R. Jadav 18/Shivkunj Society, Radhaswami satsang road, Ranip, Ahmedabad - 382480 E Mail: [email protected]

ABSTRACT

Introduction: Congenital malformations comprise 8% of the perinatal mortality in India. They rank fifth as a cause of perinatal mortality, after asphyxia, respiratory problems, infections and cerebral trauma. However, the pattern is changing rapidly with improvement in health care and living standards. Material & Method: In the present study, authors have tried to study the cases of congenital malformations specially related to Central nervous system and Gastro-intestinal system. 5240 cases of newborn babies were studied and results were analyzed and classified in to various categories. Findings: The results show that malformations are more common in still birth, more in female babies and more in central nervous system In live born babies the percentage of malformation is0.63 % whereas in still born baby it is6.53 %. Conclusions: Chances of having malformations increases as the age advances. Parity of mother also influences the incidence. Exposure to radiation & drugs also influences malformations. Incidence of congenital malformation is highest in central nervous system.

Key words: Congenital, Malformations, Central Nervous System, Gastro Intestinal Track, Still birth

INTRODUCTION 2. To determine frequency of malformations of these systems The study of birth defects has assumed greater 3. To study causative factors - associated with central importance these days than in the past because the nervous system and Gastro-intestinal tract anomalies mortality rates attributed to congenital anomalies have reduced in comparison to other causes of death such as infections and nutritional diseases.Large number of MATERIALS & METHODS malformations are incompatible with lifeand they involve one or more systems of the body. It is New born babies delivered in the Department of estimated that as many as 50% pregnancies terminate as obstetrics and gynaecology of various General Hospitals miscarriage. In majority of cases this is because of and also treated in the same hospitals including still faulty development. Experimental teratological study in borns were examined either immediately after birth or human being is not possible, whereas the same in within 24 hours after birth for any major congenital animals has advanced phenomenally. As a result of anomaly. Mother was specifically asked about, History of wide range of information that are now available from trauma, Diabetes mellitus, smoking, alcohol, infection these experiments, it has become possible to obtain an (viral & bacterial), exposure to radiation, exposure to insight into the causes, mechanism, and preventions of teratogenic drugs, etc. During examination of baby, birth defects. However considerable work will be state of birth, weight, height, Head circumference, required before these problems can be overcome. In associated illness, umbilical cord, and various systems like present study authors have made an attempt in this respiratory, cardiovascular and central nervous system direction. were examined thoroughly. Outcome of all the malformed babies were recorded during the period of The aim of present study is: mother’s hospital stay.The observations and results were 1. To find out common congenital malformations in noted and presented in tabular form. Ethical committee Central nervous system and Gastro-intestinal permission was taken. system

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NATIONAL JOURNAL OF MEDICAL RESEARCH OBSERVATIONS & RESULTS show that the incidence was significantly higher in still born babies. A study conducted in Ajmer by Gupta1 ( In the present study, authors studied total numbers of 1971) , reported congenital malformation 1.9 % in live 5240 deliveries conducted at civil hospital, Ahmedabad. born where as 20.4% in still born babies, Study by Out of which 2936 were male & 2304 were female. 5041 Purandare2 (1966) in Mumbai shows live born were live born & 199 were still born. Out of which 45 malformations to be 1.4 % and still born malformations babies were having malformations. 9.5%.

Table 1: Incidence rate of various congenital Table 4: Malformations of different systems anomalies Type of Malformation Cases Percentage Groups Babies Malformed Incidence Central nervous system Babies (%) Microcephaly 3 10.34 Total Babies 5240 45 0.86 Hydrocephaly 4 13.80 Male babies 2936 17 0.58 Meningocele 2 6.90 Female babies 2304 26 1.13 Spina Bifida 3 10.34 Live born 5041 32 0.63 Enencephaly 12 41.38 babies Encephalocele 2 6.9 Still born 199 13 6.53 Meningomyelocele 3 10.34 babies Gastrointestinal System Imperforated anus 5 16.67 From table 1 it is seen that malformation is more Anal stenosis 1 3.33 prevalent in live born babies than stillborn. It is also Oesophageal Atresia 2 6.67 more common in female than in male offspring. Cleft palate 7 23.33 Cleft lip 8 26.67 Tracheo- 2 6.67 Table 2: Age distribution of mothers Omphalocele 1 3.33 Age of Mother (Yrs) Babies Malformed Babies (%) Rectovesical Fistula 2 6.67 16-20 1540 13 (0.84) Rectovaginal Fistula 1 3.33 21-25 2847 17 (0.60) 26-30 509 8 (1.57) The values were 1.79 % and 11.4 % by Chandra & 31-35 176 3 (1.70) harilal3 ( 1977)at Madras , 1.4 % and 12.00 % by 36-40 105 2 (1.90) Mathur4 ( 1975 ) in Hyderabad area . In another study Above 40 63 2 (3.17) carried out by Gupta1 et al the percentage of C.N.S & Total 5240 45 (0.86) G.I.T malformations were 0.75% & 0.33% respectively. In study by Purandare2 it was 0.36% & 0.06% , In Younger age group is also more commonly affected. Mathur4 0.76% & 0.37%, In Saifullah5 it was 1.3% & Malformation is also more common in primi females. 0.4%, Where as in present study it was 0.49% & 0.4% respectively. It is seen that babies are born alive with G.I.T malformations where as most of the C.N.S malformed babies are born dead, Out of the C.N.S Table 3: Parity distributions malformed babies those with anencephaly born dead- Parity Cases Cases with malformation are 100%. Out of 26 cases of C.N.S malformations, 14 (%) were still born and percentage works out to be 53.85% I 2899 20 (0.69) and out of 21 cases of G.I.T malformations no still birth II 791 6 (0.76) was recorded. Chances of giving birth to malformed III 892 9 (1.01) baby increases as the age of mother advances, IV 443 6 (1.35) particularly after 40 years As the parity increases the V 120 2 (1.67) incidence of malformed baby also increase. In fourth VI 95 2 (2.11) para the incidence is three times more than primi. The incidence of babies having malformations is definitely DISCUSSION higher in mothers exposed to radiations during pregnancy. Chances of malformations also increase in In the present study, the incidence rate of congenital consanguineous marriage. malformations was found to be 0.86%. This included both live, still briths and major malformations. Out of this, C.N.S malformations were found to be 4.96% and CONCLUSION G.I.T 4.01%. Further from table-1, it is observed that malformations are much more common in still births Present study provides us an idea regarding prevalence (6.53%) as compared to live births (0.63%). Hospital of cases of congenital malformations and factors based studies carried out in various cities in India, also affecting it , in Indian environment .We can also come

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NATIONAL JOURNAL OF MEDICAL RESEARCH on conclusion that CNS & GIT are two most 3. Chandra P, Harilal KT. Congenital malformations- A study of commonly affected systems. Factors affecting consecutive births. Abstract from conference (Madurai). Indian academy of pediatrics Tamilnadu state branch 1977. development of the embryo should be found & it should be eliminated during antenatal management. 4. Mathur HC, Sheila karan, Vijaya Devi KK. Study of Congenital malformations in the newborn. Indian J of Pediatr. 1975;12:179- 83. REFERENCES 5. Saiffulah S, Chandra RK, Pathak IC, Dhait GI. Congenital malformations in new born. Indian J of Pediatr. 1967; 4:,251-6 1. Gupta BM, Mathur HC, Sharda DC. A study of congenital 6. Sagunabai NS, Mascarene M, Syamalan K, Nair PM. An malformations in central Rajasthan (Ajmer) Arch child Health aetiological study of congenital malformations in new born , 1971;13:30. Indian J of Pediatr. 1982;19:1003-7. 2. Purandare VN, Stevenson AC, Johnston HA, Stewart MI, Golding DR. Congenital malformations - A report of a study of Congenital births in 24 centres. Bull WHO. 1966; 34 (Suppl):24.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

ETIOLOGICAL PROFILE AND CLINICAL PRESENTATION OF PATIENTS WITH ATRIAL FIBRILLATION FROM A RURAL AREA OF BIHAR

Nand Vidya1, Gupta AK2, Mahmood Syed E3, Kulshrestha Malini1, Patiyal RK4

1Assistant Professor, Medicine, Rohilkhand Medical College & Hospital 2Professor, Medicine, Darbhanga Medical College, Darbhanga, Bihar 3Assistant Professor, Community Medicine, Rohilkhand Medical College & Hospital 4Professor, Medicine, Rohilkhand Medical College & Hospital

Correspondence: Dr. Syed Esam Mahmood Department of Community Medicine, Rohilkhand Medical College & Hospital, Bareilly-243006, UP Email: [email protected] Mobile No.: 08127537806

ABSTRACT

Objectives: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. This study was conducted to find the etiological and clinical profile of persistent and permanent AF patients from rural Bihar. Methods: This observational hospital based study was carried amongst indoor patients of AF of Department of Medicine, Darbhanga Medical College, Bihar. Data analysis was done using SPSS 14.0 version software. Results were presented using percentages Results: Out of 66 patients of AF, majority of patients were aged between 51-60 years and were males. Valvular heart disease was found to be the most common cause of atrial fibrillation while palpitation was the most common presenting complaint encountered. Nearly 62.1% patients had their left atrial size more than 3.5 cm. Mitral stenosis was noted as most common cause of enlarged left atrium in 47% cases. About half of patients had their left ventricular ejection fraction < 50%. Conclusions: This article has provided many insights on potential risk factors for the occurrence of atrial fibrillation and various presenting features of patients with atrial fibrillation. This would help in early diagnosis and prompt treatment of patients with AF especially in rural areas which remains a challenging problem.

Key words: Atrial fibrillation, etiological profile, clinical presentation

INTRODUCTION for more than 7 days) and permanent(sustained for more than 1 year or has failed cardio version). Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice and The overall prevalence of AF in general population is requiring treatment. Atrial fibrillation is characterized estimated to be 0.4% to 1%.4 The incidence of AF is by disorganized atrial activation and uncoordinated 0.1% per year in the population below forty years and contraction. ECG demonstrate rapid fibrillatory waves this increases to 2% in those over 80 years.5 The with changing morphology and ventricular rhythm that incidence and prevalence of atrial fibrillation both is irregularly irregular.1 This is clinically identified as increases exponentially with aging.6 The adjusted irregularly irregular pulse with rates varying from incidence and prevalence of AF is roughly double for normal to 200 and pulse deficit >10 beats. Atrial each advancing decade of life,7-9and, at any given age, fibrillation should be suspected when the ECG shows men have an ≈50% higher incidence of AF than ventricular complexes at an irregular rhythm and no women.7 Based solely on the aging of the population, obvious P wave. the prevalence of AF in the United States has been projected to increase from ≈2 to 5 million in 2000 to Atrial fibrillation has been classified 2,3 by American ≈6 to 12 million in 2050, with estimates reaching Heart Association/ American college of almost 16 million if the increase in age-adjusted AF cardiology/European Society of cardiology into first incidence continues.8,10 From the Framingham data the detected episode, recurrent (two or more episode), lifetime risk of developing atrial fibrillation after age of paroxysmal(terminates within 7 days), persistent(persist 40 has been found to be 26% for men and 23% for women. Established risk factors for AF include cardiac

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NATIONAL JOURNAL OF MEDICAL RESEARCH conditions, such as systolic and diastolic heart failure, particular mitral stenosis was noted as most common valvular heart disease, and myocardial infarction, and cause of enlarged left atrium in 47% cases. About half cardiovascular risk factors, such as hypertension, of patients had their left ventricular ejection fraction < diabetes mellitus, obesity, and cigarette 50%. (Table 4) smoking.7,9,11,12,13 Subclinical markers indicating increased AF risk include increased arterial stiffness14and echocardiographic evidence of structural Table-1: Age and gender wise distribution of heart disease, such as left atrial enlargement, left patients ventricular hypertrophy, and left ventricular systolic and diastolic dysfunction.15,16 Recently identified novel Characteristics No. of patients (%) markers associated with increased risk for AF include Age (in yrs) inflammatory and neurohumoral 16-20 3 (4.54) biomarkers,17,18obstructive sleep apnea,19 and metabolic 21-30 7 (10.60) syndrome.20 31-40 12 (18.18) 41-50 12 (18.18) AF, the commonest clinical arrhythmia is increasing in 51-60 20 (30.30) incidence and prevalence, is associated with substantial 61-70 10 (15.15) morbidity and mortality. Cerebrovascular complications 71-80 2 (3.03) are further important cause of functional limitation of Sex such patients. In non-valvular AF, it is 2-7 times more Male 36 (54.54) than those in sinus rhythm whereas in valvular AF, it is Female 30 (45.46) 17 times more than controls.5,21 Although various studies have been conducted Table-2: Clinical presentation of patients with AF worldwide there is paucity of data in this region. Hence Clinical Presentation Patients (%) this study was undertaken with the aim to find Valvular heart Disease 34 (51.51) etiological profile and clinical presentation of persistent Dilated Cardiomyopathy 10 (15.15) and permanent AF patients from rural area of Bihar. Ischemic heart Disease 8 (12.12) HTN with or Without Type II 5 (7.57) DM MATERIALS AND METHODS Chronic airway Disease 4 (6.06) This observational hospital based study was carried out Thyrotoxicosis 3 (4.54) in the Department of Medicine, Darbhanga Medical Lone AF 2 (3.03) College, Bihar from June 2006 to December 2008 after taking ethical clearance from the institution. All patients Table-3: Clinical Presentation of the Patients admitted with persistent and permanent AF (having Signs and Symptoms Patients (%) clinical and electrocardiographic evidence of AF) were Palpitation 22 (33.33) included in this study. The patients with first episode of Dyspnoea 16 (24.24) AF and paroxysmal episode of AF were excluded from Chest pain 14 (21.2) the study. The diagnosis of AF was made on the basis Loss of consciousness (stroke) 8 (12.12) of history, clinical examination, confirmation with 12 Hypotension 4 (6.06) leads ECG and 2-D Echocardiography. Data analysis Asymptomatic 2 (3.03) was done using SPSS 14.0 version software. Results were presented using percentages. DISCUSSION

Most of the patients belonged to the age group of 41 to RESULTS 60 years. The age distribution of patients in this study Out of 66 patients of AF studied, majority of patients with mean age of 47.0 is consistent with most Indian were aged between 51-60 years (48%) and were males studies but differ from western studies due to low (54.5%). (Table 1) Structural heart disease was found in prevalence of rheumatic heart disease in their 86.36% of cases and non-structural heart disease in population.22,23 A higher proportion (54.54%) of the 10.6%. Among the structural heart disease, valvular patients were males as compared to females (45.46%). heart disease was seen in 51.51% cases as a cause of AF Similar observations were made by other studies .24,25,7 while among the non structural heart disease Structural heart disease was found in 86.36% of cases Thyrotoxicosis (4.54%) and chronic obstructive airway and non-structural heart disease in 10.6% of cases in disease (6.06%) were most important causes found. this study. Among the structural heart disease, valvular (Table 2) Palpitation (33.33%) was the most common heart disease was seen in 51.51% cases as a cause of presenting complaint encountered followed by AF. Thyrotoxicosis (4.54%) and chronic obstructive dyspnoea (24.2%), chest pain (21.2%) and stroke airway disease (6.06%) were most important causes (12.12%). (Table 3) Nearly 62.1% patients had their left among non structural heart disease in this study. The atrial size more than 3.5 cm. Valvular heart disease, in

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NATIONAL JOURNAL OF MEDICAL RESEARCH etiological profile of our patients is almost similar to those reported by previous studies.26

Table-4: Echocardiographic Observations of the Patients Clinical Conditions LA Size LVEF LA Clot <3.5cm (%) >3.5cm (%) <50% (%) >50% (%) Not present (%) Present (%) Valvular heart disease 3 (4.54) 31 (46.96) 15 (22.72) 19 (28.78) 27 (40) 7 (10.6) Dilated cardiomyopathy 4 (6.06) 6 (9.09) 9 (13.63) 1 (1.51) 10 (15.15) 0 Ischemic heart disease 6 (9.09) 2 (3.03) 4 (6.06) 4 (6.06) 8 (12.12) 0 Hypertension 4 (6.06) 1 (1.51) 4 (6.06) 1 (1.51) 5 (7.57) 0 Chronic airway disease 3 (4.54) 1 (1.51) 1 (1.51) 3 (4.54) 4 (6.06) 0 Thyrotoxicosis 3 (4.54) 0 0 3 (4.54) 3 (4.54) 0 LA = Left Atrium

Palpitation was the most common presenting complaint 8. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby encountered followed by dyspnoea , chest pain and JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke stroke. These observations are similar to a previous prevention: the AnTicoagulation and Risk Factors in Atrial reported study by Fuster et al.2 Fibrillation (ATRIA) Study. JAMA. 2001; 285: 2370–2375. 62.1% had their left atrial size more than 3.5 cm. 9. Psaty BM, Manolio TA, Kuller LH, Kronmal RA, Cushman M, valvular heart disease, in particular mitral stenosis was Fried LP, White R, Furberg CD, Rautaharju PM. Incidence of and risk factors for atrialfibrillation in older adults. Circulation. noted as most common cause of enlarged left atrium in 1997; 96: 2455–2461. 31(47%) cases. Dilated cardiomyopathy was found in 10. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, 6(9.09%) cases as cause of enlarged left atrium. These Abhayaratna W, Seward JB, Iwasaka T, Tsang TS. Incidence findings are consistent with those reported by ALFA and mortality risk of congestive heart failure in atrial fibrillation study.27 About half of patients had their left ventricular patients: a community-based study over two decades. Eur Heart ejection fraction < 50% in the current study which is J. 2006; 27: 936–941. higher than that reported by previous studies 27. 11. 11 .Wang TJ, Parise H, Levy D, D'Agostino RB Sr, Wolf PA, Vasan RS, Benjamin EJ. Obesity and the risk of new-onset atrial fibrillation. JAMA. 2004; 292:2471–2477. CONCLUSION 12. 12 .Dublin S, French B, Glazer NL, Wiggins KL, Lumley T, Psaty BM, Smith NL, Heckbert SR. Risk of new-onset atrial This article has provided many insights on potential risk fibrillation in relation to body mass index. Arch Intern Med. factors for the occurrence of atrial fibrillation, such as 2006; 166: 2322–2328. valvular heart disease, hypertension, cardiomyopathy, 13. 13.Thomas MC, Dublin S, Kaplan RC, Glazer NL, Lumley T, ischemic heart disease and various presenting features Longstreth WT Jr, Smith NL, Psaty BM, Siscovick DS, of patients with atrial fibrillation. This would help in Heckbert SR. Blood pressure control and risk of incident atrial early diagnosis and prompt treatment of AF especially fibrillation. Am J Hypertens. 2008; 21: 1111–1116. in rural areas which remains a challenging problem. 14. 14.Mitchell GF, Vasan RS, Keyes MJ, Parise H, Wang TJ, Larson MG, D'Agostino RB Sr, Kannel WB, Levy D, Benjamin EJ. Pulse pressure and risk of new-onsetatrial fibrillation. JAMA. 2007; 297: 709–715. REFERENCES 15. 15 .Vaziri SM, Larson MG, Benjamin EJ, Levy D. 1. Eric N Prystowsky, Benzy J Padanilam, Albert L Waldo;.Hurst’s Echocardiographic predictors of nonrheumatic atrial : The Heart, edited by Valentin fuster et al. Mcgraw Hill 13th fibrillation: the Framingham Heart Study. Circulation.1994; 89: edition 2011. Vol I . 963-981. 724–730. 2. 2.Fuster, V Ryden LE . Asinger RW et al. ACC/ AHA /ESC 16. 16 .Tsang TS, Gersh BJ, Appleton CP, Tajik AJ, Barnes ME, guidelines for the management of patient with atrial fibrillation Bailey KR, Oh JK, Leibson C, Montgomery SC, Seward JB. (committee to develop guidelines for the management of Left ventricular diastolic dysfunction as a predictor of the first patients with AF )circulation 2001; 104: 2118-2150 diagnosed nonvalvular atrial fibrillation in 840 elderly men and women. J Am Coll Cardiol. 2002; 40: 1636–1644. 3. 3.Levy S. Classification system of AF. Cur opin cardiol 2000;15:54-57 17. 17 .Aviles RJ, Martin DO, Apperson-Hansen C, Houghtaling PL, Rautaharju P, Kronmal RA, Tracy RP, Van Wagoner DR, 4. Go AS , Hylek EM, Phillips KA et al, Prevalence of atrial Psaty BM, Lauer MS, Chung MK. Inflammation as a risk factor fibrillation in adults. JAMA 2001;285:2370-5. for atrial fibrillation. Circulation. 2003; 108:3006–3010. 5. Wolf PA , Abbott RD, Kannel WB, Atrial fibrillation: A major 18. 18.Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, contributor to stroke in the elderly. The Framingham study. Omland T, Wolf PA, Vasan RS. Plasma natriuretic peptide Arch Intern Med 1987; 147:1561-4. levels and the risk of cardiovascular events and death. N Engl J 6. 6.Rodney H Falk, MD. Atrial Fibrillation; new eng. J. Med. 2004; 350: 655–663. med.2001;344:1067-1077. 19. 19 .Gami AS, Hodge DO, Herges RM, Olson EJ, Nykodym J, 7. Benjamin EJ, Levy D, Vaziri SM, D'Agostino RB, Belanger AJ, Kara T, Somers VK. Obstructive sleep apnea, obesity, and the Wolf PA. Independent risk factors for atrial fibrillation in a risk of incident atrial fibrillation.J Am Coll Cardiol. 2007; 49: population-based cohort: the Framingham Heart Study. JAMA. 565–571. 1994; 271: 840–844.

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NATIONAL JOURNAL OF MEDICAL RESEARCH

20. 20 .Watanabe H, Tanabe N, Watanabe T, Darbar D, Roden 24. Furberg CD, Psaty BM, Manolio TA et al. Prevalence of atrial DM, Sasaki S, Aizawa Y. Metabolic syndrome and risk of fibrillation in elderly subject (the cardiovascular health study) development of atrial fibrillation: the Niigata preventive Ame. J Cardiol 1994; 74 : 236-41. medicine study. Circulation. 2008; 117: 1255–1260. 25. Kannel WB, MC Namara, Abott RD , coronary heart disease 21. Wolf PA, Abott RD,Kannel WB, Atrial fibrillation as an and atrial fibrillation, The Framingham study. Am heart J. independent risk factor for stroke: the Framingham 1993;106: 389-96. study.Stroke 1991;22:983-8. 26. AHA guideline for the management of AF 2006.circulation. 114 22. Falk RH, Atrial Fibrillation. N. Eng. J. Med. 2001;344: 1067-68. (7)e: 257-384. 23. Markides V, Schilling RJ , Atrial fibrillation; classification, 27. Levy S, Marek M, Coumel P et al . For the college of French pathophysiology, mechanism and drug treatment. Heart 2003 cardiologist, the ALFA Study circulation 199, 99: 2765-70. Aug; 89: 939-43.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

TYPES OF TALAR ARTICULAR FACETS AND MORPHOMETRIC MEASUREMENTS OF THE HUMAN CALCANEUS BONE

Nagar SK1, Malukar Ojaswini2, Kubavat Dharati3, Gosai SR4, Andani RH5, Patel Bhaskar6

1Professor & Head, Anatomy Department, 2Associate Professor, Anatomy Department, GMERS Medical College, Gotri, Vadodara, 3Assistant Professor, M.P.Shah Medical College Jamnagar, 4Professor D.S. Medical College, Perambalur, Tamilnadu, 5Associate Professor, GCRI, Ahmedabad, 6Assistant Professor, Smt.NHL Municipal Medical College Ahmedabad

Correspondence: Dr. Ojaswini Malukar, 402 Heritage Residency,Ellora park, Vadodara E mail: [email protected]

ABSTRACT

Introduction: The calcaneum is the largest tarsal bone. On its dorsal or superior surface, there are three articular facets for the talus. Objective: The main purpose of the present study has been to find the incidences of variations in types of the talar facets and their association with racial factors, if any. The other objective of the study has been is to find the relation between the total length of the calcanei and the types of calcanei. Method: In the present study of 529 calcanei of unknown sex in Gujarat State, were studied. Result: We found that in 73.67 % of calcanei, the anterior and the middle facets are continuous with each other and in 22.3 % calcanei these two facets are separate from each other. In 1.13 % calcanei, the anterior facet is absent. Conclusion: The study shows racial similarities and differences. The study will serve as a prelude for biomechanics of foot.

Key-words: Calcaneal length, Articular Facets, Inter Facet distances

INTRODUCTION Few Indian workers have also worked on this subject. Jha et al (1972) have reported that type-B clacnei are The calcaneus is a weight bearing tarsal bone of the common amongst the population in Uttar Pradesh and proximal row. It also forms the posterior pillar of the also have classified type-B calcanei into four subgroups two longitudinal arches of the foot. The superior : surface has articular facets on the body and the sustentaculum tali by which it articulates with the talus. Subgroup-1: Anterior and middle articular facets completely fused and form a single facet. Normally there are three facets for synovial joints Subgroup-2: Anterior and middle articular facets between calcaneus and talus, Anterior, Middle and incompletely separated from each other by means of a Posterior. The anterior and the posterior facets are notch. situated on the body and the middle is situated on the Subgroup-3: Anterior and middle articular facets sustentaculum tali. There is considerable variation in separated from each other but with no non-articular the number and arrangement of these facets.. area intervening. Bunning and Barnett (1963) have observed that there Subgroup-4: Absence of anterior articular facet. Only are three types of variations in the arrangement of middle and posterior articular facets were being facets. They have classified these variations as follows: present. Type-A: There are there facets separated by variable Gupta et al (1977) have classified the calcanei in intervals. numerical types as follows: Type-B: There are two facets anterior and middle which Type-I(1): Corresponds to type-B of the Bunning and are either continuous or have a notch between them. Barnett classification (1963). Type-C: There is only one facet i.e. the three form a Type-II(2): Corresponds to type-A of the Bunning and continuum. Barnett classification (1963).

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NATIONAL JOURNAL OF MEDICAL RESEARCH Type-III(3): Has only two facets, not corresponding to Type-D: In this group, the anterior facet is absent and any type of Bunning and Barnett. The anterior facet is only the middle and posterior articular facets are absent. Only the middle and the posterior facets are present. (Fig 1) present. Type-E: Here the anterior articular facet is absent and Type-IV (4): Corresponds to type-C of the Bunning the middle and the posterior articular facets are and Barnett classification (1963). continuous with each other. (Fig :2) However, this subject is interesting but comparing the larger population of the Indian subcontinent and the amount of study carried on the variation of facets is much less. Similar study in population of Gujarat State has not yet been undertaken so far. It was therefore, considered necessary to carry out the study of calcaneal facets in Gujarat State.

MATERIAL AND METHOD Five hundred twenty nine grossly normal adult human calcanei were procured from the departments of Anatomy, Medical College, Baroda; B.J. Medical College, Ahmedabad; Government Medical College, Surat and Dental College, Ahmedabad. Fig 1 Fig 2 Sexual dimorphism was not considered. A good Fig 1 Type-D Calcaneum (Left Side) Absent properly aligned sliding calliper was selected for the Anterior Facet measurement of the total lengths of the calcanei. The total length of the calcaneum was taken in the Fig:2: Type-E Calcaneum (Left Side) Continuous horizontal position. The anterior point was the upper middle and posterior facet part of the cuboidal articular facet situated on the anterior surface of the calcaneum. The posterior point was the rough bony part for the attachment of the Table 1: Percentage incidence of the types of tendo clacaneus. The measurements were taken in calcanei decimal system. Type of Right Left side Total Where the anterior and the posterior facets were Calcaneum side bones bones (%) separated from each other, the distance between the Bones (%)(n=269) (n=529) two was measured with the help of the blunt pointers (%) of the sliding calliper. The posterior most part of the (n=260) anterior facet was taken as the anterior point and the Type-A 54 (20.76) 64 (23.79) 118 (22.30) anterior most part of the posterior facet was taken as Type-B 204 200 (74.34) 404 (76.37) the posterior point. (78.46) All the observations and the measurements were put Type-C 0 (0 0 (0) 0 (0) into tabular form. Type-D 01 (0.38) 05 (1.85) 06 (1.13) Type-E 01 (0.38) 00 (0) 01 (0.18)

OBSERVATION From the Table -I, it is clear that the pattern of facets of type-B is commonest. The percentage of incidence The total numbers of calcanei examined were 529, out on the right side is 78.46 and that on the left side, it is of these 260 were of the right side and 269 were of the 74.34. The difference is 4.The next common type is the left side. type-A group. On the right side the percentage These calcanei were classified into type A, B, C, D and incidence is 20.76 and that on the left side is 23.79 %. type E according to the configuration of the superior The incidence of type-A facet is higher by 3 % on the talar articluar facets. The criteria to group them into left side than the right side. There are no calcanei various types are as follows : belonging to type-C. The incidence of type-D and type- E is very less. The type-D has an incidence of 1.138, Type-A: Presence of three separate articular facets while the type-E is only 0.18 %. The type-B calcanei anterior, middle and posterior on superior surface. were further classified into two subgroups on the Type-B: Presence of two articular facets where anterior following criteria : and middle are continuous with each other. The posterior facet is separate. Subgroup-I In this subgroup, the anterior and Type-C: Here all the three facets i.e. anterior, middle middle articular facets were completely fused and and posterior are continuous with each other. formed a single continuous facet.

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NATIONAL JOURNAL OF MEDICAL RESEARCH Subgroup-II In this subgroup, the anterior and are separate) falls in the range of 6.6 cm. to 8.5 cms. middle articular facets were incompletely separated The percentage which falls below 6.6 cm is 1.69 %. from each other by means of a notch Constriction. The total length of type-B calcanei falls in the range of 6 cm to 8.5 cm. The percentage of the type-B calcanei which falls in the range of 6 cm to 6.5 cm is 6.43 %. Table 2: Percentage of Incidence of the Two Subgroups of Type-B Calcanei (n=404) The type-A clacanei where all the three articular facets are separate (anterior, middle and posterior) ,the Subgroup Type B Calcanei distance between the anterior and the middle was Right side Left side (%) Total (%) measured. The measurement was in millimeters. The (%) (n=204) (n=200) (n=404) detailed analysis is shown in the following table 5 I 126 (61.76) 111 (55.5) 237 (58.66) One hundred eighteen type -A calcanei of right and left II 078 (38.23) 089 (44.5) 167 side classified according to the distance between the (41.33) anterior and the middle articular facet measured in millimeters. The total length of the calcanei was measured and the range was found between 5 cms and 9 cms. They were further grouped into smaller units, each unit having a Table -5: Distance between Anterior and Middle difference of 0.5 cm. These units were designated as a, Facet in Type A Calcanei b, c, to h. Type A Right side Left side Total (%) calcaneum (%) (%) (n=64) (n=118) (n=54) Table 3: Incidences of the Various Types of the Small interval 19 (35.18) 19 (29.68) 38 (32.20) Calcanei in Relation to the Total Length (Right (<2mm) Side - Total Bones 259) Moderate interval 24 (44.44) 33 (51.56) 57 (48.30) Type of Total length range measured in cm. RT. (2 mm to 5 mm) calcanei a b c d e f gh Large interval 11 (20.37) 12 (18.75) 23 (19.49) Type-A 0 0 01 04 25 14 09 1 (>5mm) Type-B 1 1 15 15 95 44 29 4 Type-C 0 0 00 00 00 00 00 0 Table 6: Total Length of Calcanei of the Right Side Type-D 0 0 00 00 00 01 00 0 Classified as per Interfacet Distance Type-E 0 0 00 00 00 00 00 0 Total Length Interfacet distance in mm

of calcanei in Small Moderate Large The above table shows that the type-A calcanei falls in cm interval less interval 2 interval the range between 'e' and 'g' i.e. between 7 cm to 8.5 than 2 mm mm to 5 mm more than 5 cm.The type-B calcanei falls in the range of 'c' to 'g' i.e. mm between 6 cm to 8.5 cm. Those smaller units or ranges 5.0 to 5.5 0 0 0 were omitted where the number of calcanei where less 5.6 to 5.9 0 0 0 than 5. The type-A calcanei falls in the range of 'd ' to 6.0 to 6.5 1 0 0 'g' i.e. their total length is between 6.6 cm to 8.5 cms. 6.6 to 6.9 2 2 0 The type-B calcanei fall in the range of 'c' to 'g' i.e. 7.0 to 7.5 9 13 3 between 6.0 cm to 8.5 cms. The number of calcanei in 7.6 to 7.9 4 6 4 the other types was too small to record any significant 8.0 to 8.5 2 3 4 finding. 8.6 to 8.9 1 0 0

Total (n=54) 19 (35.18) 24 (44.44) 11 (20.37) Table 4: Incidences of the Various Types of the Calcanei in Relation to the Total Length (Left Side - Total Bones 270) The range of total length of the calcanie of type-A of the right side falls between 7 cm to7.5 (vide Table -3), Type of Total length range measured in correlating this length with the interfacet distance from calcanei cm.LT. the above table, it indicates that the number of calcanei a b c d e f gh with the moderate interval is more (44.44 % ) . The Type-A 00 00 01 08 27 18 10 00 next common range is the small interval with the Type-B 01 11 25 70 59 31 03 percentage of 35.18 % and the least common range is Type-C 00 00 00 00 00 00 00 00 the large interval having a percentage of 20.37 %. Type-D 01 00 01 00 01 02 00 00 From the table, it is inconclusive that with the increase Type-E 00 00 00 00 00 01 00 00 of the total length of calcanei there is increase in

interfacet distance. The reverse is also not true that From the Table -3 and Table -4, It is evident that the total length of type-A calcanei (where the three facets

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NATIONAL JOURNAL OF MEDICAL RESEARCH with decrease in the interfacet distance, there is also study it is 76.37 %, which gives a difference of 43 %. In decrease in the total length of the calcanei. the British calcanei there were no type-C calcanei. In the present study also no type-C calcanei were found.

In the British calcanei there were no type-D and type-E Table-7: Length of Calcanei of Type-A of the Left calcanei as reported in the present study. Side Classified as per Interfacet Distances In the Veddah, 6 calcanei were of type-B and 4 were of Total Length of Interfacet distance in mm type-C, out of 10 bones reported by them. This small calcanei in cm Small Moderate Large number was not considered in the present study for interval less interval 2 interval comparison to arrive at any positive conclusion. than 2 mm mm to 5 more than 5 In their study of 78 Indian calcanei the type-A was 22 mm mm %, type-B was 78 % and there was no type-C 5.0 to 5.5 0 0 0 calcaneum. Comparing these findings with the present 5.6 to 5.9 0 0 0 study, it is observed that the incidence of various types 6.0 to 6.5 0 1 0 of clacanei is very much close to findings in the present 6.6 to 6.9 4 3 1 study. It also confirms that the type-B calcanei have 7.0 to 7.5 7 13 7 higher incidence of occurrence than type- Jha and 7.6 to 7.9 5 11 2 Singh (1972) studied 1600 calcanei of which 800 were 8.0 to 8.5 3 5 2 of right side and 800 were of left side. They had sutdied 8.6 to 8.9 0 0 0 the calcanei belonging to U.P. State. They found that Total (n=54) 19 (29.68) 33 (51.56) 12 (18.75) the type-B calcanei were the commonest. Less common were the type-A and the least were the type-C. the The range of the total length of the calcanei of type-A incidence of type-B was 62.37 %, of which the right of the left side falls between 6.6 cm. to 8.5 cm (Vide side was 63 % and the left side was 61.75 %. The Table-5) correlating this with interfacet distance from incidence of type-A calcanei was 37.25 % of which the the Table-7, it is evident that interfacet distance of right side was 36.75 % and the left side was 38.25 %. In moderate interval is more common with the percentage the present study, the incidence of the type-B calcanei of 51.66 %. The next common range is the small is 76.37 % of which the right side is 78.46 % and the interval percentage being 29.68 %. And the least left side is 74.34 %. Although in the present study the common in the large interval with 18.75% type-B calcanei is commonest type, it shows a There is no correlation that with increase in the total difference of 16 %. on the right side, the incidence in length of the calcanei, with the increase of the interfacet their findings was 63 % and on left side it was 61.75 %. distance. The reverse is also inconclusive that with In the present study on the right side it is 78.46 % and decrease in the total length of the calcanei, there is on the left, it is 74.34 %. Their study shows the decrease in the interfacet distance. preponderance of type-B calcanei on right side over the left side. On right side it is more by 1.25 %. In the present study also the type-B has preponderance over DISCUSSION the left side. It is 4 % showing a difference of 2.75 %. The main purpose of the present study has been to find Hamdy El-Eishi (1974) studied 200 adult Egyptians the incidences of variations in types of the talar facets calcanei for the variation of talar articula facets on its and their association with racial factors, if any. superior surface. Sex and sides of the calcanei were not considered by him. According to his classification, 49 % of calcanei were of type-1, which corresponded to Table 8: Comparison with various studies type-B of the present study, 40 % calcanei were of type- 2 which corresponded to type-A of the present study Author Types of calcanei and 11 % calcanei were of type-3 which corresponded Type Type Type Type Type to type-D of the present study.Comparing these A B C D E findings with the present study, we find that the type-B A. Barnett (1964) calcanei has higher rates of occurrence compared to a) British calcanei 67.0 33.0 - - - type-A. The incidence of type-B calcanei in Egyptian (194) population was 49 %, while in the present study, it is b) Veddah calcanei 60.0 40.0 - - 76.37 % which gives a difference of 27 %. (10) In his study the type-A calcanei were 40 % while in the c) Indian calcanei (78) 78.0 - - - present study, it si 22.30 % the difference being 18 %. B. Present study (529) 22.3 76.4 -- 1.1 0.2 Thus, it could be inferred that the type-A calcanei has (All figures in percentage) higher incidence in the Egyptian than the Indian calcanei. Forriol campor and Gomez (1989) studied 176 The incidence of type-A in British calcanei (67 %) was calcanei of the Sapnish people irrespective of sex and much higher than in the present study which is 22.3 %, side. They reported that 46 % of calcanei belonged to showing a difference of 45 %. While in the British type- type-A and 53 % of them belonged to type-5. They B calcanei the incidence was 33 % which in the pesent

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NATIONAL JOURNAL OF MEDICAL RESEARCH found no type-C, D and E calcanei. Their study shows 6. El-Eishi H. Variations in the talar articular facets in Egyptian the preponderance of type-B calcanei. calcanei. Acta anatomica. 1974; 89:134-8. 7. Gupta et al : Pattern of talar articular facets in Indian calcanei. J. In the present study, the incidence of type-A calcanei is Anat., London. 1977;124:651-5. 22.30 %, while in their study it was 46 %. This gives a 8. Humilton W.J. : Textbook of Human Anatomy, 2nd edition, difference of 24 %, which shows that in the Spanish 1976. people the occurrence of type -A calcanei is higher than in the Indians 9. Hollinshead Henry : Textbook of Anatomy, 2 nd edition, 1970. 10. Jhamaria NL, Lal KB, Udamwat M, Banerji P, Kabra SG. The trabecular pattern of the calcaneum as an index of osteoporosis. REFERENCES The journal of bone and Joint surgery 1983; 65-B (2): 195-8. 11. Jha and Singh : Variations in the articular facets on the superior

1. Breathnach AS. Frazer's Anatomy of the Human Skeleton, 6th surface of calcaneus. J.Anat. Soc. India. 1972; 21(1);40-44. ed., p. 147. London: J. & A. Churchill Ltd. 1965. 12. Last RJ. Anatomy, Regional and Applied, 4th ed., London: The

2. Bunning and Barnett : Variations in the talocalcaneal English Language Book Society and J. & A. Churchill Ltd. articulations. J.Anat.London, 97 : 643,1963. 1970: p. 341.

3. Bunning P.S.C.: Some observations on the West African 13. Laidlaw PP. The varieties of the os calcis. .J. Anat., Lond. 1904; calcaneus and the associated talocalcaneus interosseous 38:133-43. ligamentous apparatus. Amer.J.Phys. Anthrop. 22 : 467-472, 1964. 14. Padmanabhan R. The talar facets of clcaneus- an anatomical note. Anat Anz 1986; 161(5): 389-92. 4. Bunning PSC, Barnetr CH. A comparison of adult and foetal talocalcaneal articulations. Journal of Anatomy. 1965; 99: 71-6. 15. Warwick R, Williams PL. Gray's Anatomy, 35th ed. Edinburgh: Longman. 1973: p. 377. 5. Drayer-Verhagen F. Arthritis of subtalar joint associated with sustentaculum tali facet configuration. J Anat, 1993 ; 183(Pt 3): 631–4

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

A HISTOPATHOLOGICAL STUDY OF OPHTHALMIC LESIONS AT A TEACHING HOSPITAL

Chauhan Sanjay C1, Shah Sejal J2, Patel Amul B3, Rathod Hitesh K4, Surve Sunil D5, Nasit Jitendra G6

1Assistant Professor, 2Tutor, Pathology Department, 3Assistant Professor, Community Medicine Department, 4Assistant Professor, Forensic Medicine Department, 5Tutor, Forensic Medicine Department, GMERS Medical College, Gotri, Vadodara 6Assistant Professor, Pathology Department, PDU medical college, Rajkot

Correspondence: Dr. Amul B. Patel “Gurukrupa”, 229, Nandanvan society, Near Abhilasha cross roads, New Sama Road, Vadodara-390008. Email: [email protected], Mobile: 9429823997

ABSTRACT

Background: Objectives of the study was to study the morphological and clinico-pathological correlation of ophthalmic lesions, to know the pattern of prevalence of ophthalmic lesions in hospital and to compare the data and other investigations with similar studies from India as well as abroad. Materials and methods: The study was carried out in the pathology department of NHL municipal medical college, Ahmedabad during 2009. Total 100 biopsies & whole specimen of tumours were obtained from patients admitted in various wards of an Ophthalmology department. Results: Ophthalmic lesions were highest (18%) in 31-40 year age group. Eyelid (57%) was the most commonly involved site. Clinical diagnosis was consistent with histopathological diagnosis in approximately half (49%) cases. Among eyelid lesions, dermoid cyst (21%) was highest. Among conjunctival lesions, granuloma pyogenicum (22.5%) was highest. Conclusion: All ophthalmic lesions removed surgically should always (without exception) be subjected to histopathological examination to establish correct diagnosis for further management.

Keywords: ophthalmic lesions, histopathological study, eyelid, conjunctiva, orbital lesion

INTRODUCTION The goal of the ophthalmic pathology service is to enhance communication between the ophthalmic Ophthalmic histology techniques differ from those of surgeon and the pathology laboratories and to provide normal tissue in fixation, processing and sectioning. detailed histopathological information that can be Most anatomical pathology laboratories do not have correlated with patient history and other clinical data. necessary set up to provide these special techniques. In this way, histopathological studies have the greatest Again it is required to train the personnel to identify benefit to ongoing patient care.3 disease processes unique to eye diseases or demonstrate them on a microscopic slide along with the pupil and Objectives of this study were to study the optic nerve.1 morphological and clinico-pathological correlation of ophthalmic lesions, to know the pattern of prevalence Ophthalmic Pathology is the subspecialty of Pathology of ophthalmic lesions in hospital and to compare the and Ophthalmology that focuses on diseases of the eye data and other investigations with similar studies from and its neighbouring tissues. Ophthalmic Pathologists India as well as abroad. study tissues excised by Ophthalmologists to provide a precise diagnosis of the disease. The diseased tissue is examined macroscopically (gross examination) and by MATERIALS AND METHODS light microscopy. Other techniques, such as transmission and scanning electron microscopy, The study was carried out in the pathology department immunehistochemistry, as well as molecular biological of NHL municipal medical college, Ahmedabad during and other methods are also sometimes employed. The 2009. Total 100 biopsies & whole specimen of tumours diagnosis of the disease plays an important part in were obtained from patients admitted in various wards patient care.2 of an Ophthalmology Institute affiliated to the medical

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NATIONAL JOURNAL OF MEDICAL RESEARCH college. A detailed history of each patient regarding age, chief complaints, & other relevant findings were taken. Location wise, Eyelid (57%) was the most commonly involved site followed by conjunctiva (22%) and orbit The surgically resected specimens fixed in the 10% (8%), while lacrimal sac (2%) was the least commonly formalin were received. Thorough gross examination of involved site (Table 2). Clinical diagnosis was consistent each mass for its size, shape, and consistency was done. with histopathological diagnosis in approximately half Several representative areas of tissue were taken from (49%) cases. received surgical specimen & subjected to routine paraffin embedding. Four to five sections 2-3 mm thick were taken from different areas of specimen & Table 3: Prevelance of different Eyelid lesions processed in automatic tissue processor. Blocks were (N=57) prepared with the help of leuckhart’s piece. After trimming of blocks, sections 5-7 um thick were cut with Eyelid Lesions Cases (%) help of rotatory microtome. Sections were floated on Dermoid cyst 12 (21.0) water at temperature of 45 degree & were taken on Epidermal inclusion cyst 8 (14.0) albuminized slides. The sections were stained by Intradermal Nevus 7 (12.2) haematoxylin & eosin stain in all cases. Special stain Sebaceous (meibomian ) carcinoma 5 (8.7) such as PAS stain was used whenever required. Capillary haemangioma 4 (7.0) Cavernous haemangioma 3 (5.2) Fibroepithelial Polyp 2 (3.5) RESULTS Eccrine hydrocystoma 2 (3.5) Seborrheic keratosis 2 (3.5) Total 100 cases of ophthalmic lesions were observed. Malignant melanoma 2 (3.5) It was found that ophthalmic lesions were highest Adenoid basal cell carcinoma 2 (3.5) (18%) in 31-40 year age group and lowest (1%) in the Pigmented basal cell carcinoma 2 (3.5) age group 81-90. After 10 years of age, proportion of Schwannoma 1 (1.7) lesions increases up to 40 years of age and then Chalazion 1 (1.7) declined in each decade afterwards. Sex wise there was Lipoma 1 (1.7) not much difference as lesions were found in 49% Keratinous cyst 1 (1.7) females and 51% males. But in the age group of 31-40 Neurofibroma 1 (1.7) & 41-50 years proportions were found higher in Moderately differentiated Squamous 1 (1.7) females (10%) compared to males (6-8%). While male cell carcinoma preponderance (11%) was found in 21-30 years of age group (Table 1). From malignancy point of view, Among eyelid lesions, dermoid cyst (21%) was highest lesions were benign in 70% cases and malignant in 30% followed by epidermal inclusion cyst (14%), intradermal cases. nevus (12.2%) and sebaceous (meibomian) carcinoma (8.7%) (Table 3). Table 1: Distribution of ophthalmic lesions Among conjunctival lesions, granuloma pyogenicum according to age & sex (22.5%) was highest followed by capillary haemangioma (13.5%) (Table 4). Age Group (Yr) Male (%) Female (%) Total (%) 1-10 09 (18.4) 06 (11.8) 15 (15.0) 11-20 04 (8.2) 06 (11.8) 10 (10.0) Table 4: Prevalence of different conjunctival 21-30 11 (22.4) 02 (3.9) 13 (13.0) lesions (N=22) 31-40 08 (16.3)10 (19.6) 18(18.0) 41-50 06 (12.2)10 (19.6) 16 (16.0) Conjunctival Lesions Cases 51-60 04 (8.2) 09 (17.6) 13 (13.0) (%) 61-70 04 (8.2) 06 (11.8) 10 (10.0) Granuloma Pyogenicum 5 (22.5) 71-80 02 (4.1) 02 (3.9) 4 (4.0) Capillary haemangioma 3 (13.5) 81-90 01 (2.0) 00 (0.0) 1 (1.0) Conjunctival papilloma 2 (9.0) Total 49 (100) 51 (100) 100 (100) Epidermal inclusion cyst 2 (9.0) Squamous cell carcinoma in situ 2 (9.0) Table 2: Location wise distribution of ophthalmic Well differentiated Squamous cell 2 (9.0) lesions (N=100) carcinoma Choristoma 1 (4.5) Location Cases (%) Cavernous haemangioma 1 (4.5) Eyelid 57 (57) Compound nevus 1 (4.5) Conjunctiva 22 (22) Orbital fat prolapse 1 (4.5) Orbit 8 (8) Conjunctival cyst 1 (4.5) Lacrimal Gland 6 (6) Moderately differentiated Squamous cell 1 (4.5) Retina 5 (5) carcinoma Lacrimal Sac 2 (2)

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NATIONAL JOURNAL OF MEDICAL RESEARCH Table 5 shows distribution of different orbital lesions, (meibomian) carcinoma and 33.3% basal cell among which Non Hodgkin’s Lymphoma (37.5%) was carcinoma. While study carried out by Jahagirdar SS et highest. Lacrimal sac lesions (2) included only chronic al12 observed 37% sebaceous (meibomian) carcinoma dacryocystitis and retinoblastoma was the only and 44% basal cell carcinoma. pathology amongst all five intraocular lesions. Out of 6 lacrimal gland lesions half were pleomorphic adenoma (50%) and rest (50%) were sebaceous carcinoma. Table 6: Comparison of Incidence of benign and malignant lesions of eyelid tumors with study

carried out by Obata H et al11, Abdi U et al study13, Table 5: Prevalence of different orbital lesions Tesluk GC et al14 (N=8) Name of Study Eyelid lesions Orbital Lesions Cases (%) Benign Malignant Non Hodgkin’s Lymphoma 3 (37.5) 11 Cavernous Haemangioma 1 (12.5) Obata H et al study-2005 73% 27% Abdi U et al13 study-1996 58.90% 41.10% Mucocele 1 (12.5) 14 Schwannoma 1 (12.5) Tesluk GC et al -1985 82.60% 17.40% Alveolar Rhabdomyosarcoma 1 (12.5) Present study-2009 79% 21% Embryonal Rhabdomyosarcoma 1 (12.5) Table 6 shows that results of present study are DISCUSSION comparable with the study carried out by Obata H et al11 study, Abdi U et al13 study, Tesluk GC et al14 study. Results of the present study were compared with In the study of Obata H et al11 most common benign various other similar studies. The results of present lesion was intradermal nevus (21.3%).While in our study are comparable with the study carried out by Ud- study most common benign lesion was dermoid cyst Din N et al4.In our study, benign lesions were 70% (21%), while intradermal nevus (12.2%).In the study of while malignant lesions were 30%, while other study4 Obata H et al11 most common malignant lesion was found it 61.5% and 38.5% respectively. The most sebaceous (meibomian) carcinoma (15%).In our study important is bimodal peak seen in our study is same as also the most common malignant lesion was sebaceous the study carried out by Ud-Din N et al4. Like Ud-Din (meibomian) carcinoma (8.7%). In the study of Abdi U N et al4 study, most common malignancy in children in et al13 most common benign lesion was vascular present study was also retinoblastoma. tumour(21.3%).While in our study most common benign lesion were dermoid cyst(21%) followed by Regarding sex wise distribution in malignant intradermal nevus (12.2%). In the study of Abdi U et ophthalmic tumour, in present study 53.3% were males al13 most common malignant lesion was basal cell and 46.7% were females. Thakur SK et al5 reported carcinoma (38.8) while in our study most common 51.2% males and 48.8% females. While malignant lesion was sebaceous (meibomian) carcinoma Sunderraj P6 observed 56% males and 44% (8.7%). In the study of Tesluk GC et al14 the most females. Frequency among children was 18 % in common lesion of the eyelid was basal cell carcinoma, present study while Tikur Anbessa et al7 found it 20% which represented 14.3% of the total and 82.4% of the which was almost similar. Frequency of malignant lesions while in our study most common retinoblastoma in our study was 27.5 which malignant lesion is sebaceous (meibomian) carcinoma were less compared to other study7 (39%). (8.7%). Clinical accuracy was decided on the basis where clinical diagnosis matches with histo-pathological In summary, we can conclude that all ophthalmic diagnosis. In our study clinical accuracy was in almost lesions removed surgically should always (without half (49%) cases, while other studies8-10 found it on exception) be subjected to histopathological higher side as it was 84%, 91.5% and 96%.These examination to establish correct diagnosis for further comparisons are clearly emphasizing need for biopsy of management. all surgically removed specimens.

Prevalence of benign and malignant lesions of conjunctival tumors in present study was 79% and 21% REFERENCES respectively. The same was observed in other study11 as 1. Histology of eye. Available from: they were 78.5% and 21.5% respectively. In the study http://ophthapg.blogspot.com/2008/12/histology-of-eye.html. of Obata H et al11 most common benign lesion was Accessed January 24th 2012. intradermal nevus(13%).While in our study most 2. Ophthalmic Pathology Primer. Available from: common benign lesion were granuloma http://www.vetmed.ucdavis.edu/courses/vet_eyes/eye_path/e path_overview_index.html. Accessed January 24th 2012. pyogenicum(22.5%) followed by intradermal nevus (4.5%). In the study of Obata H et al11 most common 3. Ophthalmic Pathology Service. Available from: malignant lesion was malignant lymphoma (9%).While http://www.smbs.buffalo.edu/ophthalmology/clinicalServices/ pathology_fed.htm. Accessed January 24th 2012. in our study most common malignant lesion was squamous cell carcinoma (22.5 %). Among eyelid malignancy, present study found 41.7% sebaceous

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NATIONAL JOURNAL OF MEDICAL RESEARCH

4. Ud-Din N, Mushtaq S, Mamoon N, Khan AH, Malik IA. , 10. Margo CE: Eyelid tumors: accuracy of clinical diagnosis. Am J Morphological spectrum of ophthalmic tumors in northern Ophthalmol.1999 Nov; 128(5):635-6. Pakistan. J Pak Med Assoc. 2001 Jan; 51(1):19-22. 11. Obata H, Aoki Y, Kubota S, Kanai N, Tsuru T, Incidence of 5. Thakur SK, Sah SP, Lakhey M, Badhu BP, Primary malignant benign and malignant lesions of eyelid and conjunctival tumors. tumours of eye and adnexa in Eastern Nepal. Clin Experiment Nippon Ganka Gakkai Zasshi. 2005 Sep; 109(9):573-9. Ophthalmol.2003 Oct; 31(5):415-7. 12. Jahagirdar SS, Thakre TP, Kale SM, Kulkarni H, Mamtani M 6. Sunderraj P, Malignant tumours of the eye and adnexa. Indian J Other A clinicopathological study of eyelid malignancies from Ophthalmol. 1991 Jan-Mar;39(1):6-8. central India. Indian J Ophthalmol.2007 Mar-Apr; 55(2):109-12. 7. Tikur Anbessa and Menelik, Pattern of ophthalmic lesions at 13. Abdi U, Tyagi N, Maheshwari V, Gogi R, Tyagi SP, Tumours two histopathology centres in Ethiopia. East Afr Med.2001 of eyelid: a clinico- pathologic study. : J Indian Med Assoc.1996 May; 78(5):250-4. Nov; 94(11):405-9, 416, 418. 8. Kersten RC, Ewing- Chow D, Kulwin DR, Gallon M: Accuracy 14. Tesluk GC, Eyelid lesions: incidence and comparison of benign of clinical diagnosis of cutaneous eyelid lesions. and malignant lesions.Ann Ophthalmol. 1985 Nov; 17(11):704- Ophthalmology. 1998 Feb; 105(2):203-4. 7. 9. Deokule S, Child V, Tarin S, Sandramouli S: Diagnostic accuracy of benign eyelid skin lesions in the minor operation theatre. Orbit. 2003 Dec; 22(4):235-8.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

A PROFILE OF CASES OF HEMOGLOBINOPATHIES AT A MEDICAL COLLEGE

Shah Sejal J1, Chauhan Sanjay C2, Rathod Hitesh K3, Patel Amul B4, Sharma Vaibhavi Y1

1Tutor, 2Assistant Professor, Pathology Department, 3Assistant Professor, Forensic Medicine Department, 4Assistant Professor, Community Medicine Department, GMERS Medical College, Gotri, Vadodara

Correspondence: Dr. Amul B. Patel “Gurukrupa”, 229, Nandanvan society, Near Abhilasha cross roads, New Sama Road, Vadodara-390008. Email: [email protected] Mobile:9429823997

ABSTRACT

Background: Present study was carried out with objectives of creating a profile for cases of hemoglobinopathies coming at NHL medical college and comparing the results obtained in present study with those of various studies done in India and abroad. Materials and methods: The study was carried out at the Department of Pathology, N.H.L. Municipal Medical College, Ahmedabad. A total of 35 cases of thalassemias and other hemoglobinopathies were studied. The criteria for case selection were hemoglobin level less than 10 gm%, presence of hepatosplenomegaly, icterus and clinical presumption of hemolytic anemia in general. Details of the cases were recorded in a proforma. Data were then analysed using microsoft excel software. Results: Out of total 35 cases Beta0 Thalassemia Major was the most frequent (40%) followed by homozygous sickle cell disease (20%). More than one third cases (34.3%) were of 10 or more years of age while 31.4% cases were in 1-3 years of age group. Sex wise distribution showed male preponderance (74.3%). Religion wise majority were hindus (80%). Caste wise majority were of general category (83%). Pallor was found in all cases. Most of the cases showed hypochromia, microcytosis, Anisopoikilocytosis, polychromatophilia.

Key words: hemoglobinopathies, Beta Thalassemia Major, sickle cell disease

INTRODUCTION leads to deficient synthesis of haemoglobin polypeptide chains. In contrast to the hemoglobinopathies, no basic Hemoglobinopathies constitute a very important chemical abnormality of haemoglobin species lies causative factor for anemias of childhood. This is behind the thalassemias. Different types of thalassemias especially so in those regions where abnormal with different clinical and biochemical manifestations hemoglobin genes are prevalent in a frequency of high are associated with defects in each kind of polypeptide order. They may mimic nutritional anaemias and they chains (alpha, beta, gamma, and delta). In India, it has prove refractory to the usual corrective measures. The been observed that beta chain production is commonly two common hemoglobinopathies widely distributed affected9. across our country are the beta thalassemic syndromes and the sickling disorders. The former is more common This study was carried out with objectives of creating a in certain non-tribal ethnic groups and the later among profile for cases of hemoglobinopathies coming at the tribal population1. A couple of earlier studies had NHL medical college and comparing the results incriminated them in the causation of anaemias of obtained in present study with those of various studies childhood2-8. done in India and abroad. The thalassemia is not a single disease, but a group of disorders, each of which results from the inherited MATERIALS AND METHODS defects in the rate of synthesis of one or more of the globin chains. They cause imbalance globin chain The study was carried out at the Department of production, which leads to ineffective erythropoiesis, Pathology, N.H.L. Municipal Medical College, hemolysis and variable degree of anaemia. The exact Ahmedabad. The study period was of two years from nature of the defect is not yet understood, but its result January 2006 to December 2007. A total of 35 cases of is an unaltered quantity or quality of the m-RNA, which thalassemias and other hemoglobinopathies were come

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NATIONAL JOURNAL OF MEDICAL RESEARCH in the attached hospital during that period and were males, while only one fourth cases were females (Table studied. Out of 35 cases, 23 cases were children < 10 3). years and 12 cases were ≥ 10 years. The criteria for case Table 4 shows religion and caste wise distribution of selection were haemoglobin level less than 10 gm%, cases of hemoglobinopathies. Religion wise majority presence of hepatosplenomegaly, icterus and clinical were hindus (80%), followed by muslim (17.1%) and presumption of haemolytic anaemia in general. Family Christian (2.9%). Caste wise majority were of general study was carried out when needed. Details of the cases category (83%), while rest were schedule tribe (14.3%) were recorded in a proforma which included age, sex, and chaudhari (2.9%). Table 5 shows distribution of caste, religion, residence and clinical details, blood cases according to blood transfusion requirement. transfusion requirement and haematological findings. Data were then analysed using Microsoft excel According to clinical findings, Pallor was found in all software. cases. While spenomegaly and hepatomegaly were found in 88.6% and 71.4% cases respectively. Icterus was observed only in 22.9% cases (Table 6). RESULTS Table 4: Religion and Caste wise distribution of Table 1: Type wise distribution of cases of hemoglobinopathies (N=35) hemoglobinopathies (N=35) Religion and Caste Cases (%) Nature of Disease Cases (%) Hindu 28 (80.0) Beta0 Thalassemia Major 14 (40.0) Lohana 5 (14.3) Beta+ Thalassemia Major 2 (5.7) Scheduled Tribe 5 (14.3) Thalassemia Intermedia 2 (5.7) Sindhi 3 (8.6) Homozygous sickle cell disease 7 (20.0) Jain Banias 3 (8.6) Sickle cell trait 4 (11.4) Chaudhari 1 (2.9) Sickle cell Beta thalassemia 4 (11.4) Other (Rajput, Patel, Brahmin, Daraji) 11 (32.9) HBE - Beta thalassemia 2 (5.7) Muslim 6 (17.1) Christian 1 (2.9) Table 1 shows type wise distribution of hemoglobinopathies. Beta0 Thalassemia Major was the Haematological findings: Hb levels ranging from 2.2 - most frequent (40%) followed by Homozygous sickle 10 gm%. MCV and MCH found to be decreased in cell disease (20%). most of the cases raised from 60.3 - 90.8 fl. and 14 - 28.7 pg. respectively. Peripheral smear study showed many abnormalities regarding the size and shape of Table 2: Age distribution of cases of RBC. Most of the cases showed hypochromia, hemoglobinopathies (N=35) microcytosis, Anisopoikilocytosis, polychromatophilia. Target cells and leptocytes were seen in many cases. In Age Group (years) Cases (%) some cases there were also presence of howell jolly 0 - 1 4 (11.4) bodies and basophilic stippling in the RBCs. 1 - 3 11 (31.4) 4 - 6 6 (17.2) 7 - 9 2 (5.7) DISCUSSION ≥ 10 12 (34.3) The results of present study were compared with those Table 2 shows age distribution of cases of of other studies. The maximum numbers of cases were hemoglobinopathies. Out of 35 cases, more than one noted between 1 - 3 years of age group. Present study third cases (34.3%) were of 10 or more years of age includes 62.5% cases between 1 - 3 years of age group, while 31.4% cases were in 1-3 years of age group. 25% cases below one (1) year of age and 12.5% cases in 4 - 6 year of age group. Out of 16 cases of Beta thalassemia major, 10 (62.5%) belong to 1 - 3 years of age group, which is expected. Out of 7 cases of sickle Table 3: Sex distribution of hemoglobinopathies cell disease, 6 cases presented after 7 years. Hence, it (N=35) can reasonably be assumed that thalassemia major Sex Cases (%) disease became manifest in early childhood in most of Male 26 (74.3) the cases. Similar age incidence was observed in O.P. Female 9 (25.7) Ghai series3, Manchanda and Khanna series6, Magotra and Phadke series5 and Giri, Patra and Patel series9. Sex wise distribution showed male preponderance as approximately three fourth cases (74.3%) cases were

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NATIONAL JOURNAL OF MEDICAL RESEARCH Table 5: Distribution of cases according to blood transfusion requirement (N=35) Nature of Disease Total Transfused Frequency of blood transfusion (in Cases cases times) 2-5 6-10 > 10 Beta0 Thalassemia Major* 14 14 5 5 4 Beta+ Thalassemia Major* 2 2 2 - - Thalassemia Intermedia 2 1 1 - - Homozygous Sickle cell 7 5 5 - - disease Sickle cell trait 4 0 - - - Sickle cell - B Thalassemia 4 4 1 3 - HBE - Beta Thalassemia 2 1 1 - - * Require regular blood transfusion (At least one unit / 30 - 60 days)

Table 6: Distribution of cases according to chief Present study found pallor in all cases, while clinical findings splenomegaly and hepatomegaly were seen in 88.6% and 71.4% cases respectively. All these three clinical Clinical Findings Cases (%) signs were found in all cases by other studies2-3. Pallor 35 (100.0) Regarding haematological findings, majority of the Splenomegaly 31 (88.6) cases showed hypochromic microcytic anaemia. This Hepatomegaly 25 (71.4) finding is in agreement with the other series of Coelho2, Icterus 8 (22.9) Pal and Ghai3. Raised reticulocyte count was found in 80% cases in the present study, while it was reported in It was observed in present study that compared to Beta 100% and 76.5% cases by Ghai3 and Coelho2 thalassemia major, sickle cell anaemia patients respectively. presented at later age. Average age for presentation in sickle cell syndromes were HbSS at 13 years, HbAS at 12 years and HbS Beta Thalassemia at 10 CONCLUSION years of age. Regarding sex distribution, out of 35 cases, 74.3 % were male with male to female ratio being Beta thalassemias and sickle cell disorders were found approximately 3:1. Ghai3 reported 63.7% males and to be the commonesthemoglobinopathies in the 36.3% females, while other study2 found 70.6% males present study. HbS was found to be the commonest and 29.4% females. In the present study, out of 35 Hb variant followed by HbE. Thalassemia major cases, 5 were Lohanas, 6 were muslims, 5 were usually presents in early childhood while sickle cell scheduled tribes, 3 were Sindhis, 3 jain, 1 Chaudhary, 1 disordersusually present after five years of age. HbE - Christian and 11 were from other castes i.e. Patel, beta thalassemia often behaves like Thalassemia Brahmin, Rajput, Kachi, Daraji. intermedia in its clinical presentation. Lohana, Muslim, Sindhi, Scheduled Tribes communities comprised the Regarding the distribution of thalassemia among larger group though other communities are also found various castes of central and Eastern India, it may be to be involved. mentioned that of the 13 cases reported by Khandelwal and Solanki in 195911 from Nagpur, 7 were Sindhis. In the J.J. Group of hospitals, Bombay8, 85 cases were REFERENCES investigated and their regional distribution was as follows : Saurashtra - 26, Maharashtra - 21, Sindhi - 12, 1. Marewaha RK, Asutosh lal. Present status of Gujarat excluding Saurashtra - 9, Goa and Adjacent hemoglobinopathies in India. Ind. Ped. 1994; 31(3): 267. region - 9, Bengal - 7, U.P. - 1. Out of 26 cases from 2. Coelho G, Setna S, Simmons C. HFE mutation on iron Saurashtra, 16 were Memons and Khojas and 10 were metabolism in beta thalassemia. Ind. Jr. Child Health 1958; Hindus, mostly Lohanas. Studies3, 8, 10 show that 7:378. maximum incidence was noted in Sindhis, Lohanas and 3. G. C. Degruchy. Clinical Haematology in medical Practice, 6th Muslims. Present study also shows that there are higher ed. Berlin, Germany : Blackwell sciences Publishers; 2002. p numbers of cases among Muslims, Lohanas, Sindhis 302-15. along with scheduled tribes in thalassemia cases. Out of 4. Kulozik AE, Bail S, Kar BC, Serjeant BE, Serjeant GE. Sickle 17 other cases in present study, 15 cases are of sickle Cell - Beta+ Thalassemia in Orissa State, India. Br. Jr. Hemato 1990; 3:215-20. cell syndrome which includes homozygous sickle cell disease, sickle cell trait, sickle cell beta thalassemia and 5. Magotra ML, Phadke MV. Anemia in infancy and childhood. 2 cases are of HbE Beta thalassemias which were Ind. Ped. 1975; 2: 493. Muslims. In these hemoglobinopathies also there are 6. Manchanda SS, Khanna HL. Severe Anemia in childhood. Ind. higher number of cases among Luhanas, Muslims and Jr. of Child health 1961; 11: 462. Scheduled Tribes. 7. Mehta MB, Vaishnav V P. Anemia in infancy and childhood. Ped. Cli. Ind. 1975; 10: 138.

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8. Parekh JG. Study of hemoglobinopathies. Journal of JJ Group 10. Weatherall DJ, Clegg JB. Inherited hemoglobin disorders - an of Hospital and GMC 1963; 35:493-500. increasing global health problem. WHO Bulletin 2001; 79: 704- 12. 9. Giri DD, Patra SB, Patel RZ. Hemoglobinopathies in childhood. Ind. Jr. Patho. Micro 1984; 81: 27 11. Khandelwal MK, Solanki BR. A study of thalassemia in Baroda. Ind. Jr. Child Health 1959; 8: 487

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

OCCUPATIONAL STRESS AND BURNOUTS AS PREDICTORS OF JOB SATISFACTION AMONGST LAWYERS IN DISTRICT SANGLI

Patel Kriti A1, Rajderkar Shekhar S2, Naik Jayashree D3

1Post Graduate Student, 2Professor & Head, 3Associate Professor, PSM Department, Government Medical College, Miraj

Correspondence: Dr. Kriti A Patel Resident-2, Dept. of Preventive & Social Medicine, Government Medical College, Miraj Dist. Sangli – 416410 Maharashtra . Email: [email protected], Mobile No.: 07620346924

ABSTRACT

Background: The practice of law is a high prestige, high skill, high income and high stress profession. The present study was conducted to find out the role of stressors on mental well being of the lawyers. Objectives: To study the occupational stress amongst the lawyers and to examine the correlates of job satisfaction in them, and to study the gender difference (if any) of stress and job satisfaction. Also to study the association between levels of stress and substance abuse disorders. Methodology: A cross sectional study was conducted in Dist. Court Sangli, which involved collection of data using predesigned proforma. By using Systematic Random sampling technique, out of total 240 lawyers 120(76 males and 44 females) were interviewed. Presumptive Stress Life Event Scale (PSLES) was used as a validated screening tool to calculate their Mental Stress Score. The level of Job Satisfaction was scored by 3 point scaling system taking 10 independent variables as the predictors of job satisfaction. Data was analyzed using appropriate statistical tests. Results: 88.3% lawyers had experienced stress. The female lawyers had high Mean Mental Stress Score. 81.8% female lawyers had high Job satisfaction Score i.e. low Job satisfaction. 52.8% of the male lawyers having stress reported substance abuse disorders. Conclusion: The female lawyers experience significantly greater stress and burnouts as compared to males. Job satisfaction is significantly and negatively correlated with stress. The need of the hour is to make an effort in coping with stress amongst lawyers.

Keywords: Job satisfaction, burnout and stress.

INTRODUCTION what is expected and what is received then dissatisfaction occurs. Today an increasing number of lawyers are experiencing burnouts, insomnia, low productivity and Due to high Job demands (overload) there is stress related illness¹ due to lack of balance in personal significant impact of stress on their mental and physical and professional lives. A psychosocial interplay health, which in turn leads to Job strains. There are between personality, power, status and service and varieties of factors that can influence a person’s level of intellectual challenge forms the career dilemma of job satisfaction like pay, promotion system, working lawyer’s conflicts. conditions, leadership, social relationships and the job itself.² Job–satisfaction has been defined as the positive orientation of an individual towards the work role The happier the people with the jobs, the more satisfied which he is presently occupying and the pleasurable they are said to be. It is an integral part of natural emotional state resulting from the appraisal of one’s job fabrics of life. It is an “underload or overload of matter, as achieving or facilitating one’s values. It is basically an individual matter and refers to what one expects from energy or information input to or output from a living his or her job and when there is mismatch between system.”Some degree of stress is the normal part of life and provides the stimulus to learn and grow, without an

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NATIONAL JOURNAL OF MEDICAL RESEARCH adverse effect on health.³ But when stress is intense, 82.8% male counterparts and the difference was found continuous or repeated –as is often the case with to be statistically significant(P<0.5)(Table 2). occupational stress, ill health can result. It can destroy Quality of life and also affect family life. Table: 1 Genderwise Mental Stress scores It can lead to Emotional reactions like depression, Sex Mental Stress Score Total irritability, anxiety, fatigue withdrawl, low self esteem. No stress Less More Physiological (heartburn, eating disorders) muscle pain and Behavioral reactions like (increased smoking, stress stress drinking).4 Male 10 (71.4) 38 (65.5) 28 (58.3) 76 (63.3) Female 4 (28.6) 20 (34.5) 20 (41.7) 44 (36.7) Total 14 (11.6) 58 (48.3) 48 (40.1) 120 (100.0) METHODOLOGY The maximum possible Mental Stress Score calculated A cross-sectional study was conducted in a Dist. Court from PSLES was 2504 and minimum was 20.In the Sangli from October- December 2010, covering a total present sample, females and males had maximum score of 120 lawyers consisting of 76 males and 44 females. of 488 and 449 respectively. And minimum score was The total lawyers working in the court were 240 and 20 in females and 0 in males. Calculated Mean Stress systematic random sampling technique was used. Score for the total sample was 172.18±124.45. The mean stress score for female lawyers was 206.3±141.49 A predesigned proforma was prepared for the collection of data. Presumptive Stress Life Events Scale and for male it was 152±109.6. (PSLES) ³ framed by Gurmeet Singh was used as a validated screening tool, to calculate the Mental Stress Score. It gives the quantitative estimate of presumptive Table: 2 Association of gender with stress levels stress (weighted score) as experienced by Indian adult Sex Stress Total population on each specified life events in past one Present Absent year. It is further divided according to desirability, into Male 66 (62.2) 10 (71.4) 76 (63.3) Desirable Events and Undesirable Events. The events Female 40 (37.8) 4 (22.6) 44 (36.7) which could not be classified as either were put as Total 106 (88.3) 14 (11.7) 120 ambiguous, however their number was less. (100.0) Mean score was assigned to each individual item SE (p1-p2) = 9.14, Z=8.3, P<0.5, Significant varying from 0-100 and then ranked them according to decrease in the severity of perceived stress. Total score The level of Job satisfaction was low in 51.6%, was graded according to No stress (<40), Less stress Intermediate in 40% and High in 8.4% of the total (40-200) and More stress (>200). The scale is simple to lawyers. Out of the total lawyers having Low Job administer to literate as well as illiterate adults.5 satisfaction i.e. High Job Satisfaction Score, 36 (58.0%) were females and amongst the total High Job The level of Job Satisfaction was scored by 3 point satisfaction score subjects all were males. scaling system taking into 10 independent variables² as the predictors of Job satisfaction (dependent variable). 81.8% of the female lawyers had low job satisfaction as Total score was graded as High satisfaction (0-9), compared to 34.2% males (Table 3). Intermediate satisfaction (12-21) and Low satisfaction (24-30).² Regression analysis was also computed to find out the best predictor of Job satisfaction. Table: 3 Genderwise Job satisfaction Scores Data was analyzed using SPSS Software. The test Sex Job Satisfaction Score Total applied were Mean, Standard Deviation, Chi square Low Intermediate High test, Standard error of difference between two Male 26 (41.9) 40 (83.3) 10 (100.0) 76 (63.3) proportions & regression analysis. Female 36 (58.1) 08 (16.7) 0 (0) 44 (36.7) Total 62 (51.7) 48 (40.0) 10 (8.3) 120 (100.0)

RESULTS Maximum possible Job Satisfaction score was 30 and minimum was 0. In the present sample, females and Total number of lawyers interviewed were 120 males had maximum score of 30 and 30 respectively. consisting of 76 males and 44 females. They But the minimum was only 12 in females and 0 in represented upper Socio economic Class according to males. Modified Kuppuswami scale. 60 (78.9%), out of 76 males and 38(86.3%), out of 44 females were married. Calculated Mean Job satisfaction Score was 20.15±8.3 No significant difference was found in the level of for the total sample. It was found to be 26.04±3.37 in stress between the married and unmarried subjects. females and 16.73±8.13 in males. 88.3% lawyers had experienced stress (Table 1). About The main contributing predicting factors in job 90.2% females experienced stress as compared to satisfaction were computed through regression analysis

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NATIONAL JOURNAL OF MEDICAL RESEARCH and it revealed job satisfaction is significantly and social position and economic reward brings in more negatively correlated to emotional exhaustion(r=-.53, satisfaction. Moreover, it has been found that p<.01), stress (r=-.52,p<.01), work overload (r=-.48, increasing competition results in stress and low levels p<.05), depersonalization(r=-.39, p<.05), reduced of satisfactions.6 personal accomplishment(r=-.35,p<.01), strained The working women have more stress because of interpersonal relationship (r=-.28,p<.01), over stereotypical discrimination, social isolation and work expectation (r=-.25,p<.01), jealousy (r=-.25, p<.01), home conflicts. All the above studies support the poor social position (r= -.24, p<.01),competition(r=- obtained results. .23, p<.01) in males (Table 4).

CONCLUSION Table: 4 Regression Analysis: Predictors of Job Satisfaction in male lawyers. The productivity of the lawyers is the most decisive factor for the success of the practice, which is in turn Variables r value p- value dependent on psychosocial well being of the lawyers in Emotional exhaustion -0.53 <0.01 the age of highly dynamic and competitive world. The Stress due to clients -0.52 <0.01 study shows there are no differences on the PSLES for Work Overload -0.48 <0.05 age, marital status, education and occupation. However Depersonalisation -0.39 <0.05 marked sex differences were found in the perceived Reduced personal accomplishment -0.35 <0.01 stress levels. Female lawyers experience more burnouts Strained interpersonal relationship -0.28 <0.01 and stress as compared to males.7 Mean Mental Stress Over expectation -0.25 <0.01 Score and Mean Job satisfaction score was also found Jealousy -0.25 <0.01 to be high in female lawyers suggestive of low job Poor social position -0.24 <0.01 satisfaction. It is significantly and negatively correlated Competition -0.23 <0.01 with stress. A positive association between levels of stress and substance abuse was also explored.8,9 Table: 5 Regression Analysis: Predictors of Job Satisfaction in female lawyers. Although certain limitations were met with the study, every effort has been made to make it much Variables r p- comprehensive. Nothing can isolate stress from human value value being. It can be managed but not simply done away Emotional exhaustion -0.59 <0.05 with. A balance between work and family, a support Work Overload -0.55 <0.05 network of friends and co-workers ,and a relaxed and a Reduced Personal -0.51 <0.01 positive outlook are the necessary preventive strategies accomplishment in coping from the stress.10,11 The research expects to Stress -0.51 <0.05 draw attention of the administrators, researchers and Jealousy -0.38 <0.01 academicians in related fields to resume further Over expectation -0.31 <0.05 research.12,13 Depersonalization -0.28 <0.05 Strained interpersonal relationship -0.24 <0.05 Poor social position -0.24 <0.05 REFERENCES Competition -0.23 <0.05 1. Akiomi Inoue, Norito Kawakami, Takashi Haratani: Job Stressors and long term sick leave due to depressive disorders Whereas, in female lawyers, job satisfaction has been among Japanese male employees; Journal of Epidemiology and found to be significantly and negatively related to Community Health 2010; 64 , 229-235 emotional exhaustion (r=-.59, p<.05), workload(r=-.55, 2. Anita Sharma, Shweta Verma, Dalip Malhotra: Stress and p<.05), reduced personal accomplishment (r=-.51, Burnout as predictors of Job Satisfaction amongst Lawyers; p<.01), stress(r=-.51, p<0.05), jealousy(r= -.38, p<.01), European Journal of Social Sciences; Number 3(2010); 14,348- over expectation(r=-.31, p<.05), depersonalization(r=- 359 .28, p<.05), strained interpersonal relationship (r=-.24, 3. Raija Kalimo, Mostafa Batawi, Cary Cooper: Psychosocial <.05), poor social position (r=-.24,p<.05), competition Factors At Work And their relation To Health; WHO, Geneva (r=-.23, p<.05) (Table 5). (1987); 1-15 4. H K Jenson, J Wieclaw, T Munch-Hansen:Does dissatisfaction with psychosocial work climate predict depressive, anxiety and DISCUSSION substance abuse disorders. A prospective study of Danish public service employees; Journal of Epidemiology & The study of occupational stress is hindered by lack of Community Health 2010; 64, 796-801 compact and comprehensive standardized 5. Gurmeet Singh, Dalbir Kaur, Harsharan Kaur: Presumptive measurement tools. In the present study, it is clear from Stressful Life Events Scale (PSLES),India; Indian Journal of Regression analysis that emotional exhaustion, Psychiatry (1984); 26(2), 107-114 depersonalization and work overload are the common 6. Bonita. C.: Women and Work Place Stress. Doctorial Thesis predictors of job satisfaction for male as well as female (2002); Himachal Pradesh University, Shimla, (India). lawyers. The law profession is the one where a good

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7. Bentsi-Enchill, J.: Cases and Chaos: Life balancing Strategies for 11. Eaton, W.W., Mandel, W. and Garrison, R.: Occupations and Busy Lawyers. Canadian Bar Association. National Magazine. the Prevalence of Major depressive Disorders”; Journal of Legal insights and practice trends (2006), 15(2): 1-59. Occupational Medicine (1990), 32, 1083-1132. 8. Professor Marjorie: Substance Abuse, Stress, Mental Health and 12. WHO Report: Mental health,New understanding new hope; the Legal Profession;2003; 32,1-36 2001;Chapter 2 9. Laura Rothstein: Law Students and Lawyers with Mental Health 13. World Health Organization. World Health Report. Available on and Substance Abuse Problems; University of Pittsburgh Law http://www.who.int/whr/2001/chapter2/en/index.html Review ;69, 531-566 10. Banet, Plint & Clifford: Reducing stress and avoiding burnout. A collection of activities for prescholars (2005), 11(2): 28-32

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

FACTORS AFFECTING TREATMENT SEEKING BEHAVIOUR OF INDIVIDUALS WITH LOCOMOTOR DISABILITIES

Padhyegurjar Mansi S1, Padhyegurjar Shekhar B2

1Associate Professor, 2Professor, Department of Community Medicine, Karpaga Vinayaga Institute of Medical Sciences (KIMS), Tamilnadu.

Correspondence: Dr Manasi Shekhar Padhyegurjar C/o Dr B. K. Padhyegurjar, 9, Narmada Niwas, Topiwala Wadi, Station Road, Goregaon (West), Mumbai 400 062. E-mail address: [email protected], Phone numbers: 09840873796, 08122695816

ABSTRACT

Background: Among the different types of disabilities, the prevalence of locomotor disability is highest in the country. Quality of life and disability limitation is affected by the availability and utility of rehabilitative services. Thus knowledge of the treatment seeking behaviour will help in implementing successful intervention programmes. Materials and Methods: A community based cross-sectional observation study was conducted in an urban slum of Mumbai. Total sample of 3665 individuals were screened. 205 were identified with loco motor disabilities who were subjected to a structured questionnaire. The study was conducted over a period of 3 months. The data was analysed using SPSS software (Version 17). 95 % confidence limits for prevalence was calculated to estimate the prevalence in the general population and Chi-square test was applied to identify the association between two variables. Results: The prevalence of loco motor disabilities is found to be 5.59 %. Females were more affected than the males.75% of the sample was unemployed and 49.3 % was illiterate. Utility of rehabilitative services was found to be poor (35.6%). 50.7 % of these were treated by General practitioners. Very few approached speciality rehabilitative services. Low literacy levels and poor awareness of rehabilitation facilities were the major factors affecting treatment seeking pattern of individuals with locomotor disability (p<0.001) Conclusion: Improving literacy rates, developing community based rehabilitation services and training medical under-graduates, creating awareness regarding the available facilities, will lead to greater utilization of rehabilitative services and thus early diagnosis and disability limitation.

Key Words: Locomotor Disability, treatment seeking behaviour

INTRODUCTION pilot study was conducted which showed a prevalence of 10% of loco motor disability among randomly Locomotor disability is the most prevalent type of screened population. Based on this minimum sample of disability affecting the population of all ages in India.1 3600 was estimated. A household was taken as a single Locomotor disability is not life threatening but greatly unit by stratified systematic random sampling in two affects the quality of life led by the disabled people. demarcated areas of the slum. All members of the Timely interventions go a long way in disability household were included in the study. A sample of limitation. The treatment seeking behaviour of disabled 3665 individuals was taken. persons reflects a wider differential according to different background characteristics. 1 Thus this study Participants were screened for detection of loco motor was conducted with the aim of identifying the factors disabilities by trained health professional. Criteria used affecting treatment seeking behaviour of individuals in 58th Round National Sample Survey Organisation with locomotor disability to help to formulate and (NSSO) was used to identify individuals with design intervention programmes. locomotor disability. Persons having locomotor disability included in the study were those with (a) loss or absence or inactivity of whole or part of hand or leg MATERIALS AND METHODS or both due to amputation, paralysis, deformity or The study was carried out in an urban slum which is the dysfunction of joints which affected his/her “normal field practice area of a teaching hospital in Mumbai. ability to move self or objects” and (b) those with The study is cross sectional and observation based. A physical deformities in the body (other than limbs),

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NATIONAL JOURNAL OF MEDICAL RESEARCH such as, hunch back, deformed spine, etc. Dwarfs and Table 1: Knowledge of rehabilitative services and persons with stiff neck of permanent nature who treatment seeking pattern of individuals with generally did not have difficulty in the normal Locomotor disability movement of body and limbs was also treated as disabled.2 A structured questionnaire was administered Variables Number(%) to individuals detected with locomotor disability in the Knowledge of rehabilitative services local language. The study was conducted over a period Yes 42(20.5) of 3 months. The data was analysed using SPSS No 163(79.5) software (Version 17). 95 % confidence limits for Total 205(100) prevalence was calculated to estimate the prevalence in Treatment Taken the general population and Chi-square test was applied Yes 73(35.6) to identify the association between two variables. No 132(64.4) Total 205(100) Reason for not taking treatment RESULTS Lack of knowledge of rehabilitative 115(87.1) services Total sample of 3665 individuals was screened for Lack of time 3(2.3) locomotor disabilities. Among 3665 individuals 205 Cannot afford 3(2.3) were identified with loco motor disabilities. Thus, the Not needed 11(8.3) prevalence of loco motor disabilities is 5.59 % (95 % Total 132(100) C.L. 4.85 % to 6.33 %). The study was further carried Treatment Personnel out on these 205 disabled individuals. Mean age of the Orthopaedic Surgeon 7(9.6) affected sample was 38.89 years with standard deviation Private General Practioner 37(50.7) 15.1 years. 28.9 % are males and 71.1 % are females. Occupational / Physiotherapist 3(4.1) 69.3 % were married. Out of the total sample, 62.7 % Urban Health Centre 22(30.1) of disabled people had families with per capita income Traditional mode of Treatment (Bone 4(5.5) of less than 500 rupees per month and 75 % were un- Setter Homeopathy etc.) employed. 101 affected individuals (49.3%) were Total 73(100) illiterate and only 3.9% were educated beyond tenth class.

Table 2: Factors affecting treatment seeking pattern of individuals with Locomotor disability Education Status and knowledge of rehabilitation Education Status Knowledge Total P value Yes (%) No (%) Illiterate 9 (8.9) 92(91.1) 101(100) < 0.001 Primary 3(12.5) 21(87.5)24(100) Secondary and above 30(37.5) 50(62.5) 80(100) Total 42(20.5) 163(79.5)205(100) Knowledge of rehabilitation and Treatment taken Knowledge of rehabilitation Treatment taken Total P value Yes (%) No (%) Yes 26 (61.9) 16 (38.1) 42(100) < 0.001 No 47(28.8) 116 (71.2)163(100) Total 73 (35.6) 132 (64.4) 205(100)

As observed in Table 1, majority of the individuals services available for their disabling conditions 163(79.5%) were unaware of any rehabilitative services. (p<0.001). 132 (64.4 %) had not taken any treatment for their locomotor disability. Out of these 115(87.1%) stated the lack of knowledge of rehabilitative services as the DISCUSSION reason for not taking treatment. Out of the 73 individuals who had taken treatment, 50.7% had The prevalence of loco motor disabilities in the current approached the General Practitioner in their nearby study is 5.59 %. Census of India 2001, estimated 28 % area and 30% had visited the Urban Health Centre. of total disabled population with movement disabled where as NSS (National Sample Survey, 58th round, Table 2 indicates that presence of knowledge of 2,3,4. rehabilitation is associated with improved education 2002) estimates them at 51%. 71.2 % of individuals level (p<0.001). Affected individuals opt for treatment with locomotor disability were females. Similar findings of their disabling condition if they are aware about have been observed in Census 2001, where Tamil Nadu existence of various treatment and rehabilitation was observed to have a higher number of disabled

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NATIONAL JOURNAL OF MEDICAL RESEARCH females than males.4 However in an empirical study approached a physician from alternate system or conducted by Patel observed that males were more Allopathy.7 susceptible for developing disability than females.5 Out In the present study 132 individuals identified with of the total sample, 49.3 % were illiterate and 69.3 % locomotor disabilities had not availed any treatment. were married. Hidary SZ observed that in India, almost Out of these, 115(87.1%) did not avail any treatment three quarters of those with severe disabilities are because of lack knowledge of rehabilitative services. illiterate, and even for those with mild disabilities, the Knowledge of rehabilitative services is observed to be illiteracy rate is around half.6 Similar findings were associated with the educational status of the individual observed in some other research studies.5,7 The present (Table 2).Literate individuals had significantly better knowledge of the available rehabilitative services. Also study shows very high rate of unemployment (75.1%) as observed in Table 2, individuals who are aware of as well as most of the families having per capita income the services avail it significantly more than those who less than Rs 500 per month (62.5%). Based on National are not aware of them. In literature search it was Sample Survey data, Mitra and Sambamoorthi showed observed that, various studies have observed different that the employment rate of persons with disabilities is reasons for non utility of rehabilitative services. Laskar only 60% that of the all India working age population.8 et al. observed that the most common reasons cited for not using government speciality rehabilitative services Out of 205 affected individuals, only 73(35.6%) have were long hours in queue (57%), ill-treatment by staff taken treatment for their locomotor disability. Similarly, especially those relying on aids and appliances (45%), Disler PB et al. observed that 80 % of the study complicated paper work (36%) and overall poor quality 12 population had no contact with health services in black of care (28%) in government set-up. Agrawal G et al. observed better socio-economic status is closely residential area of the Cape Peninsula. 9 However associated with greater utilization of health care services Chopra A et al. observed in the COPARD study among older persons.14 Patel SK states that treatment conducted in rural India, that only 21 % of the patients seeking behaviour of disabled persons depends not had never visited the doctor.10 Osman and Rampal only on socio-economic factors but also on cultural observed that 42 (85.7%) of the 49 cases had received factors, area of residence, literacy status, sex etc.1 treatment in a Malay Community in Tanjung Karang, Hidray SZ observed that the physical access to health service is a major hurdle for people with disabilities to Kuala Selangor. 11 reach and utilize these services.6 Among the 73 individuals in the current study who availed some type of treatment, only 9.6% had approached an orthopaedic specialist, 4 % had CONCLUSION approached a therapist. Similarly, Laskar A et al. Low literacy rates have always been a cause of concern observed that rehabilitative institutions such as Institute in India. Low literacy rates among disabled individuals for Physically Handicapped (IPH), Delhi, providing have been specially found to be associated with low specialized care such as occupational therapy or awareness and poor utilization of rehabilitative services in the current study. The poor treatment seeking in an physiotherapy, aids and appliances and psychological urban set up such as Mumbai is a cause of concern. counselling services were rarely consulted in the initial More studies need to be conducted related to this few consultations and about 40% patients approached aspect. Also similar studies need to be conducted in private hospitals or clinics.12 The current study shows rural areas to understand the complete scenario. In a that majority of the individuals approached General situation where speciality rehabilitative services are Practitioner of Allopathic field (50.7%) and the Urban unable to reach the beneficiaries, strategies like Community Based Rehabilitation (CBR) 15 should be Health Centre (30.1%) of a Municipal teaching College. implemented with priority. As majority of the disabled Only 4 (5.5 %) of the sample availed the traditional individuals are at present being treated by General mode of treatment. Laskar A et al. observed that 68 % Practitioners (who are usually graduate doctors, approached General Practitioner for treatment and 39.4 including alternate medicine), physicians should be % availed the alternate system of medicine.12 Similarly appropriately trained to detect disability and provide Joshi stated that the most popular type (system) of rehabilitation during their undergraduate training. Lastly medicine preferred by those who were seeking developing sustainable services and creating awareness regarding them, will lead to greater utilization of treatment was Allopathic, which was adopted by nearly rehabilitative services and thus early diagnosis and 92.2% people. The rest, 7.7% of the people, rely on disability limitation. either Ayurvedic or Homeopathic medicine 13 In the study conducted by All India Institute of Physical Medicine and Rehabilitation, it was observed that, out REFERENCES of 100 patients, 13 took local/herbal treatment and 30 1. Patel SK, Ladusingh L. Age pattern of onset of disability and treatment seeking behaviour of disabled persons in India [

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Internet][cited 2012 Jan 12] Available from: [internet] [Cited 2012 Jan 5]. Available from: http://iussp2009.princeton.edu/download.aspx?submissionId= http://web.up.ac.za/UserFiles/MitraxSambamoorthi_Village_ 91173 TN_July06.pdf 2. Government of India. Disabled Persons in India, 58th Round 9. Disler PB, Jacka E, Sayed AR, Rip MR, Hurford S, Collis P. National Sample Survey Organisation, Ministry of Statistics and The prevalence of loco motor disability and handicap in the Programme Implementation, Report No.485 (58/26/1), 2003. Cape Peninsula. Part II. The black population of Nyanga. S Afr [internet] [cited 2012 Feb 10]. Available from: Med J 1986; 69(6):353-5. http://mospi.nic.in/rept%20_%20pubn/485_final.pdf 10. Chopra A, Saluja M, Patil J, Tandale HS. Pain and disability, 3. Walia GK .Disability. South Asia Network for Chronic Disease perceptions and beliefs of a rural Indian population: A WHO- [internet] [cited 2012 Feb 11]. Available from: ILAR COPCORD study. WHO-International League of http://sancd.org/uploads/pdf/disability.pdf Associations for Rheumatology. Community Oriented Program for Control of Rheumatic Diseases. J Rheumatol 2002 Mar; 4. Government of India. Census and You – Disabled Population 29(3):614-21. [internet] [cited 2012 Feb 10]. Available from: http://censusindia.gov.in/Census_And_You/disabled_populati 11. Osman A, Rampal K G. A study of loco motor disabilities in a on.aspx - Malay community in Kuala Selangor. Med J Malaysia 1989; 44(1):69-74. 5. Patel SK. An Empirical Study of Causes of Disability in India. The Internet Journal of Epidemiology [serial on the internet] 12. Laskar AR, Gupta VK, Kumar D, Sharma N, Singh M. 2009 [Cited 2012 Feb 21]: 6 (2) : Available from: Psychosocial Effect and Economic Burden on Parents of http://www.ispub.com/journal/the-internet-journal-of- Children with Locomotor Disability. Indian J Pediatr 2010; 77 epidemiology/volume-6-number-2/an-empirical-study-of- (5): 529-533. causes-of-disability-in-india.html 13. Joshi K, Kumar R, Avasthi A. Morbidity profile and its 6. Haidry SZ. Community Health Global Network (CHGN). relationship with disability and psychological distress among Uttarakhand Disability Situation Analysis. [internet] [cited 2012 elderly people in Northern India. International Journal of Feb 20] . Avaliable from: Epidemiology 2003; 32: 978-987. http://docs.google.com/viewer?a=v&q=cache:WzwrcZZedcE J:www.chgnukc.org/docs/ 14. Agrawal G, Keshri K, Gaur K. Aging, Disability and Health Care Services Among Older Persons in India. Middle East 7. Fernandes A. Problems of women with locomotor Journal of Age and Ageing 2009;6(5) disabilities, CIF International Conference, Goa 2003. [internet] [Cited 2012 Jan 28]. Available from: 15. Rehabilitation Council of India. Manual for Training of PHC http://www.karmayog.org/LIBRARY/libartdis.asp?r=152&libi Medical Officers, Prepared for: National Programme on d=192 Orientation of Medical Officers Working in Primary Health Centres to Disability Management, 2001.[internet] [Cited 2012 8. Mitra S, Sambamoorthi U. Disability and the Rural Labor Mar 1]. Available from: Market in India: Evidence for Males in Tamil Nadu, 2006 http://rehabcouncil.nic.in/pdf/phcdoctors.pdf.

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SOCIO DEMOGRAPHIC PROFILE OF TB-HIV CO- INFECTED PATIENTS IN BUNDELKHAND REGION, UTTAR-PRADESH

Jaiswal Rishi K1, Srivastav Shalini2, Mahajan Harsh2

1Assistant Director Public Health,National Center for Disease Control, New-Delhi 2Assistant Professor, Community Medicine, School of Medical Sciences & Research, Greater Noida (U.P)

Correspondence: Dr. Shalini Srivastav D/o Dr. K.K. Srivastav, “ Shanti-kunj” , 408/20, L/1 , Bakshi -khurd Daraganj , Allahabad (U.P) Email: [email protected] Mobile No.:08285662039, 09451660069, 8588026528

ABSTRACT

Background: Concomitant Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) infection is a lamentable medical phenomenon with dreadful social and economic impact across the globe, aptly described as the "accursed duet". The HIV epidemic has posed major and almost insurmountable challenges to TB control efforts across the world. Aim: To study the socio-demographic correlates of TB - HIV co-infected cases. Material & Methods: This is a hospital based observational study which was conducted in district Jhansi of Utter Pradesh. The study was carried out in District Jhansi for a duration of one year from Dec.2007-Dec. 2008. The study subjects were selected from District Tuberculosis Center, Jhansi, TB clinic and Tuberculosis ward of MLB Medical College, Jhansi. After collecting necessary information from the study subjects, their blood samples were collected to test the HIV status. Results: Maximum TB-HIV co-infection cases(8.65%) were found in 26-45 years of age, and the cases of co- infection were more in males(6.08%) as compared to females(1.84%). There was no significant variation found amongst TB-HIV co-infected cases by religion, however more TB-HIV co-infected cases were significantly found in SC/ST population and among illiterate group. Conclusion: TB-HIV co-infection deserves special attention. Screening of HIV among TB patients should be attached more importance, which would be much more helpful for treatment and outcome of both diseases.

Keywords: Co-infection, TB-HIV, Accursed duet

INTRODUCTION worldwide. Mycobacterium tuberculosis and HIV have a synergistic interaction; each accentuates progression More than 125 years into its ‘known’ existence, of the other. Mycobacterium tuberculosis (MTB) continues to haunt the mankind and tuberculosis (TB) the disease caused by it Mycobacterium tuberculosis (TB) and human immune remains the leading cause of preventable death deficiency virus (HIV) infections are two major public worldwide. Tuberculosis is considered as a ‘reemerging health problems in many parts of the world, particularly disease’, because of its resurgence and increased in many developing countries1,2. TB is the most incidence in the twenty-first century particularly in common opportunistic disease and cause of the death immuno-compromised patients as in HIV-AIDS.1-3 for those infected with HIV 3. HIV infection is one of HIV/AIDS pandemic has caused a resurgence of TB, the most important risk factors associated with an resulting in increased morbidity and mortality

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NATIONAL JOURNAL OF MEDICAL RESEARCH increased risk of latent TB infection progressing to samples were first screened by ELISA, the samples active TB disease 4, 5. found to be non-reactive on first testing were declared as negative. All samples found to be reactive on ELISA Mycobacterium tuberculosis is therefore indeed an enigmatic testing were subjected to HIV ELISA (enzyme linked bug. Not only has it defied our efforts to eradicate it immunosorbent assay), a solid phase enzyme immuno but is reemerging as the commonest lethal assay for the detection of antibodies to HIV-1 and opportunistic infection, considering this it is essential to HIV-2 in human serum or plasma. The repeated decipher that if the socio demographic factors affects ELISA positive samples were further subjected to the TB-HIV co-infection. Tridot test for confirmative diagnosis. Every attempt The rationale of the present study was to find the was made to ensure the confidentiality of blood sample Socio-demographic profile of TB-HIV co-infected results. cases in the district Jhansi.

The current study was undertaken to find out the socio- RESULTS demographic correlates of TB and HIV co-infected cases. Table 1: Seropositivity for HIV amongst Tuberculosis Cases By Age and Sex METHODOLOGY Category TB HIV Positive (%) P value Study Design: This is an observational study which was Cases (n=28) conducted from December 2007-December 2008 at (n=574) district Jhansi. Age Groups(yrs) 2 Sample Size Calculation: 6-15 61 00 (0.00) χ =13.66, 16-25 178 03 (1.68) p= <0.01 The desired sample size was calculated using the 2 26-45 208 18 (8.65) formula-n = 4pq/L where n = no. of subject required 45+ 127 07 (5.51) to conduct the study, p = positive character of previous Sex study, q = 1-p and L = maximum allowable error and it 2 Male 411 25 (6.08) χ = 4.53, is 10 or 20% of Positive character. Female 163 03 (1.84) p= <0.05 Different studies from India have reported rate of HIV infection among tuberculosis patient to range from Out of 574 TB study subjects, 28 (4.87% ) were found 0.4% to 20.1%. Study from national AIDS research to be HIV positive (Table-1). institute in Pune has reported the increase of HIV Study subjects between age group 26-45 yrs. showed prevalence in newly diagnosed tuberculosis patient highest prevalence for HIV i.e. 8.65% (table-1), it was from 3.1% in 1991 to 20.1% in 1996 and reaching up to followed by 45+ year’s age group (5.51%). None of the 30% in year 2000. 2 case was positive in 6-15 years age groups (χ = 13.66, By putting the appropriate value of p, q, and L (i.e. p= p= <0.01). Sex distribution of cases indicates that male 15, q= 85 and L= 3) the required sample size came out were significantly more co-infected (6.08%) with HIV 2 to be 566. than the females i.e. 1.84% (χ = 4.53, p= <0.05).

Methods Table 2: Prevalence of HIV amongst Cases by The present study was a Hospital based observational Religion and caste study carried out in M.L.B Medical College Jhansi, for a duration of one year from Dec.2007-Dec.2008. Category TB Positive P value cases for HIV After taking the written consent from each patient and (n=574) (%) detailing them about aim and procedure of the study, (n=28) patients were interviewed on the pretested Religion questionnaire at District Tuberculosis clinic (DTC), TB Hindu 428 25 (5.84) χ2 3.42, clinic, and Tuberculosis wards at DTC and MLB = Muslim 139 03 (2.15) p= >0.10 medical college, Jhansi on every Monday, Wednesday, Christian/Other’s 7 00 (0.00) and Friday till the desired sample size was completed. Caste After recording the desired information, 3 ml blood 2 was taken from each patient and stored in a labeled General 58 01 (1.72) χ = 19.32, OBC 319 07 (2.19) p= tube for HIV testing. A separate code was given to each sample after collection. SC/ST 197 20 (10.15) <0.001

The blood specimens thus collected were stored at 40 The difference in prevalence of HIV infection in Celsius and later on blood was centrifuged and serum different religion was found statistically insignificant was separated on the same day and stored in the (Table-2), however the TB-HIV co-infection was found department of Microbiology of the institution. The

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NATIONAL JOURNAL OF MEDICAL RESEARCH significantly higher among SC/ST community than the DISCUSSION General and OBC caste. In the present study, majority of the co-infected cases

(8.65%) were in sexually active age group (26-45 years). Table 3: Seroprevalence of HIV amongst Similar are the findings of study carried out by Deshwal Tuberculosis Cases by Social Class (according to et.al 6which found that most of the TB-HIV cases Kuppuswamy classification) (99%) were in sexually active age group (20-49 years) Social Class TB cases Co-infected with HIV (%) which is in conformity with other studies by Kataria I 0 0 (0) et.al7. However in the present study the TB-HIV co- II 15 2 (13.33) infection among males was 6.08% and among females III 08 1 (12.50) was found to be 1.84%. The difference between two IV 69 19 (27.53) sexes is appreciably significant (p<0.05) which is similar V 482 06 (1.24) to the findings of the study carried out by Anand. K Total 574 28 (4.87) Patel et.al 8 which states that of all the detected patients, 2 χ = 92.72, p= <0.001 82% were males and the rest were females. However contradictory were the findings of Deswal et.al 6 in Maximum no. of co-infected cases was found amongst whose study the occurrence of co-infected cases in the class IV (27.53%) which was followed by class II different sex was not found to be significant. TB-HIV (13.33%). No TB-HIV co-infected case was detected in co-infection was found in all religions and there was no upper class. significant difference which goes along with the findings of study carried out by Kataria et al.7 Difference in prevalence of HIV among different social 2 class were found statistically significant (χ = 92.72, p= In the present study it was found that TB-HIV co- <0.001) Table 3. infection was significantly associated with literacy status as 7 .96% TB-HIV co-infected cases were found Table 4: Relation of HIV Status and Place of among illiterate patients as compared to 1.25% co- Residence infected cases among literate ones, this is in concordance with the study carried out by Jain et.al 9. Place of Total HIV status +ve (%) residence Rural 247 7 (2.83) REFERENCES Urban 304 21 (6.90) 1. Harrington M .HIV to Tuberculosis and Back Again: A Tale of Slum 23 0 (0.00) Activism in 2 Pandemics. Clin Infect Dis. 2010 ;50 :260-6 Total 574 28 (4.87) 2. Friedland G, Churchyard GJ, Nardell E. Tuberculosis and HIV 2 χ = 12.76, p= <0.01 coinfection: current state of knowledge and research priorities. J Infect Dis 2007; 196: Suppl 1S1–3. Study subjects living in urban area were reported 3. Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, et al. significantly higher number of co-infection than the The growing burden of tuberculosis: global trends and subject living in urban and slum areas (Table-4). interactions with the HIV epidemic. Arch Intern Med 2003; 163: 1009–1021.

Table 5: Relation between HIV Positive Status and 4. Meya DB, McAdam KP The TB pandemic: an old problem Literacy Status of Cases seeking new solutions. J Intern Med 2007; 261: 309–329. 5. Girardi E, Raviglione MC, Antonucci G, Godfrey-Faussett P, Literacy status Total HIV +ve (%) Ippolito G .Impact of the HIV epidemic .on the spread of Illiterate 251 20 (7.96) other diseases: the case of tuberculosis. AIDS 14: (2000) Up to junior. High school 243 07 (2.88) Suppl3S:47–56. Intermediate & above 80 01 (1.25) 6. BS Deswal, D. Bhatnagar, D. Kumar, VR Deshpande. A Study Total 574 28 (4.87) of Prevelance of HIV in Tuburculosis Cases. Indian Journal of 2 Community Medicine 2002;27 (2):4-6 χ = 9.99, p= <0.01 7. Kataria VK, Rosha D, Maudar KK. HIV and tuberculosis co- TB-HIV co infection amongst the studied cases was infection in referral chest hospital. Med J Armed Forces India significantly associated with the literacy status, HIV co- 2000; 56: 298-300. infection was more among illiterate (7.96%) compared 8. Anand K. Patel, Sandip J. Thakrar, and Feroz D. Ghanchi to those who were educated up to high school (2.88%). Clinical and laboratory profile of patients with TB/HIV coinfection: A case series of 50 patients. Lung India;2011; 28(2): Least number of TB- HIV co-infected cases were 93–96. 2 found among graduate and above (χ = 9.99, p= <0.01) 9. S.K. Jain, J.K. Aggarwal, S. Rajpal and U. Baveja .Prevalence of HIV Infection Among Tuberculosis Patients in Delhi - A Sentinel Surveillance Study. Ind. J. Tub. 2000;47:21-26.

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HISTOPATHOLOGICAL STUDY OF 100 CASES OF VASCULARTUMOURS

Kapuriya Dharmesh P1, Patel Prashant2, Shah Amrish N3

1Assistant Professor, Department of Pathology, GMERS, Gotri, Vadodara 2Tutor, Department of Pathology, Govt. Medical College, Surat 3Proffessor, Department of Pathology, Baroda Medical College, Vadodara

Corresponding author Dr. Dharmesh Kapuriya C/42, Swati Soceity, New sama road , Vadodara -390024 Email: [email protected], Mobile No.:9898117549

ABSTRACT

Introduction: Vascular tumors show a broad variety of morphological appearances and cilinical behavior, the lesions are ranging from benign hemangiomas to intermediate lesion, which are locally aggressive, to highly malignant angiosarcoma. There is also the grey zone between true neoplasia and hamartoma, which makes difficulty in histopathological assessment. It is also important to decide the degree of malignancy as it can strongly influence the choice of treatment and prognosis. Methodology: Hundred cases of vascular tumors received at the department of pathology, medical college and SSG hospital, Baroda have been studied with a view to carrying out a histopathological analysis. Results: mploying modified Enzinger’s classification (2001) the break up of 100 cases was as follows : 37 – capillary hemangiomas, 26 – granuloma pyogenicum, 15 – cavernous hemangiomas, 07 – lymphangiomas, 04 – masson’s hemangiomas (papillary endothelial hyperplasia), 03 – epithelioid hemangiomas, 03 – lymphangiomas circumscriptum, 01 – cystic hygroma, 01 – spindle cell hemangioendothelioma, 01 – epithelioid hemangioendothelioma, 01 – glomus tumor, 01 – angiosarcoma. Majority of vascular tumors were benign, more common in children and young adults, most common sites were head and neck, which required only local surgical excision. Conclusion: Malignant and intermediate tumors formed as extremely small proportion of vascular tumors, which should be treated aggressively and closely followed up.

Key words: Vascular tumors, Enzinger’s classification

ACRONYMS benign hemangiomas to intermediate lesion, which are locally aggressive, to highly malignant angiosarcoma.1 CAP – Capillary Hemangioma CAV – Cavernous Hemangioma The histopathological assessment of soft tissue vascular G.P. – Granuloma Pyogenicum tumors is considered difficult not only because of the M.H. – Masson’ Hemangioma grey zone between neoplasia and hamartoma but also E.H. – Epithelioid Hemangioma because it is frequently difficult to distinguish between LY – Lymphangioma benign and malignant lesion.2 L.C. – Lymphangioma Circumscriptum The main issue remains not only the distinction C.H. – Cystic Hygroma between benign and malignant lesions but also the SCHE – Spindle Cell Hemangioendothelioma degree of malignancy as it strongly influence the choice EHE – Epithelioid Hemangioendothelioma of treatment and prognosis.1 GT – Glomus Tumor AS – Angiosarcoma The majority of soft tissue vascular tumors in children are benign.3 Unless pleomorphism and abnormal mitoses are seen, malignancy should be diagnosed with INTRODUCTION caution. Vascular tumors includes the tumors arising from Since most vascular tumors of intermediate malignancy blood vessels and lymph vessels as well as perivascular do not behave aggressively, complete and ideally wide tumors, are among the few groups of tumors, which local excision without adjuvant therapy should be can show a broad variety of morphological appearances offered to patients and close follow up is needed.1 Over and clinical behaviour. They constitute a spectrum from

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NATIONAL JOURNAL OF MEDICAL RESEARCH treatment such as amputation, chemotherapy or radiation can thus be avoided. OBSERVATIONS The present study includes the vascular tumors in the Table 1: Proportion of benign and malignant modified version of classification of vascular tumors vascular tumors with relation to sex proposed by Enzinger and Weiss.1 It is an endeavour to classify vascular tumors into benign, intermediate and Male Female Total malignant based on histopathology. Benign (n=97) 52 % 45 % 97 % Intermediate 01 % 01 % 02 % Malignant (n=2) Objectives Malignant (n=1) 00 % 01 % 01 % 1. To study the histopathological patterns of vascular Total ( n =100) 53 % 47 % 100 tumors. 2. To study the incidence of vascular tumors in Table 2: Site distribution of vascular tumors relation to age, sex and site. 3. To classify tumors into benign, borderline Site Percentage malignant and malignant neoplasms so as to decide Head and Neck 67 % mode of treatment. Trunk 04 % Extremities 29 % Total ( n=100) 100 % MATERIAL & METHODS A study of 100 cases of benign and malignant vascular Table 3: Relationship between Age and Sex neoplasms was carried out during the period of one distribution year at Pathology Dept., Medical Colloge, Baroda. The Age (In years) Male Female cases were classified according to modified classification of Enzinger and Weiss (2001). Detailed 0-10 09 % 09 % macroscopic examination was carried out. For 11-20 15 % 18 % histopathogical examination, formalin fixed paraffin 21-30 15 % 06 % embedded representative tissue sections were stained 31-40 05 % 06 % with Hematoxylin and Eosin.4 Where necessary, 41-50 05 % 06 % relevant sections were stained with Reticulin stain4 and 51- 03 % 03 % final confirmation of the diagnosis was done. The Total( n=100) 52 % 48 % details of clinical history and relevant investigations were obtained in every case and analyzed.

Table 4: Relationship between age and histological type of tumors(n=100) Age (In (years) CAP CAV G.P. M.H. E.H. LY L.C. C.H SCHE EHE GT AS 0-10 07 03 02 01 05 11-20 12 06 05 02 02 01 03 01 01 21-30 10 03 08 31-40 04 02 04 01 41-50 03 01 06 01 >51- 01 00 01 01 01 01 01 Total 37 15 26 04 03 0703 01 01 01 01 01

RESULTS males showed higher incidence from 20-40 years of age and again after the age of 51 years. (Table No.3). In the present study, majority of the vascular tumors were benign (Table No. 1). The commonest sites were Benign tumors were more common than malignant head and neck followed by extremities and trunk.(Table tumors. No. 2) and the tumors were found predominantly in Capillary hemangiomas were the commonest vascular males (Table No.1). tumors followed by granuloma pyogenicum and The incidence of benign was higher in males as cavernous hemangiomas (Table No.4). compared to females. But the incidence of malignant Capillary and cavernous hemangiomas were tumors was higher in female as compared to males commonest tumors before 30 year of age. (Table No.1). Lymphangiomas were most commonly found in first 10 The incidence of vascular tumors was more in females years of life. (Table No.4). as compared to males upto the age of 20 years. The

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NATIONAL JOURNAL OF MEDICAL RESEARCH There were three cases of lymphangioma circumscriptum. All presented with multiple vesicles Most of the patients with benign lesions presented with over skin. Microscopical features agree with the complaints of disfigurement and came for cosmetic description given by Enzinger and Ackerman. reasons particularly where lymphangiomas and hemangiomas were concerned. Cystic Hygroma In the present study one case of cystic hygroma was Follow up of patients was attempted in borderline and found in 13 year old female who presented with malignant cases but the patients were untraceable and swelling on neck. lost to follow up study. Spindle Cell Hemangioendothelioma

Present as solitary or multiple nodules in distal DISCUSSION extremities usually in second or third decades of life.1,2 Clinical course is intermediate between hemangiomas Capillary Hemangioma and angiosarcoma.1 In the present series there was one 5,6 Most common of all vascular tumors. Fletcher case in a 20 year old female who presented with a mass reports its proportion to be 32-42 % of all vascular over right index finger. Excision biopsy was done and 2 tumors. The tumors are most common in infancy and sent as a skin covered soft tissue mass of about 3x2x1 1 childhood. All the cases in the present study were cm in size. Histological findings are in conformity with located in head and neck region. We have not come the observations made by Enzinger and Ackerman.1,3 across any case of deep haemangioma in our study. Gross and microscopic findings are in conformity with Epithelioid Hemangioendothelioma those described by Fletcher & Enzinger.1,2 It is found to be most common in extremities followed by head and neck and trunk.7 Age range is wide but it is Pyogenic Granulomas most common in middle age.1,7 In the present study a These form the second largest group of vascular 65 year old male patient presented with gradually tumors found in all decades of life which agrees with increasing swelling on right great toe with discharging 1 Enzinger’s observations. In the present study most of sinuses for two years. On X – ray examination soft the lesions (15 out of 26) were located in head and neck tissue opacity with areas of calcification and underlying region including gingiva, buccal mucosa, scalp and chin, bone destruction was found. The above features are in remaining lesions were located in distal extremities conformity with the description given by Enzinger and including fingers and toes. Histopathological findings Fletcher.1,2 agree with those described by Enzinger, Fletcher and Rosai & Ackerman.1,2,3 Angiosarcoma Is a rare malignant vascular tumor.8,9 They are Cavernous Hemagiomas aggressive with poor prognosis.60 % occur in skin and These form the third largest group of vascular tumors superficial soft tissue.8 50 % cutaneous angiosarcoma commonest in the first three decades of life. (Table No. occur in head and neck.8 The lesions are most common 5 & 6). The commonest site were head and neck in elderly males. There was one case of angiosarcoma in followed by extremities. The above findings are in the present study. The patient was a 55 years old female conformity with the observations of Enzinger and presenting with a growth in buccal mucosa as mucosal 1 Weiss. The histological findings are in conformity with tag. The tumor was differentiated from benign vascular those described by Enzinger, Fletcher, Rosai & tumor by the presence of nuclear atypia and the 1,2,3,6 Ackerman and lever. anastomosing nature of blood vessels. The above Epithelioid Hemangioma features were in conformity with observation made by Also known as Angiolymphoid Hyperplasia with Enzinger and Fletcher.1,2 1,2 Eosinophilia. Glomus Tumor Ocuurs in early to mid adult life commonly in females Glomus tumor was the one case of parivascular tumor in head and neck region.1 in this study. It formed 1 % of total vascular tumors. Glomus tumors are uncommon tumors with as Masson’s Hemangioma estimated incidence of 1.6 % in the 500 consecutive Papillary endothelial hyperplasia, it is an unusual form soft tissue tumors reported from Mayo clinic.1 The of organizing thrombus. Most commonly located in most common site was subungual region followed by 1 veins of head, neck, fingers and trunk. palm, wrist, forearm and foot. Sex incidence was equal. Lymphangiomas In the present study the patient was a 70 year male In the present study the lesions were commoner in patient who presented with swelling and pain on males and the maximum incidence was in the age group forearm. Reticulin stain was done to demonstrate of 0 – 10 years. The histological features agree with extravascular location of tumor cells and an individual those described by Enzinger, Fletcher, Ackerman and pericellular reticulin network. The tumor was diagnosed lever.1,2,3,6 on the basis of clinical presentation and histology. It was differentiated from eccrine spiradenoma on the Lymphangioma Circumscriptum basis of absence of focal ductal differentiation and two population of cells. Intradermal naevus was ruled out

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NATIONAL JOURNAL OF MEDICAL RESEARCH by absence of nesting and evidence of maturation. The 2. Christopher D. M. Fletcher. Diangostic Histopathology of above features are in conformity with observation made Tumors, 2nd Edition. London:Churchill Livingstone ; 2000. p 45-80. by Enzinger and Fletcher.1,2 3. Juan Rosai. Rosai and Ackerman's Surgical Pathology, 9th Edition.Singpore:Elsevier; 2004. P 2237-2330. CONCLUSIONS 4. JohnD.Bancroft.Theory and Practice of Histological Techniques, 4thedition.Edinburgh:Chruchil Living stone; 1996. The present study concludes that Majority of tumors p 99-111, p 135. were benign vascular tumors which require only local 5. Robbins and Cotran. Pathological basis of disease, 7th Edition. surgical excision. Malignant and intermediate malignant Philadelphia: Elsevier; 2004. p 511-554. tumors formed as extremely small proportion of 6. Lever P Walter, David E. Elder. Lerver’s Histopathology of the vascular tumors, should be treated aggressively with Skin, 9thedition. Philadelphia, USA:Lippincott Williams and regular follow up. Capillary hemangiomas were the Wilkins; 2005. p 1015-1052. commonest vascular tumors. Vascular tumors were 7. Weiss Sharon, F.M. Enzinger. Epithelioid more common in males. The tumors were more hemangioendothelioma: A vascular tumour often mistaken for a common in children and young adults. The most carcinoma. Cancer 1982; 50:970-981, common sites of vascular tumors were head and neck. 8. Mark J. Rufus et. al. Angiosarcoma: A report of 67 patients: A review of literature. Cancer 1996; 77:2400-2406. 9. Stacey E. Mills.Sternberg’s Diagnostic Surgical Pathology, 4th REFERNCES Edition. Philadelphia, USA: Lippincott Williams and Wilkins ; 2004. p 49-105, p 137-205, p 1369-1395. 1. Sharon W. Weiss. Enzinger & Weiss’s Soft tissue tumours, 4th Edition. Philadelphia, USA:Mosby Elsevier; 2001. p 837-1036.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

ANTIBIOTIC RESISTANCE PATTERN IN PSEUDOMONAS AERUGINOSA SPECIES ISOLATED AT A TERTIARY CARE HOSPITAL, AHMADABAD

Rajat Rakesh M1, Ninama Govind L2, Mistry Kalpesh3, Parmar Rosy3, Patel Kanu4, Vegad MM5

1Tutor, 2Associate Professor, 3Assistant Professor, Microbiology Department, GMERS, Gotri Medical College, Vadodara 4Associate Professor, 5Professor & Head, Microbiology Department, B. J. Medical College, Ahmadabad

Correspondence: Dr. Rakesh M Rajat C/o Dr. Kalpesh Mistry, B/102,Manorath flates, B/h Mother`s School Nr.Jalaram Nagar bus stop, Gotri, Vadodara 390021 Email: [email protected]

ABSTRACT

Introduction: Pseudomonas aeruginosa (Ps.aeruginosa) is one of the important bacterial pathogens isolated from various samples. Despite advances in medical and surgical care and introduction of wide variety of antimicrobial agents against having anti-pseudomonal activities, life threatening infection caused by Ps. aeruginosa continues to cause complications in hospital acquired infections. Several different epidemiological studies indicate that antibiotic resistance is increasing in clinical isolates. Material and Method: This study was conducted during April 2009 to april 2010. During this period total of 630 samples were tested, in which 321 samples showed growth of bacteria. Out of 321 samples, 100 clinical isolates of Pseudomonas aeruginosa were isolated. The samples were selected on the basis of their growth on routine MacConkey medium which showed lactose Non-fermenting pale colonies which were oxidase test positive and on Nutrient agar pigmented and non-pigmented colonies with oxidase positive. Antimicrobial susceptibility of all the isolates was performed by the disc-diffusion (Modified-Kirby Baur disc diffusion method) according to CLSIs guidelines. Result: In present study, maximum isolates of Ps. aeruginosa isolated from various samples are resistant to tobramycin (68%) followed by gentamycin (63%), piperacillin (50%), ciprofloxacin (49%) and ceftazidime (43%). Conclusion: To prevent the spread of the resistant bacteria, it is critically important to have strict antibiotic policies while surveillance programmes for multidrug resistant organisms and infection control procedures need to be implemented.

Key words: Pseudomonas aeruginosa, Resistance, Antimicrobial agents, Antibiotic sensitivity

INTRODUCTION samples. Despite advances in medical and surgical care and introduction of wide variety of antimicrobial agents Antibiotic when first introduced was considered as a against having anti-pseudomonal activities, life magic bullet. A single injection of penicillin could threatening infection caused by Ps. aeruginosa eradicate a life threatening infection. Unfortunately continues to cause complications in hospital acquired with time due to malpractices of natural causes, most infections. Ps.aeruginosa is increasingly recognized as of the cheaper antibiotics have lost their efficacy and an emerging opportunistic pathogen of clinical more and more expensive and complicated antibiotics relevance that causes infections in hospitalized patient were introduced and marketed to combat simple particularly in burn patients, orthopaedic related infection2. The microbial pathogens, as well as, their infections, respiratory diseases, immunosuppressed and antibiotic sensitivity pattern, may change from time to catheterized patients. time and place to place. Therefore knowledge of current drug resistance pattern of the common Several different epidemiological studies indicate that pathogenic bacteria in a particular region is useful in antibiotic resistance is increasing in clinical isolates3. clinical practice. Being gram-negative bacteria, most pseudomonas spp. are naturally resistant to penicillin and majority of Pseudomonas aeruginosa (Ps.aeruginosa) is one of the related beta-lactum antibiotics, but a number are important bacterial pathogens isolated from various sensitive to piperacillin, imipenem, tobramycin or

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NATIONAL JOURNAL OF MEDICAL RESEARCH ciprofloxacin. Nowadays more and more resistance of Total 630 samples were tested, out of 630 samples, 321 Ps.aeruginosa are encountered in routine clinical samples were showing growth on culture and out of practice, a serious problem, increase morbidity and 321 samples, 100 Ps.aeruginosa were isolated and tested mortality and also cost of treatment. for antibiotic sensitivity

MATERIAL AND METHOD4 Table 1: Sex wise distribution of cases This study was conducted at the Department of Sex Total no Percentage (%) Microbiology in a tertiary care hospital, Ahmedabad. It Male 61 61 is tertiary care center, referral and teaching hospital. Female 39 39 This study was conducted during April 2009 to April Total 100 100 2010. The present study comprises 100 Pseudomonas Table-2 Shows sex wise distribution of samples. positive samples: swab, urine, sputum, pus, pleural Ps.aeruginosa was isolated from 61(61%) males and fluid, BAL, ascitic fluid and blood samples submitted 39(39%) females. for microbiological diagnosis to the Microbiology Department. All these samples were obtained from various wards of hospital. The clinical data was Table 2: Isolation of Pseudomonas aeruginosa obtained from the respective units and wards of the from different clinical samples patients. Name of No. of Sample in which Pseudomonas Sample proccessing sample aeruginosa Isolated Pus 3 The samples were selected on the basis of their growth Sputum 12 on routine MacConkey medium which showed lactose Stool 1 Non-fermenting pale colonies which were oxidase test Swab 68 positive and on Nutrient agar pigmented and non- Urine 16 pigmented colonies with oxidase positive. Total 100 Confirmation of pseudomonas spp Table 3: Antibiotic resistance of Pseudomonas After obtaining the pure strains, the strains were aeruginosa isolated from different clinical samples subjected to biochemical identification tests to identify Pseudomonas spp. For this purpose samples were Antibiotic Resistance (%) inoculated in Triple Sugar Iron media (TSI), Citrate Ceftazidime (AZ) 43 media, Peptone water, Urease media and kept in an Piperacillin (MP) 50 incubator for 18 hrs at 37°C. Next day the results were Piperacillin tazobactam (PT) 04 noted on TSI, Citrate media and Urease media. Part of Cefepime tazobactam (TT) 03 growth on Peptone water was subjected to Indole test Cefoperazone (CM) 33 with Kovac’s Reagent and part for motility test by Ciprofloxacin (CG) 49 ‘Hanging drop’ method. A strain of Pseudomonas in Tobramycin (TF) 68 the TSI medium showed alkaline slant, no reaction in Levofloxacin (GF) 25 butt. It showed negative reaction for indole test, Polymyxin B (AK) 45 negative urease test and positive citrate test. Glucose is Gentamycin (GM) 63 utilised oxidatively, forming acid only Aztreonam (AC) 39 Netilmycin (NT) 36 Antimicrobial disc: susceptibility test Imepenam (IM) 14 Application of antibiotic discs to the inoculated agar plates: DISCUSSION Antimicrobial susceptibility of all the isolates was Pseudomonas aeruginosa emerged as an important performed by the disc-diffusion (Modified-Kirby Baur pathogen and responsible for the nosocomial disc diffusion method) according to CLSIs guidelines. infections.It is one of the important causes of The following antibiotics were tested by disc diffusion morbidity among hospital patients. method, Ceftazidime, Piperacillin, Piperacillin- The pre-eminent of pseudomonas aeruginosa in tazobactam, Cefipime tazobactum, Imepenam, hospital infections is due to its resistance to common Gentamicin , Ciprofloxacillin , Levofloxacillin, antibiotics and antiseptics, and its ability to establish Cefoperazone, Tobramycin, Polymyxin B, Aztreonam, itself widely in hospitals. Being an extremely adaptable Netilmycin organism, it can survive and multiply even with minimum nutrients, if moisture is available. RESULTS AND ANALYSIS As pseudomonas aeruginosa causes serious infections, and is one of the leading causes of hospital acquired

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NATIONAL JOURNAL OF MEDICAL RESEARCH infections, several studies were carried out to detect Out of 100 clinical isolates of Ps. aeruginosa, maximum antibiotic sensitivity pattern for the various drugs isolates (71%) are isolated from pus/swab followed by available. Such study helps clinicians for the better 16% from urine and 12% from sputum, 3% from other management of patients. samples. So the present study was conducted to determine the Out of 100, 61% are males and 39% are females. Most antibiotic sensitivity pattern of Pseudomonas of patients were aged between 31-45 years. Most of aeruginosa isolated from various clinical samples. In samples were collected from surgical wards, followed present study the isolation rate of Pseudomonas by paediatric ward, medical ward, orthopaedic and aeruginosa was comparable with other studies. gynaecology and obstetrics ward and ICU. Maximum resistant isolates of Pseudomonas aeruginosa were In the present study sex wise prevalence of clinical isolated from pus/swab samples. isolates shows that infections caused by Pseudomonas aeruginosa are more common in males (61%) In present study, maximum isolates of Ps. aeruginosa compared to females (39%). This is comparable with isolated from various samples are resistant to study of Javia et al.5 , Jamshaid Ali Khan et al.6 and tobramycin (68%) followed by gentamycin (63%), Rashid et al.7. piperacillin (50%), ciprofloxacin (49%) and ceftazidime (43%). In present study the age wise prevalence of clinical isolates shows that most of patients 29 (29%) were It is evident from the study that now a days Ps. aged between 31-45 years. This is comparable with aeruginosa is becoming less sensitive to cephalosporins, study of Rashid et al. aminoglycosides and B-lactamase inhibitors. The sex wise and age wise distribution of patients To prevent the spread of the resistant bacteria, it is diagnosed with infections followed the natural critically important to have strict antibiotic policies epidemiological pattern. while surveillance programmes for multidrug resistant organisms and infection control procedures need to be In present study, the maximum clinical isolates of Ps. implemented. In the meantime, it is desirable that the aeruginosa were isolated from pus/swab (71%), antibiotic susceptibility pattern of bacterial pathogens followed by urine (16%). These results are in line with like Ps. aeruginosa in specialized clinical units to be studies of Jamshaid A K et al. 32 and other studies,7-12 continuously monitored and the results readily made In present study the highest percentage (48%) of available to clinicians so as to minimize the resistance. Pseudomonas aeruginosa infections were observed in The solution can be planned by continuous efforts of the surgical ward, followed by paediatric ward (23%) microbiologist,clinician, pharmacist and community to and medical ward (17%). Prevalence of infection was promote greater understanding of this problem. higher in surgical ward as maximum isolates were Frequent hand washing to prevent spread of organism isolated from pus/swab samples. should be encouraged. Better surgical and medical care In present study it is evident from table 7 that there is should be provided to patients during hospital stay. distinct difference in the sensivitity pattern of isolates of pseudomonas aeruginosa from specimen to specimen 9. REFERENCES This study shows that the clinical isolates of 1. Irvani A. Efficacy of lomefloxacin as compared to norfloxacin Pseudomonas aeruginosa are becoming resistant to in the treatment of uncomplicated urinary tract infections in adults. Am J Med 1992;92(suppl.4A), 75-81. commonly used antibiotics and gaining more and more resistance to newer antibiotics. The antimicrobial 2. Betty A. F. Daniel F. S. and Alice S. W. Bailey & Scott’s Diagnostic Microbiology, Twelfth edition, 2007, Pseudomonas, agents are losing their efficacy because of the spread of Burkholderia and similar organisms, 340-350, mosby Elsevier, resistant organisms due to indiscriminate use of St. Louis, Missouri. antibiotics, lack of awareness, patient non compliance 3. Koneman, Koneman’s color Atlas and textbook of diagnostic and unhygienic condition. Microbiology, Sixth Edition, 2006, The Nonfermantative It is the need of the time that antibiotic policies should Gram-Negative Bacilli, 303-391, Lippincott Williams & Wilkins. be formulated and implemented to resist and overcome 4. Javiya VA, ghatak SB, Patel KR, Patel JA. Antibiotic this emerging problem. Every effort should be made to susceptibility patterns of Pseudomonas aeruginosa at a tertiary care hospital in Gujarat, India. Indian J Pharmacol 2008;40:230- prevent spread of resistant organisms. 4. 5. Jamshaid A K, Zafar I, Saeed U R, K. Farzana, Abbas K. Prevalence and resistance patterns of Pseudomonas aeruginosa SUMMARY AND CONCLUSION against various antibiotics. Pak. J. Pharm. Sci. Vol21, No. 3, July 2008:311-315. This study was conducted during April 2009 to april 2010. During this period total of 630 samples were 6. Rashid A, chowdhury A, Sufi HZ R, Shahin A B, Naima M. infections by Pseudomonas and antibiotic resistance pattern of tested, in which 321 samples showed growth of the isolates from Dhaka Medical college Hospital. Bangladesh J bacteria. Out of 321 samples, 100 clinical isolates of Med Microbiol 2007;01(02):48-51 Pseudomonas aeruginosa were isolated.

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7. Shenoy S, baliga S, Saldanha DR, Prashanth HV. Antibiotic Psedomnas aeruginosa. Jpn. J. Antibiot,1995., 48(10):1581- sensitivity patterns of Pseudomonas aeruginosa strains isolated 1589. from various clinical specimens. Indian J Med Sci. 2002 Sep;56(9)427-30. 10. Stark RP, Maki Dg (1984) Bacteriuria in the catheterized patient. New Engl. Med. 311:560-564. 8. 34. Arshi syed, Manzoor thakur, Syed Shafiq, Mr. assad Ullah sheikh, In vitro sensitivity patterns of Pseudomonas aeruginosa 11. Henwood CJ, Livermore DM, James D, Warner M and the strains isolated from patients at skims-role of antimicrobials in Pseudomonas study group (2001). Antimicrobial susceptibility the emergence of multiple resistant strains. JK-Practitioner of Pseudomonas aeruginosa:results of a UK survey and 2007; evaluation of the British society for Antimicrobial chemotherapy disc susceptibility test. J. Antimicrobial 9. Murase M, Miyamoto H, Handa T, Sahaki S and Takenchi . chemother. 47:789-799. Activity of antipseudomonal agent against clinical isolates of

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

A STUDY OF SUPERFICIAL MYCOSES WITH CLINICAL MYCOLOGICAL PROFILE IN TERTIARY CARE HOSPITAL IN AHMEDABAD, GUJARAT

Bhavsar Hitendra K1, Modi Dhara J2, Sood Nidhi K3, Shah Hetal S4

1Assistant Professor, Department of Medicine, 2Tutor, 3Professor, 4Associate Professor, Department of Microbiology, GMERS Medical College, Sola, Ahmedabad

Correspondence: Dr Dhara Modi B/8, Sunita Appartments, Nr.Meghavi flats, Navavadaj, Ahmedabad-380013. E-mail address: [email protected], Phone numbers: +919909429936

ABSTRACT

Aims & objectives: Superficial mycoses are commonly encountered fungal diseases prevalent in most parts of the world. It is a fungal disease infecting hair, skin & nails. In most of the cases, it does not produce any symptoms but in some cases it has cosmetic & systemic complications. The present study was carried out to know the prevalence of various superficial fungal pathogens in our institute. Materials & Methods: In our study, a total of 377 samples from skin department were processed & all were examined by conventional direct KOH preparation & fungal culture methods. Identification of the species was done by Lactophenol Cotton Blue mount from colony smear. Results: in present study, males are infected more than females with a ratio of 2.14:1. Tinea corporis was the commonest clinical type (52.78%). The positivity rate of KOH preparation is 68.16% & of culture is 20.15%. Trichophyton rubrum is the commonest fungal isolate (35.26%) followed by Trichophyton mentagrophytes. The maximum number of the cases was seen in the monsoon months. Conclusion: Male have higher fungal infection rate than females. Trichophyton rubrum is the common isolate in our geographical area. KOH preparation has higher positivity rate than culture.

Key words: Superficial mycoses, Dermatophytes, Trichophyton rubrum, Tinea corporis

INTRODUCTION prevalent species throughout the world.2Though several reports on dermatophytosis are available from Superficial mycoses refer to the diseases of the skin and different parts of the country, there are only few its appendages caused by fungi. This groupincludes reports on non dermatophytic fungi & yeast like fungi Dermatophytosis, Pityriasisversicolorand as causes of superficial mycoses along with Candidiasis.1They possess the affinity for parasitizing dermatophytosis.4 keratin rich tissues like skin, hair & nails and produce dermal inflammatory response and intense itching in Though there are many studies available from across addition to a cosmetically poor appearance.1The India and world, there is very little data of superficial causative fungi colonize only cornified layer of mycoses from our region. The present study was epidermis or suprafollicular portions of hair & do not carried out to find out the clinical & mycological penetrate into deeper anatomical sites.2 pattern of dermatophytosis & non dermatophytic fungi in tertiary care hospital, Ahmedabad, Gujarat, West The dermatophytes are “among the commonest India. infectious agents of man”.3A dermatophytosis is a mycotic infection of the hair, skin or nails.3On the basis of clinical, morphologic & microscopic characteristics MATERIALS & METHODS three anamorphic genera are recognized as Dermatophytes: Epidermophyton, Microsporum & A retrospective study was done from January 2011 to Trichophyton.3 December 2011 over a period of 12 months and total of 377 specimens were processed from clinically The epidemiology of most of the clinically significant suspected cases of superficial mycoses attending the dermatophytosis has substantially changed over the last few years. Now, Trichophytonrubrum is predominantly

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NATIONAL JOURNAL OF MEDICAL RESEARCH outpatient department of Dermatology and 15.64%. T. versicolor (47/377) occupied the third Venereology of our hospital. position 12.46%. Nineteen patients (5.04%) had infection at multiple sites.Among different age groups, Detailed history of the patients regarding age, sex, site maximum cases 287/377 (76.12%) were seen in the of lesion, occupation, and associated illness was taken adult age group. (Figure 1) and patients were examined clinically for the type & site of the lesion and classified accordingly. Before collection of the sample, patient was explained about the procedure & informed consent was taken. The sample collection site was cleaned with cotton soaked in normal saline. The Clinical specimens (like skin scrapping, infected hair taken by plucking, clipped nails) were collected in a small piece of sterile aluminium foil. Immediately after collection, 10 % KOH mount examination was done and samples were inoculated on saboraud’s dextrose agar (SDA) with & without antibiotics. Nail clippings were dipped in 40% KOH solution overnight for study on the next morning .If KOH finding suggested of meatball and spaghetti appearance, then sample was inoculated on SDA with sterile olive oil overlay. Two bottles of SDA were incubated at different temperature, one at 25°C & another at 37°C for a period of 1 month before giving negative result. If any growth was found on culture; then the isolate was identified by colonial morphology, pigment Figure 1: Clinical Picture of T.Corporis production and direct examination of smear from the colony by tease mount & cellophane tape mount using lactophenol cotton blue preparation. In all age groups, T. corporis is the commonest manifestation, except school age group (6-11 years) RESULTS where T. capitis is the commonest(6/10 or 60%). Tinea versicolor shows commonest incidence in Adult In this study, out of total 377 patients, 257 were male followed by Adolescent group. Tinea versicolor, Tinea (68.16%) & 120 were female (31.83%). pedis & onychomycosis infections were not noted in In general, it was noted that most common clinical Pre-school and School age group in our setup. presentation was T. corporis (199/377) with overall Distribution of clinical types with age and sex is shown incidence of 52.78% followed by T. cruris (59/377) in table no1.

Table1: Distribution Of Clinical Types According To Age & Sex Clinical Age group Sex manifestation Pre-school School age Adolscent Adult Elderly Total Male Female Total (0-5) (6-11) (12-18) (19-59) (≥60) T. corporis 4 2 20 151 22 199 139 60 199 T. versicolor 0 0 7 38 2 47 33 14 47 T. corporis + T. 0 0 0 1 0 1 1 0 1 versicolor T. cruris 0 2 4 47 6 59 43 16 59 T. corporis + T. cruris 0 0 2 11 1 14 8 6 14 T. capitis 1 6 0 3 0 10 6 4 10 T. mannum 0 1 2 7 1 11 7 4 11 T. facie 2 0 0 4 0 6 4 2 6 T. facie + T.corporis 0 0 1 3 0 4 1 3 4 T. pedis 0 0 1 8 0 9 6 3 9 Onycomycosis 0 0 2 14 1 17 9 8 17 Total (%) 7(1.85) 11(2.92) 39(10.34) 287(76.12) 33(8.75) 377(100) 257(68.16) 120(31.83) 377(100)

In our study, total positivity rate for fungal infection in only 60 cases showing low positivity rate of culture. was 72.41% (273/377) by KOH examination and/or In general, out of total 377 samples, culture was Culture examination. positive in 76 cases (20.15%). Among this, 16 cases were diagnosed negative in KOH preparation from Most of the clinically diagnosed cases were KOH direct specimens but showed fungal growth.Only 60 positive. Out of total 377 samples, KOH was positive cases (15.91%) were positive in KOH preparation & in 257 cases (68.16%). Among this, culture was positive

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NATIONAL JOURNAL OF MEDICAL RESEARCH culture both. KOH and culture examination results are isolated from T. corporis& one from T. cruris.Three shown in table no. 2 isolates of Microsporumspp. were grown from T. corporis& T. crura.Only one species of

Candida&Madurella isolated, which was from T.cruris Table 2: Results of Culture & KOH Preparation and T. pedis respectively.None of the dermatophytes could be cultured from T.versicolor. Culture Culture Total (%) positive negative KOH positive 60 197 257(68.16) Figure 2: Culture &Microscopic Picture Of T. KOH negative 16 104 120 (31.83) Rubrum Total (%) 76(20.15) 301 (79.85) 377 (100)

As is evident by table 3, in present study the most common isolate is T. rubrum (55.26%) mainly isolated from T. corporis & T.cruris cases.(Figure 2). The second common isolate is T. mentagrophytes (27.63%) which is also isolated most commonly from T.corporis followed by T. cruris & Onychomycosis. Two isolates of T. violaceum were obtained, both from T.capitis.T.rubrum was main isolate in cases of onychomycosis(3/4). Out of two T. scholeinae,one was Isolated from T.corporis& another from T. mannum. The highest incidence of superficial mycoses was found Only one species of T. verrucosum from T.corporis was in the month of September (64 cases) and lowest isolated.Out of three Epidermophyton spp., two were incidence in February (1case). (Figure 3)

Table 3: Clinico-Mycological Co-Relation of Dermatophytosis Fungus T. T. T.corpori T. cruris T.corpori T. capitis T. T. facie T. facie T. pedis Onycom Total (%) corporis versicolo s + T. s + T. mannum + ycosis r versicolo cruris T.corpori r s T. rubrum 22 0 1 10 1 0 1 1 1 2 3 42(55.26) T. mentagrophytes 14 0 1 4 1 0 0 0 0 0 1 21(27.63) T. violaceum 0 0 0 0 0 2 0 0 0 0 0 2 (2.63) T. scholeinae 1 0 0 0 0 0 1 0 0 0 0 2 (2.63) T. verrucosum 1 0 0 0 0 0 0 0 0 0 0 1 (1.31) Epidermophyton spp. 2 0 0 1 0 0 0 0 0 0 0 3 (3.94) Microsporum spp. 2 0 0 0 1 0 0 0 0 0 0 3 (3.94) Candida spp. 0 0 0 1 0 0 0 0 0 0 0 1 (3.94) Madurella spp. 0 0 0 0 0 0 0 0 0 1 0 1 (1.31) Total 42 0 2 16 3 2 2 1 1 3 4 76 (100)

Figure 3: Monthly Positivity Rate of Superficial hospital in Ahmedabad, Gujarat. Hospital caters to the Mycoses patients from most parts of North Gujarat as well as border areas of M.P and Rajasthan. The temperature in this area is very high most of the time. The higher temperature as well as body sweating facilitates fungal growth.5, 6, 7 Observations of this study are compared with studies of other authors in table no.4. In present study, males are more affected than females; with male to female ratio are 2.14:1.Other studies, done by ArunaAggarwal (1.8:1)4, Nawal(1.8:1)7, Grover WCS (4.26:1)1, Parul (1.79:1)6, V bindu(2.06:1)8 have similar observation. In our study, adult age group (76.12%) is most commonly affected followed by adolescent age group. It is explained by the higher incidence of physical DISCUSSION activity & sweating in them. This finding is well Superficial mycoses form a large group of patients correlated with studies done by Aruna Aggarwal, attending the Dermatology OPD of our tertiary care Nawal, Grover WCS, Parul, M Misra respectively. 4,7,1,6,5

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Table 4: Comparison with Other Studies

Present study Aruna Grover WCS1 Parul7 Nawal6 V Bindu8 Misra5 Sen10 Aggarwal4 Male:Female 2.14:1 1.8:1 4.26:1 1.75:1 1.8:1 2.06:1 - - ratio Commonest Adult 76.12% >20yrs (68%) 21-30 yrs 21-30 yrs Adult (66.5%) 11-20 yrs adult - age group followed by (39.6%) (29.3%) (23.3%) affected adolescent, elderly Commonest T.corporis T.corporis T. pedis T.corporis T.corporis T.corporis T. versicolor T.corporis clinical site (52.78%), (36.1%), (29.2%), (64%), (40.8%), (54.6%), (33.95%), (52.78%), involved T.cruris T.cruris T.cruris T.capitis T.cruris T.cruris T.corporis T.cruris (15.64%), (28.1%) (26.2%), (11.11%) (27.8%) (38.6%) (24.55%), (15.64%) T.versicolor T.corporis T.cruris (12.46%) (15.5%) (16.33%) Infection 5.06% - 17.3% - - - 25% - involving multiple sites Commonest T. rubrum T. rubrum T. tonsurans T. rubrum T. rubrum T. rubrum T. rubrum T. rubrum species (55.26%), T. (62.3%), T. (20.5%), T. (54%), T. (67%), T. (66.2%), T. (76%) (68.63%), T. mentagrophyt mentagrophyt rubrum mentagrophyt mentagrophyt mentagrophyt mentagrophyt es (27.63%) es (23.4%) (8.7%), T. es (32%) es (14.1%) es (25%) es (25.53%) mentagrophyt es(2.9%) KOH 68.18% 59.20% 53.30% 62.12% 72.40% 64% - 49% positivity rate Culture 20.15% 50.40% 79.10% 29.29% 62.80% 45.30% - 51% positivity rate KOH & 15.91% 45.40% - 26.77% - - - - culture both positive KOH 4.20% 1.60% 28.5% 2.53% 7.70% 11.30% - 4% negative but culture positive

The commonest clinical type seen in our study is T. pathogens, faster nail growth, smaller nail surface for corporis (52.78%) followed by T. cruris (15.64%) invasion & lower prevalence of T. pedis. which is also corroborated well with other studies Among various methods, the KOH preparation has i.e.Amritsar36.1%4, Surat 64%6, Ahmedabad 40.8%7, shown good sensitivity in comparison with culture. In Calicut 6%8. However study done in military recruits in our study, KOH positivity rate is 68.16% & culture North east India by Grover et al involving soldiers as a positivity rate is 20.15% The study is in lines with the major group, showed T.pedis as the commonest other studies done across various parts of India , they manifestation1 which could be well correlated to the had also shown KOH positivity rate as 59.20%4, profession of army personnel as they have to wear 53.3%1, 62.12%6, 72.4%7, 64%8, 49%10. However, high closed shoes for longer hours of the day. In sharp culture positivity rate are depicted in other studies i.e. contrast is the study by M Mishra, where T. versicolor 50.4%4, 79.1%1, 29.29%6, 62.8%7, 45.3%8, 51%10, was major group.5 which is in sharp contrast to our study of 20.15%. In our study, most common clinical manifestation There are 16 cases in which KOH is negative but among school age group patients is T. capitis (60%) culture is positive (1.6%).Similar finding is also noted showing that T. capitis is the disease of pre pubertal age by other investigators 1.6%4, 28.5%1, 2.53%6, 7.7%7, group. This finding corroborates well with the various 11.3%8, 4%10. This can be explained by drying out other studies i.e. ArunaAggarwal4 (57.14%), Parul procedure.1 (45.45%) 6, Nawal (78.5%) 7, V bindu8. Post pubertal The commonest isolated fungal species in present study changes in hormones resulting in acidic sebaceous is T. rubrum (35.26%) followed by T. mentagrophytes gland secretions are responsible for decrease in the (27.63%).T. rubrum was also the commonest species in incidence with age. the studies done by Aruna Aggarwal (62.3%) 4, Parul In the present study, Tinea versicolor infection was not (54%) 6, Nawal (67%) 7, V bindu (66.2%) 8, S sen found in Pre- school and School age group because of (68.63%) 10, M Misra (76%) 5. However Grover et al lipophilic nature of fungus as is also reported by Nawal had reported T. tonsurans (20.5%) as the commonest et al.6 isolate. It could be explained on the basis of different climatic conditions and geographic distribution. 1 Onychomycosis was not observed in present study in the children which is on the lines of other studies by From onychomycoses, T. rubrum is the commonly R.Kaur, Nawal & Parul (0%).9,7,6 This could be isolated species. It is due to better adaptation, more explained due to less exposure to fungus because of virulence and easy colonization on hard keratin. Other less time spent in the environment containing researchers have also reported the same.6, 11, 12

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T.violaceum is the most commonly isolated species from 4. Aggarwal A, Arora U, Khanna S. Clinical andMycological Study T. capitis On the similar lines is the finding on Kannan of Superficial Mycoses in Amritsar. Indian J dermatology 2002; 47:4: 218 – 20. et al.13 The higher incidence of superficial mycoses is seen in month of September due to rainy season & 5. Mishra M, Mishra S, Singh PC, Mishra BC. Clinico-mycological Profile of Superficial Mycosis. Indian J Dermatology, humid atmosphere which is also correlating well with Venereology,Leprology 1998;64:283-5 other studies. 4, 6. Nawal P, Patel S, Patel M, Soni S, Khandelwal N. A Study of In conclusion, the present study of 377cases at our Superficial Mycosis in Tertiary Care Hospital. NJIRM 2012; tertiary care hospital, Ahmedabad shows that males are 3(1) : 95-99 predominantly affected with preponderance of cases in 7. Patel P, Mulla S, Patel D, Shrimali G.A Study of Superficial the monsoon months. KOH examination is shown to Mycosis in South Gujarat Region.National Journal of be more sensitive than culture. Majority of the cases Community Medicine 2010, Vol. 1, Issue 2 were from T. corporis and most common etiological 8. Bindu V, Pavithran K. Clinico - mycological Study of agent is T.rubrum. Although the findings of this study Dermatophytosis in Calicut. Indian J Dermatology matches with many studies done across India, it differs VenereologyLeprology 2002;68:259-61 significantly with some studies suggesting the role of 9. R Kaur, B Kaashyap, P Bhalla. Onychomycosis- Epidemiology, geographical variation in clinical and mycological Diagnosis & Management. Indian Journal of Medical pattern. Microbiology 2008:26:2108-16. 10. SS Sen, ES Rasul, Dermatophytosis in Assam.Indian Journal of Medical Microbiology 2005,vol24 ,no 1. REFERENCES 11. Das N, Ghosh N, Das S, Bhattacharya S, Dutta R, S 1. Grover WCS, Roy CP. Clinico–mycological Profile of Sengupta.A Study on the Etiological Agent and Clinico- Superficial Mycosis in a Hospital in North-East India. Medical mycological Correlation of Fingernail Onychomycosis in Journal Armed Forces India 2003; 59:2:114- 6. Eastern India.Indian J Dermatol. 2008; 53(2): 75–79. 2. Chander J. Superficial Cutaneous Mycosis. In:Textbook of 12. Kaur R, KashyapB.Evaluation of Clinicomycological Aspects of Medical Mycology. 2nd ed. Mehta Publishers, New Delhi, Onychomycosis.Indian Journal of Dermatology: 2008;vol53(4). India; 2009; 92-147. 13. Kannan P, Janaki c, Selvi GS. Prevalence of Dermatophytes 3. Fisher F, cook N. Superficial mycosis &Dermatophytes in and Other Fungal Agents Isolated from Clinical Samples. Ind J Fundaments of Diagnostic Mycology. W.B. Sauders Med Microbiololgy 2006; 24: 3: 212 - 5. company.1998; 103-156.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

EFFECT OF DIFFERENT SITTING POSTURES IN WHEELCHAIR ON LUNG CAPACITY, EXPIRATORY FLOW IN PATIENTS OF SPINAL CORD INJURY (SCI) OF SPINE INSTITUTE OF AHMEDABAD

Prajapati Namrata P1, Bhise Anjali R2

1Physiotherapist, Vadodara 2Principal & Head, Government Physiotherapy College, Civil Hospital Campus, Ahmedabad

Correspondence: Namrata Prajapati C – 77, Pancham Villa, Ajwa Main Road, Vadodara - 390019 Email: [email protected], Mobile No.: 9275000835

ABSTACT

Background: People with Spinal Cord Injury (SCI) frequently experience various complications. Subjects with SCI are in a sitting posture for prolonged periods of time, it is important to know how different sitting postures affect pulmonary function. Aim: To see the effect of different sitting postures on lung capacity and expiratory flow (LC-EF) in patient of Spinal Cord Injury (SCI). Material and Method: Hospital based experimental study carried out on 26 patients of SCI during July to September 2009 at Spine Institute of Civil Hospital, Ahmedabad in which two different sitting positions given to patients in wheelchair: 1) Normal sitting posture and 2) WO-BPS sitting posture. The lung capacity and expiratory flow (LC-EF) measures forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rate (PEFR) and average forced expiratory flow between 25-75% FVC levels (FEF25-75%). Results: All variables including FEV1, FVC, and PEFR were analyzed statically significant in both sitting posture: Normal and WO-BPS posture and FEF25-75% was also increase but not statically significant. Conclusions: WO-BPS with lumbar curve is better option for patients of SCI, sitting for prolong period of time because in this position improve the lung function in SCI patients than normal sitting posture.

Key Words: spinal cord injury, posture, lung volume measurements

INTRODUCTION important to know how different sitting postures affect pulmonary function. A new seating position that People with Spinal Cord Injury (SCI) frequently changes in ischial and lumbar support17 has been experience a range of complications. Respiratory developed to suggest a new sitting posture to mimic the dysfunction1, pain2, 3, muscle fatigue4, and pressure spine’s natural curvature in the stance, and provide ulcers5-12 are among the most common complaints. A better postural support for seated subjects17. This major cause of morbidity and mortality in these people posture has been designated as the back part of the seat is long-term respiratory complication in the form of without ischial support (WO-BPS), 18 and the enhanced pneumonia or atelectasis5, with pneumonia being the lumbar support. leading cause of their deaths.13 Because the WO-BPS’s design imitates standing spinal Many factors can contribute to poor lung function, alignment, it was expected that use of this model by including smoking habits, surgical history, hazardous subjects would result in improved sitting posture and occupational or environmental exposure, asthma, respiratory capacity. This study was already performed allergies, chronic obstructive pulmonary disease, and in normal individual and purpose of this study to know obesity. Additionally, the connection between posture effect of these postural changes on lung capacity and and lung performance has proved significant.1, 6, 14-16 expiratory flow in spinal cord injury patient. In SCI populations, Chen1 and Baydur14 and colleagues Purpose of this study is to evaluate the effect of found that the supine posture produced the best different sitting posture in wheelchair on lung capacity spirometric recordings. But subjects with SCI are in a sitting posture for prolonged periods of time, it is

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(LC) and expiratory flow (EF) in spinal cord injury The lung capacity and expiratory flow (LC-EF) patients. measures forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rate

(PEFR) and average forced expiratory flow between MATERIALS AND METHOD 25-75% FVC levels (FEF25-75%). A Helios 401 spirometer with RMS software was used to measure The present study is hospital based experimental study each subjects LC-EF. carried out during July to September 2009 at Spine Institute of Civil Hospital, Ahmedabad in which After all the subjects completed the breathing independent variable: sitting posture and dependent measurements we selected higher value among the 3 variable: lung function. Total 26 patients of age group trails in each posture. The mean and standard deviation of 17 to 50 years of SCI were taken as sample (SD) of FVC, FEF25-75%, PEFR and FEV1 were population without gender disparity. calculated. When significance was found, paired t tests were done to test posture effect on each of LC-EF Material comprised in this study were pen, paper, nose parameters between two sitting posture. Statistical clip, mouth piece, spirometer, weighing machine analysis was performed with SPSS software. standard measures tape for height measurement, wheelchairs etc. All 26 subjects were selected from wards and OPD in the hospital. Explained whole RESULT procedure to the subjects before the study carried out and then randomly given two different sitting positions Data were analyzed by student ‘t’ test. Paired ‘t’ test in wheelchair in patients: was used to find out if there in any significant difference in lung function test in two different sitting 1) Normal sitting posture, with full ischial support and posture. All variables including FEV1, FVC, and PEFR flat lumbar support were analyzed stastical significant in both sitting 2) WO-BPS sitting posture; back part of seat without posture; Normal and WO-BPS posture and FEF25- support with partially removed Ischia support and total 75% was also increase but not stastical significant. back rest with lumbar curve.

In sitting postures, knees were flexed at 900 with feet Table 1: Comparison of mean values of variables fully supported. with Normal sitting posture and WO-BPS sitting posture in wheel chair Outcome Normal sitting WO-BPS ’t’ measures posture sitting posture values Mean+ SD Mean+ SD FVC 1.97+.71 2.20+.65 4.74 FEV1 1.72+.59 2.02+.52 7.26 FEF25-75% 2.51+1.01 2.75+.87 1.51 PEFR 3.72+1.43 4.64+1.41 5.95

FVC: A “t’’ value of FVC is 4.744 which is higher than that of table value 2.787.This indicate that there is significant difference in FVC values in Normal and WO-BPS sitting posture.(p<0.01) FEV1: A “t’’ value of FEV1 is 7.263 which is higher than that of table value 2.787.This indicate that there is

significant difference in FEV1 values in Normal and Subject were told how to properly complete 1 trial, WO-BPS sitting posture. (p<0.01) which consisted of (1) deepest inhalation possible FEF25-75%: A “t’’ value of FEF25-75% is 1.511 (without spirometer), (2) clamping of the nostrils with which is less than that of table value 2.060.This help of nose clip and (3) exhalation with maximum indicate that there is no stastical significant difference effort into transducer tube of spirometer. Subjects were in FEF25-75% values in Normal and WO-BPS sitting given time to practice the breathing protocol until they posture. felt comfortable in the wheelchair and could reproduced, to fullest extent possible, consistent trend PEFR:A “t’’ value of PEFR is 5.944 which is higher on flow –volume loop. Three trails were then recorded than that of table value 2.787.This indicate that there is for each of the postures. The posture testing sequence significant difference in PEFR values in Normal and was randomized according to a randomization schedule WO-BPS sitting posture. (p<0.01) generated beforehand. Brief rest of 30 seconds between All variables including FEV1, FVC, and PEFR were trials minimized the fatigue effect on the respiratory analyzed statically significant in both sitting posture: muscles.

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Normal and WO-BPS posture and FEF25-75% was 2. To evaluate postural change effect on lung also increase but not statically significant. function particular in WO-BPS with lumbar curve, over a longer period of time by full wheelchair

users with SCI patients. DISCUSSION

We evaluated the biomechanical effects on the LC-EF REFERENCES of different sitting postures on the LC-EF. Results show that posture significantly influenced spirometric 1. Chen CF, Lien IN, Wu MC. Respiratory function in patients parameters in tested subjects. The flow-volume loop is with spinal cord injuries: effects of posture. Paraplegia 1990; 28:81-6. widely used in clinical practice to assess lung function for the condition of airways and the strength of the 2. Dyson-Hudson TA, Kirshblum SC. Shoulder pain in chronic spinal cord injury. Part I: Epidemiology, etiology, and respiratory muscles. pathomechanics. J Spinal Cord Med 2004; 27:4-17. The PEF reflects and measures the rate of flow from 3. Gironda RJ, Clark ME, Neugaard B, Nelson A. Upper limb the large airways; it is also affected by the strength of pain in a national sample of veterans with paraplegia. J Spinal the thoracic and abdominal muscles and the degree of Cord Med 2004; 27:120-7. muscular effort generated by the subject.20 The FVC is 4. Rodgers MM, McQuade KJ, Rasch EK, Keyser RE, Finley MA. the total volume of air exhaled with maximal effort. Upper-limb fatigue-related joint power shifts in experienced FEF25%–75% is the flow rates at the corresponding wheelchair users and nonwheelchair users. J Rehabil Res Dev percentage point of the FVC exhaled, and indicate the 2003; 40:27-37. function of small or distal airways.19 The results of 5. McKinley WO, Jackson AB, Cardenas DD, DeVivo MJ. lumbar lordosis in this study are, in general, consistent Longterm medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med 22-26 with other published studies. . Rehabil 1999; 80:1402-10. In parallel with Subjects’ improved respiratory 6. Hobson DA, Tooms RE. Seated lumbar/pelvic alignment. A performance in the WO-BPS sitting posture over comparison between spinal cord-injured and noninjured performances in the normal sitting posture. Although groups. Spine 1992; 17:293-8. there is no evidence in the literature that changes in 7. Brienza DM, Karg PE, Geyer MJ, Kelsey S, Trefler E. The lumbar lordosis and kyphosis have significant influence relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users. on lung function, we think that these significant Arch Phys Med Rehabil 2001; 82:529-33. differences in lumbar lordosis in different postures may account for the changes in pulmonary capacity between 8. Pinchovsky-Devin GD, Kaminski MV. Correlation of pressure sores and nutritional status. J Am Geriatr Soc 1986; 34:435-40. the postures we tested. 9. Velez-Campos L, Mahoney P. DRG’s and pressure sores. J A shape change in any one of these curvatures will Enterostomy Ther 1987; 14:243-7. cause compensatory changes in the others to help 10. Staas WE, Cioschi HM. Pressure sores—a multifaceted 27 maintain balance and conserve muscular energy. approach to prevention and treatment. West J Med 1991; adjustments to spinal alignment may change the 154:539-44. volume of air available to the lung and/or influence the 11. Lindan O, Greenway RM, Piazza JM. Pressure distribution on efficacy of contraction of the diaphragm and other the surface of the human body. 1. Evaluation in lying and respiratory muscles. Therefore, an increase in spinal sitting positions using a “bed of spring and nails.” Arch Phys lordosis in the lumbar region is likely to induce a Med Rehabil 1965; 46:378-85. decrease in thoracic kyphosis, thus giving the ribcage 12. Thorfinn J, Sjöberg F, Lidman D. Sitting pressure and greater room to expand during inspiration.21 in this perfusion of buttock skin in paraplegic and tetraplegic patients, study, lumbar curve more in WO-BPS with lumbar and in healthy subjects: a comparative study. Scand J Plast curve than the normal sitting posture. Reconstr Surg Hand Surg 2002; 36:279-83. 13. Jackson AB, Grooms TE. Incidence of respiratory complications following spinal cord injury. Arch Phys Med Rehabil 1994; 75:270-5. CONCLUSION 14. Baydur A, Adkins RH, Milic-Emili J. Lung mechanics in By this study, we can say that WO-BPS with lumbar individuals with spinal cord injury: effects of injury level and curve is better option for patients of SCI, sitting for posture. J Appl Physiol 2001; 90:405-11. prolong period of time because in this position 15. Appel M, Childs A, Healey E, Markowitz S, Wong S, Mead J. improve the lung function in SCI patients than normal Effect of posture on vital capacity. J Appl Physiol 1986; sitting posture. The WO-BPS with lumbar support 61:1882-4. sitting posture show significant improvement in FVC, 16. Lalloo UG, Becklake MR, Goldsmith CM. Effect of standing PEFR, FEV1 and increasing values of FEF25-75% but versus sitting position on spirometric indices in healthy it is not statistically significant. subjects. Respiration 1991; 58:122-5. 17. Makhsous M, Lin AF, Hendrix RW, Hepler M, Zhang LQ. The following are recommendation for future study: Sitting with adjustable ischial and back supports: biomechanical 1. Including upper thoracic level of SCI patients and changes.Spine 2003; 28:1113-21 cervical level also. 18. Makhsous M, Patel JC, Lin F, Hendrix RW, Zhang LQ. Sitting pressure in a wheelchair with adjustable ischial and back

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supports. In: Proceedings of the RESNA 26th International 23. Itoi E. Roentgenographic analysis of posture in spinal Conference on Technology and Disability: Research, Design, osteoporotics. Spine 1991;16:750-6. Practice and Policy; 2003 June 19-23; Atlanta (GA). 24. Stagnara P, De Mauroy JC, Dran G, et al. Reciprocal angulation 19. Lin, Fang, Sriranjani Parthasarathy, Susan Taylor, Deborah of vertebral bodies in a sagittal plane: approach to references Pucci, Ronald Hendrix, Mohsen Makhsous. Effect of Different for the evaluation of kyphosis and lordosis. Spine 1982; 7:335- Sitting Postures on Lung Capacity, Expiratory Flow, and 42. Lumbar Lordosis.(2006) Archives of Physical Medicine and Rehabilitation 87 (2006): 504-9. 25. Kimura S, Steinbach GC, Watenpaugh DE, Hargens AR. Lumbar spine disc height and curvature responses to an axial 20. Eid N, Yandell B, Howell L, Eddy M, Sheikh S. Can peak load generated by a compression device compatible with expiratory flow predict airflow obstruction in children with magnetic resonance imaging. Spine 2001; 26:2596-600. asthma? Pediatrics 2000; 105:354-8. 26. Lord MJ, Small JM, Dinsay JM, Watkins RG. Lumbar lordosis. 21. Druz WS, Sharp JT. Activity of respiratory muscles in upright Effects of sitting and standing. Spine 1997; 22:2571-4. and recumbent humans. J Appl Physiol 1981; 51:1552-61. 27. Hollingshead WH, Rosse C. Textbook of anatomy. 4th ed. 22. Andersson GJ, Murphy RW, Ortengren R, Nachemson AL. Philadelphia: Harper & Row; 1985. The influence of backrest inclination and lumbar support on lumbar lordosis. Spine 1979; 4:52-8.

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STUDY OF STEROID INDUCED RISE IN INTRAOCULAR PRESSURE USING NON-CONTACT TONOMETER AFTER CATARACT SURGERY IN CAMP PATIENTS AT P.D.U. MEDICAL COLLEGE RAJKOT, GUJARAT

Dodiya Kamal S1, Aggarwal Somesh V2, Bareth Kiran3, Shah Nirzari4

1Associate Professor, Department of Ophthalmology, PDU Medical College, Rajkot 2Associate Professor, Ophthalmology, M&J Western Regional Institute of Ophthalmology, Ahmedabad 33rd yr Resident, 42nd yr Resident, Department of Ophthalmology, PDU Medical College, Rajkot

Correspondence: Dr Somesh Aggarwal B 102, Anand Milan Tower, Near Municipal Garden, Shahibaug, Ahmedabad-380004 Email:[email protected], Mobile No.:9427029044

ABSTRACT

Objectives: To study the incidence of steroid induced rise in intraocular pressure following cataract surgery using non contact tonometer. Materials and Methods: The study was undertaken in a tertiary care centre. 500 eyes which underwent uncomplicated cataract surgery were studied for IOP changes for up to six weeks following omission of steroid eye drops using non contact tonometer. Results: At the end of six weeks of steroid therapy, 21% patients had persistently raised IOP of which 2% had raised IOP at the end of six weeks following omission of steroid therapy. Conclusion: Non contact tonometry is equally effective for diagnosis and following up patients of drug (steroid) induced glaucoma.

Key words: steroids, intra ocular pressure

INTRODUCTION • A mechanical obstruction of the trabecular The noncontact tonometer reduces the risk of meshwork by steroid particles infection due to no direct contact with patient’s eye, • The inhibition of phagocytosis by trabecular measures IOP in a very short interval and so can be meshwork cells used for mass examination, does not require topical Glucocorticoids exert their effect by increased anaesthesia and the readings correlate fairly with expression of myociline gene (MYOC) located on applanation tonometer1. However, accuracy of the locus GLC1A on chromosome 1q25.5 readings from this tonometer is lower than applanation and Schiotz tonometry.2 Trabecular cells exposed to glucocorticoids increase production of elastin, fibronectin and laminin and Steroids are known to cause elevation of IOP when decrease production of tissue plasminogen activator, given by topical, periocular or systemic routes. IOP collagenase IV and stromelysin, which causes an elevation is said to be maximum with periocular use accumulation of extracellular matrix (ECM) and and minimum with systemic use. The degree of IOP increases resistance to aqueous outflow. elevation depends on the specific drug, the dose, the frequency of administration, and the individual Cross-linked actin networks form within the trabecular patient3. cells treated with glucocorticoids, which inhibit their proliferation, migration and phagocytic activity and Evidence supports three independent potential cause accumulation of cellular debris and clogging of mechanisms of increased resistance to the outflow of the aqueous outflow channels. aqueous humor that can act synergistically to produce corticosteroid-induced ocular hypertension: 4 • Structural changes of the trabecular meshwork MATERIAL AND METHODS

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This study was carried from July 2009 to April 2010. 105 patients (21%) had an IOP rise of more than 6mm Out of 769 patients operated for cataract surgery of Hg of which 15(3%) had more than 15 mm of Hg during this period 500 patients who had completed after six weeks of cataract surgery. Thus, the routine follow-up of 3 months after surgery were percentage of steroid responders is 3%. selected. At the end of 6 weeks of cataract surgery, 75% (375) of Patients selected for this study was operated in the the patients had an IOP of less than 20 mm of Hg institute for cataract surgery by routine SICS and (Low steroid responder), 23%(115) had between 20-30 Phacoemulsification. Exclusion criteria were history/ mm of Hg (Intermediate steroid responder), and 2% family history of glaucoma, myopia, complicated (10) had IOP of more than 30 mm of Hg (High steroid cataract, complicated cataract surgery and pediatric responder) (Table 1) patients. At the end of six weeks of omission of steroids, two Informed consent of all patients was taken for the patients out of the ten had persistently raised IOP. surgery and all patients were admitted in the hospital They were then treated with anti-glaucoma drugs and one day before the surgery. none of them required any surgical treatment for glaucoma. Detailed history of all patients was taken including complaints, family history, ocular history and systemic Thus, in this study of 500 patients operated for cataract history. Patients were then examined in detail which surgery 60(12%) patients had raised IOP on first Post- included torch light examination of the eye, Best Operative day due to retained viscoelastic substances Corrected Visual Acuity with Snellen’s chart, Slit-lamp and retained lens matter. These patients were treated examination, Fundus examination and intraocular and on first week after cataract surgery only 2(0.04%) pressure measurement with non contact tonometer. patients had persistently raised IOP. All 500 patients were given steroid eye drops for 6 weeks and raised All patients admitted for cataract surgery was examined IOP after 6 weeks was found in 105(21%) patients. pre-operatively and patients were operated under local after omission of steroids for 6 weeks i.e. 3 months anesthesia by SICS and Phacoemulsification. after cataract surgery only 2(0.4%) patients had On first Post-operative day vision of all patients were persistently raised IOP. (Table 3) taken with Snellen’s chart, Slit-lamp examination, fundus examination was done and IOP was measured by non contact tonometer. Table 1: Classification of steroid responders on the basis of final IOP after 6 weeks of use of tropical On discharge those patients who were having normal steroids eye drops IOP were given antibiotic steroid eye drops (0.1% dexamethasone or 0.1% prednisolone) 6 times a day Type of Final IOP Patients for 1 week and 4 times a day for 5 weeks. Responder (mmHg) (%) Those patients who had IOP between 25 mmHg to 30 Low <20 375 (75) mmHg on first post-operative day were given tablet Intermediate 20-30 115 (23) Acetazolamide 1QDS for 3 days. High >30 10 (2) The study showed equal sex distribution of steroid Those patients who had IOP more than 30 mmHg on responders with an average age of steroid responders first post-operative day was treated with AC being 60.6 years (Table 2) Decompression and tablet Acetazolamide 1 QDS for 3 days. Table 2: Age distribution of steroid responders Patients were then followed up at one week after surgery, six weeks after surgery (patients were given Age Patients (%) antibiotic steroid eye drops during this period) and six <40 3 (2.86) week after omission of antibiotic steroid eye drops. 41-50 14 (13.33) 51-60 35 (33.33) 61-70 35 (33.33) RESULTS 71-80 15 (14.29) The medical records of 500 patients with cataract >80 3 (2.86) surgery by small incision cataract surgery and phacoemulsification was studied which showed that Table 3: Rise of Intraocular Tension 60(12%) patients had a rise of IOP more than 25 Time Interval Patients (%) mmHg on first post operative day. Out of these First post-operative day 60 (12) 48(80%) patients having IOP between 25-30 mmHg First week 2 (4) were treated with Oral Acetazolamide and 12(20%) 6 week 105 (21) patients having IOP more than 30 mmHg were treated 6 weeks of omission of steroid(3 2 (0.4) with AC Decompression + Oral Acetazolamide. On months after surgery) one week follow up only two patients had persistently raise IOP after the above treatment.

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DISCUSSION postoperatively, the incidence of IOP spikes decreased significantly to 10% and in all cases IOP was within Elevated intraocular pressure (IOP) is a common normal limits (21 mmHg) three weeks later. Another problem following cataract surgery. For most patients study found >18% of non-glaucoma patients had an it is transient and harmless. However, some patients IOP of >28 mmHg, 3 to 7 hours postoperatively, may experience ocular discomfort, increased corneal which decreased to below preoperative levels by four edema, and even sight-threatening complications days in most individuals15. The clinical data suggests demanding further intervention. Physicians involved in that as a general rule, patients with healthy eyes can cataract postoperative care should be aware of these tolerate a transient postoperative rise in IOP with no high-risk patients and know how to manage them detectable effect on visual function.16 appropriately. The increase may be marked and is the most frequent postoperative complication requiring Risk factors include preexisting primary open-angle specific treatment6,7Since then, numerous studies have glaucoma, a family history of glaucoma, high myopia, evaluated the risks of an increase in IOP following diabetes mellitus, and history of connective tissue cataract surgery, the demographics, the etiology of the disease17 (especially rheumatoid arthritis). increase, and the most effective way to treat it both Steroid-induced IOP elevation typically occurs within a short and long term8. Treatment options include few weeks of beginning steroid therapy. In most cases, preoperative and postoperative use of IOP lowering the IOP lowers spontaneously to the baseline within a agents, surgical techniques to ensure open outflow few weeks to months upon stopping the steroid. In channels, and decompression of the anterior chamber. rare instances, the IOP remains elevated. In our study, Although nearly all patients’ IOPs will return to 12% patients had rise in IOP on first post operative baseline with or without treatment, some individuals day (POD), which is comparable to a previous study with IOP spikes may experience ocular pain, corneal which showed 10%. edema and even sight-threatening complications such as retinal vascular occlusion, progressive field loss in Retained viscoelastic substance was the most common advanced glaucoma, and anterior ischemic optic cause of rise in IOP of first POD. One week following neuropathy (AION) in susceptible patients9,10,11. the surgery, 96% patients had normal IOP. 21% of the patients showed rise in IOP of more than 6mm of Hg In most patients, postoperative increase in IOP after six weeks of steroid usage, which is comparable following cataract surgery is transient12.As many as to the other studies. Steroid responders (more than 15 25% of patients experience an IOP spike >30 mmHg, mm of Hg) constituted 3% of the total population 4 to 6 hours after uncomplicated phacoemulsification under study, which is similar as observed by other according to a recent study13,14. At 24 hours studies.

Table 4: Treatment Strategy Topical and systemic steroid. Subtenon steroid. Intravitreal steroid. st 1 line of Rx Discontinuation of steroids in all Excise steroid depot and send Medical forms if possible. Medical control for histopathology. Medical of IOP for the wash off period of control of IOP for the wash off steroids. period of steroids. nd 2 line of Rx Substitute with other nonsteriodal Medical management. Vitrectomy with or drugs or use minimal dose and without trabeculectomy. duration of less potent steroid. rd 3 line of Rx Medical treatment. Laser or surgery. th 4 line of Rx Laser or surgery.

Table 5: Patients responding to steroids (IOP change after 6 weeks of steroid use) in present and other study Study % of pts. with rise of IOP after 6 weeks IOP change >6-15 IOP change of steroid use mmHg in % >15mmHg in % Armaly et al 34 29 5 Becker et al 36 - - Biedner B.A et al 12.2 10 2.5 H.V. Nema et al 13.5 10.7 2.31 Present study 21 18 3

In present study steroid eyedrops were given for 6 CONCLUSION weeks and 98.09% patients had normal IOP after Non contact tonometery as such not accurate method omission of steroids for 6 weeks. for measure of Intra ocular pressure but because of

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advantage of non contact is equally effective for 7. Hildebrand GD,Wickremasinghe SS, Tranos PG, et al. Efficacy diagnosis and follow up of drug induced rise of intra of anterior chamber decompression in controlling early intraocular pressure spikes after uneventful phaco- ocular pressure, for example steroid induced glaucoma emulsification. J Cataract Refract Surg. 2003; 29: 1087-1092. comparable with Applanation tonometry. 8. Tranos P, Wickremasinghe S, Hildebrand D, Asaria R, Mearza A,Nouri S et al. Same vs first postoperative day review after Table 6: IOP after 6 weeks of omission of steroids uncomplicated phacoemulsification. Are we overtreating early intraocular pressure spikes? J Cataract Refract Surg 2003; 29(3): in present and other study. 508-512. Study Percentage of patients having 9. Vannas S, Tarkkanen A. Retinal vein occlusion and glaucoma. normal IOP after omission of Tonographic study of the incidence of glaucoma and of its steroids (%) prognostic significance. Br J Ophthalmol 1960; 44: 583-589. H.V.Nema et al 100 10. Hayreh SS. Anterior ischemic optic neuropathy. IV. V.P.Munjal et al 85.7 Occurrence after cataract extraction. Arch Ophthalmol 1980; 98: 1410-1416. Espilora et al 98 Present Study 98.09 11. Savage JA, Thomas JV, Belcher CD III, Simmons RJ. Extracapsular cataract extraction and posterior chamber intraocular lens implantation in glaucomatous eyes. Ophthalmology 1985;92: 1506-1516. REFERENCE 12. Tranos P, Bhar G, Little B. Postoperative intraocular pressure 1. Moltolko M A, and others: Sources of variability in the results spikes: the need to treat. Eye. 2004; 18: 673-679. of applanation tonometry, Can J Opthalmol 17-19.1982 13. Ahmed IK, Kranemann C, Chipman M, Malam F. Revisiting 2. Honjo M, Tanihara H, Inatani M, Honda Y. External early postoperative follow-up after phacoemulsification. J trabeculectomy for the treatment of steroid induced glaucoma. Cataract Refract Surg 2002; 28(1): 100-108. J Glaucoma 2000; 9(6): 483–485. 14. Gokhale PA, Patterson E. Elevated IOP after cataract surgery. 3. Shingleton BJ, Garnell LS, O’Donoghue MW, et al. Long-term Glaucoma Today 2007; 5(3): 19-22. changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect 15. Drance S M: Glaucoma: A look beyond Intra Ocular Pressure. and glaucoma patients. J Cataract Refract Surg 1999; 25: 885- American J of ophthalmology page 123,817. 1997. 890. 16. Kolker AE. Visual prognosis in advanced glaucoma: a 4. Drance S M: Glaucoma: A look beyond Intra Ocular Pressure. comparison of medical and surgical therapy for retention of American J of ophthalmology page 123,817. 1997. vision in 101 eyes with advanced glaucoma. Trans Am Ophthalmol Soc 1977; 75: 539-555. 5. Gonzalez P, Epstein DL, Borras T. Gene upregulated in the human trabecular meshwork in response to elevated intraocular 17. Drance S M: Glaucoma: A look beyond Intra Ocular Pressure. pressure. Invest Ophthal Vis Sci 2000; 41: 352–361 | American J of ophthalmology page 123,817. 1997. 6. Shields M B: The noncontact tonometer: It’s value and limitations, Surv Opthalmol 24:211. 1980.

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ARE CARE TAKERS OF LINK WORKER’S SCHEME OF HIV/AIDS KNOWLEDGEABLE ENOUTH? ASSESSMENT STUDY OF LINK WORKERS SCHEME IN SURAT DISTRICT

Parmar Rohit1, Desai Binita1, Kosambiya JK2, Solanky Priti3, Prajapati Shailesh4, Kantharia SL5

1Assistant Professors, 2Professor (Addl), Department of Community Medicine, Govt. Medical College, Surat 3Assistant Professor, Department of Community Medicine, GMERS Medical College, Valsad 4Assistant Professor, Department of Community Medicine, GMERS Medical College, Gotri, Vadodara 5Professor and Head, Department of Community Medicine, Govt. Medical College, Surat

Corresponding Author: Dr. Rohitkumar Parmar Assistant Professor, Department of Community Medicine, Government Medical College, Surat-395001 E-mail: [email protected]

ABSTRACT

Introduction: Gujarat State AIDS Control Society with support from UNICEF Gujarat has initiated as unique project for prevention of HIV /AIDS at rural set up since 2008, which is known as Link Workers’ scheme. Link Workers (LWs) are working in each cluster of villages around a 5,000+ population village which will serve as the node for intervention. They are supported in their work by village level volunteers selected from the available groups in the community. Methodology: 140 Link workers and 70 volunteers from 70 villages of 14 blocks of district Surat were invited for the study. Due to few vacant posts, total 183 participants took part in the study; out of these 117 were link workers (LWs) while 66 were volunteers. Their Knowledge regarding HIV/AIDS and STI were assessed on a predesigned pretested semi structured study tool. Result: 96.59% link workers and 93.44% volunteers had knowledge about condom use as a method of preventing HIV infection. The concern issue is that only 11.11% LWs and 13.64% volunteers revealed that HIV testing during ANC check up can also prevent HIV transmission from mother to child, inspite of receiving induction training. Only 74.36% LWs and 68.31% volunteers were able to tell about three or more HIV preventive methods. Recommendations: Refresher training and exposure visit to HIV care centres are needed for these workers to strengthen their knowledge.

Key Words: Link Worker, Volunteer, HIV, STI

INTRODUCTION Districts Surat and Tapi both are having HIV care services available like17 stand alone ICTCs (funded by Surat is considered as an epi-center of HIV/ AIDS in NACO), 62 Facility Based ICTCs, 3 ART centres and 2 Gujarat as it shows consistently high positivity of HIV link ART centres and 2 Blood Banks. The Link Worker among high risk group as well as among general Scheme envisioned a new cadre of worker, the Link population reflected in HIV sentinel surveillance for Worker (LW), that were introduced at rural level. Link high risk groups and in antenatal clinic attendees Workers were a motivated, community level, paid respectively.1 Therefore, in order to saturate all high female and male youth workers with a minimum level risk and highly vulnerable groups with prevention and of education. A Link Worker is someone who is not essential services, there is a felt need to establish an “alien” to the neighbourhood, is accepted by the village appropriate low cost structure that could provide community, who can discuss intimate human relations preventive, curative and supportive services to them. and practices of sex and sexuality, help and equip high About 57% of total HIV infected people are living in risk individuals and vulnerable young people with rural areas.2 The estimated HIV prevalence among information and skills to combat the pandemic. The adults aged 15 to 49 years is 0.38% in the Gujarat.3 Link Workers covers highly vulnerable villages in National HIV infection levels are highest in South-East Districts selected through mapping exercises, using Asia, where there are disparate epidemic trends.4 India criteria such as size of the population, number of Sex has the third highest burden of HIV after South Africa Workers residing and practising sex work in the village and Nigeria with an adult HIV prevalence 0.36%.5

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NATIONAL JOURNAL OF MEDICAL RESEARCH and number of People Living With HIV/AIDS considered together as it was during the (PLWHA) in the village. They are working in each implementation time of this scheme. Total 14 Blocks of cluster of villages around a 5,000+ population village old Surat district were covered for the assessment which will serve as the node for this subgroup purpose. The LW scheme is being implemented in 70 intervention.2 They are supported in their work by villages. Each village is having one male and one female village level volunteers selected from the available Link Worker and 5 volunteers. Total 140 link workers groups in the community. Link worker scheme is and 70 randomly selected volunteers (one volunteer implemented in the state of Gujarat at Surat, Valsad from each village) out of total 350 were invited for the and Vadodara districts covering 164 villages since 2008 study at pre decided nearby place in a comfortable by Gujarat State AIDS Control Society (GSACS) and environment according to their residential blocks. A supported by UNICEF. The present study was study was conducted by team of investigators after undertaken with the objective of assessing the receiving adequate training. A pre designed semi knowledge of service providers (Link workers and structured proforma was used by the trained staff. All Volunteers) of the scheme and to understand issues the Link workers and volunteers were asked to fill the and any outstanding concern for the better functioning self administered questionnaire in Gujarati/Local of the scheme. Thus it will be helpful in the capacity language having questions on basic knowledge of STI building of the workers. and HIV/AIDS after giving enough and necessary briefing about the purpose and method of study. The All LWs have received 14 days residential induction participants were closely observed by the team of 4 training after their selection in this project. Basic’s of investigators. Data was entered in Microsoft Excel and HIV/AIDS/STD, communication skills, counselling, analysed. sex and sexuality, linkages and networking with HIV prevention and care services and NGO involved in TI program of NACP-III were included in the training. RESULTS AND DISCSSION During second year 6 days residential training was imparted to LWs. All the volunteers were underwent 1 There are few vacant posts of link Workers and day orientation training by NGO then after 1 day volunteers, so total 183 participants were enrolled in training every quarterly in a year, so total 5 trainings the study; out of these 117 were Link Workers (LWs) received by volunteers. This study assessed their while 66 were volunteers. current knowledge level. Knowledge regarding HIV:

Out of 117 LWs and 66 Volunters, 96.59% link METHODOLOGY workers and 93.44% volunteers had knowledge about condom use as a method of preventing HIV infection. Geographically the district Surat is located in the Inspite of receiving induction training on HIV/AIDS, Southern part of Gujarat .Now it was separated in two the concern issue is that, only 11.11% LWs and 13.64% districts named Surat and Tapi. Surat is having 9 blocks volunteers revealed that HIV testing during ANC while district Tapi is having 5 blocks. But for the check up can also prevent HIV transmission from purpose of assessment, both the districts were mother to child.

Table-1: Knowledge of participants on various issues related with HIV/AIDS Knowledge on issues related with HIV/AIDS Link Workers(%)(n=117) Volunteers(%)(n=66) Prevention of HIV by condom 96.59 93.44 HIV testing during ANC for prevention of transmission 11.11 13.64 ≥ 3 methods of prevention of HIV 74.36 57.57 Knowledge of name of all three High Risk Groups 68.02 57.92 Full form of HIV 67.52 50.82 Knowledge about menstrual hygiene 01.71 02.19 All three uses of condom 64.10 36.36 Knowledge about progression of HIV to AIDS 07.69 06.06 Knowledge about HIV diagnosis test 95.73 83.33 Misconception regarding HIV (Stigma & discrimination) 53.85 39.39 Knowledge about vulnerable population 17.95 10.61 Knowledge about Body secretion in which HIV virus is present 47.86 36.36

Only 74.36% LWs and 68.31% volunteers were able to volunteers were having knowledge that FSWs, MSMs tell about three or more preventive methods (By using and IDUs were member of high risk groups. 67.52% condom, By using new needle/syringe, By receiving LWs and 50.82% volunteers had knowledge about full tested blood, ANC check up, Remain faithful to form of HIV. Only 1.71% of LW and 2.19% of partner etc.).About 68% of LWs and 39.39% volunteers were able to give satisfactory answer about

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NATIONAL JOURNAL OF MEDICAL RESEARCH menstrual hygiene. 64.1% of LWs and 54.1% After assessment of HIV, knowledge of STIs among volunteers had knowledge about all three uses study participants was assessed. Knowledge of (prevention of pregnancy, STD and HIV) of condom participants on various issues related with STI (Table- while rest were able to give only one or two uses. 2). Out of 117 LWs and 66 Volunteers, 80.34% LWs 95.73% LWs and 83.33% Volunteers knows about the and 77.27% Volunteers knows that STI can be diagnostic test of HIV infection. 53.85% LWs and prevented by using condom. 01.71 LWs and 03.03% 39.39% Volunteers had misconception regarding HIV. Volunteers had misconception regarding STIs. Only 47.86% LWs and 36.36% Volunteers had knowledge 22.22% LWs and 15.15% Volunteers had knowledge of about all four body secretions (Blood, Semen, Vaginal ≥ 5 Symptoms (Vesicle over genital region, Ulcer over secretion and infected mothers breast milk) in which genitals, Veginal discharge, Itching over genital region, HIV is present (Table-1). Urethral discharge, Lower abdominal pain etc.) of STIs. Knowledge regarding Sexually Transmitted Infectins (STIs):

Table-2: Knowledge of participants on various issues related with STI Knowledge on issues related with STI Link Workers (%) (N =117) Volunteers (%) (N =66) Knowledge of prevention by using condom 80.34 77.27 Misconception regarding STIs (Stigma & discrimination) 01.71 03.03 Knowledge of ≥ 5 Symptoms of STIs* 22.22 15.15 *Symptoms of STI includes vesicles over genital region, Ulcer over genital, Vaginal Discharge, Itching over genital region, Bubo, Urethral Discharge, Lower abdominal pain etc.

RECOMMENDATIONS We are grateful to Gujarat State AIDS Control Society (GSACS) and UNICEF, Gujarat for Technical and The correct knowledge regarding HIV and STI is Financial Support. It was our privilege to receive co- essential for Link Workers for working as a Link ordination and field level support from District between Clients and HIV preventive and care service Resource Persons (DRPs) of Link Workers’ Scheme providers. Basic knowledge of LWs and Volunteers on and Supervisors -ICTC Surat District. Our special STI and HIV/AIDS is the cornerstone of the Link thanks to Faculty members from Department of Worker Scheme. All LWs and Volunteers had received Community Medicine, Government Medical College, enough induction training after their selection in this Surat, Dr. Sukesha Gamit, Dr. Mamta Verma, Dr. scheme. This was reflected in their knowledge Anjali Modi and Dr. Prakash Ghoghra for field level component, but findings revealed that ongoing supervision. refresher training is required. The issues needs to be addressed will be the difference between HIV and AIDS, how the HIV can leads to AIDS, about core and REFRENCES vulnerable population, symptoms of STIs. Regular and supportive supervision by supervisors and District 1. Gujarat State AIDS Control Society. HIV Sentinel Surveillance Resource Persons helps them in gaining knowledge and Report. GSACS, Ahmedabad, India; 2007. p1. make them confident in counselling. Exposure visits to 2. National Aids Control Organization, Link Workers Scheme, Integrated Counselling and Testing Centre (ICTC), Operational Guidelines. NACO, New Delhi, India; 2007. p13- ART Centre and Targeted Intervention projects at their 14. nearby area can help them by first hand exposure 3. National Aids Control Organization. HIV Sentinel Surveillance “Learning by doing” will improve their knowledge and HIV Estimation in India 2007, A Technical Brief. Ministry Of Health and Family Welfare and Government of India, New level. Delhi, India; 2008. p22. 4. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reports on the global AIDS epidemic. UNAIDS; 2008. p48. ACKNOWLEDGEMENT 5. United Nations Aids Control Organization. AIDS epidemic. Asia: UNAIDS; 2007. p6.

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PREVALENCE OF HEPATITIS B VIRUS INFECTION IN HEALTH CARE WORKERS OF A TERTIARY CARE HOSPITAL

Khakhkhar Vipul M1, Thangjam Rubee C2, Parchwani Deepak N3, Patel Chirag P4

1Associate Professor, 2Tutor, Department of Microbiology, 3Associate Professor, Department of Biochemistry, Gujarat Adani Institute of Medical Sciences, Bhuj, 4Tutor, Department of Microbiology, Pramukh Swami Medical College, Karamsad

Correspondence Dr. Vipul M Khakhkhar H/No-B/13 New G.K.General Hospital, Gujarat Adani Institute of Medical Sciences, Bhuj (Guj) 370001 Email: [email protected], Mobile: 09824187770

ABSTRACT

Introduction and objective: Hepatitis B infection is recognized as one of the occupational hazards among Health Care Workers (HCW). The purpose of this study was to estimate the prevalence of Hepatitis B infection among HCW in a Tertiary care Hospital. Material and method: 500 HCWs (159 physicians, 119 nurses, 49 medical laboratory technicians, 50 sanitary staff members and 119 medical students) aged between 22 and 58 years were included in the surveillance. Serum samples were screened for presence of HBsAg, HBeAg and anti-HBc with the help of ELISA. Results: The highest proportion of HBsAg positivity was found among laboratory technicians (4.1%), followed by nurses (1.7%). The distribution of the HBsAg was not associated with age and gender. However, the positive rates of HBsAg were the highest for the HCWs with greater than thirty years in job, with overall positivity of 2.4% (1/41) (odds ratio: 1.06, p value: 0.01), suggesting greater exposure to blood and other putative risk factors. Among the 5 HBsAg positive participants, 4 were chronic carrier and one is progressing towards the chronic infection. None of them were positive for HBeAg, which is suggesting that there is decreased risk of transmission. Conclusion: Based on this surveillance, we can make reasonable decisions in case of occupational exposure to hepatitis B virus. Thus, in order to prevent the nosocomial infection of hepatitis, we advocate precaution and protection from sharp injuries. Health care workers should be made aware of hazards, preventive measures and post-exposure prophylaxis to needle-stick injuries. A hospital-wide hepatitis immunization programmed should also be started.

Key words: Health care workers, HBsAg, Hepatitis, Occupational hazards

INTRODUCTION implemented in recent years to reduce nosocomial HBV infections such as improved hygiene, increased Hepatitis B, a global but preventable disease, is vaccine coverage, increased awareness of medical staff, estimated to affect at least 2 billion individuals and highly sensitive testing of blood products4. On the worldwide, and 350 million among them are suffering other hand the number of invasive diagnostic and from chronic hepatitis B virus (HBV) infection1. therapeutic procedures is increasing5 thereby further Transmission of HBV occurs through percutaneous or increasing the risk of HCWs for getting an infection permucosal exposure to infective body fluids. In with HBV; therefore, HBV vaccination has been addition to sexual contact and drug injection, strongly recommended for them. However, studies on nosocomial transmission should not be neglected as a the HBV-markers for HCWs in India are rare. Thus in risk factor, even in hospitals with high hygiene this study an attempt has been made to determine the standards. Literature shows that this form of seroprevalence of HBsAg in HCWs with the objective transmission is not unique, numerous cases of HBV- of providing data that might help to improve infected health care workers (HCWs) who potentially preventive measures and national surveillance. perform exposure prone procedures (EPPs) have been reported, as reviewed by Mele and Gunson 2,3. In India, the exact incidence of nosocomial HBV transmissions MATERIAL AND METHOD is unknown, but various measures have been

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This cross-sectional study was designed to determine (LISA PLUS, Rapid Diagnostics, New Delhi). All the the prevalence of hepatitis B infection among HCWs, positive HBsAg positive samples were then screened defined by persons working in medical profession for for HBeAg and anti-HBc by immunocomb technique at least 20 weeks i.e. performing EPPs, not performing (EIA) solid phase ELISA (Orgenics Ltd, Israel). This EPPs, or potentially performing EPPs in the future. study was carried out from January 2010 to December The latter category applied to medical students who do 2010 and was approved by Institutional Human not yet perform invasive procedures. 500 participants Research Ethical Committee. Written informed (312 males and 188 females) of varying age were consent was obtained from all participants. All enrolled which include: Resident doctors (n = 159; 112 statistical analysis was done using SPSS for Window males and 47 females), Sanitary staff (n = 54; 45 males software, version 15. For all analyses, the nominal level and 9 females), Medical students (n = 119; 90 males of statistical significance was<0.05. and 29 females), Staff nurses (n = 119; 30 males and 89 females) and Medical laboratory technicians (n = 49; 35 males and 14 females). Anyone inoculated at least once RESULTS was classified as the vaccinated: according to the number of doses, they were divided into the complete The overall positive rates of HBsAg were 1% (5/500) (3 or more) and incomplete (1 or 2) vaccinated groups. and none of them had previous vaccination histories Participants with known HBsAg, history of unsafe (Table 1). The trend was similar when the sexes were blood transfusion, parenteral drug abusers, spouse of examined separately, and no significant difference with hepatitis B patients, lack of approval by physician and age, education, socio-economic status and other persons showing disinterest were excluded from the lifestyle variations was found. However, according to study. duration of profession, the positive rates of HBsAg were the highest for the HCWs with greater than thirty Information on demographics (such as gender, age, years in the job, with overall positivity of 2.4% (1/41) education, economic status, and residency), occupation, (odds ratio: 1.06, p value: 0.01) (Table 1 and 3). parenteral exposures, sexual partners, vaccination status, duration of employment, medication and history suggestive of any systemic illness were collected Table 1: Sero-positivity among serving HCW through a self-administered questionnaire. Present and according to duration of profession past history of each case was recorded in detail. Duration of Samples HBsAg positive A sample of blood was drawn with an aseptic technique Profession (%) and was collected in plain vial. Serum was separated by 0-15 341 2 (0.6) centrifugation and were tested for HBsAg [by Enzyme 16-30 118 2 (1.7) Linked Immunosorbant assay (ELISA)] using >30 41 1 (2.4) commercially available kits (Genedia, Green Cross, Total 500 5 (1) Korea). Tests were carried out by an ELISA reader

Table 2: Sero-positivity among serving health care workers according to occupation Occupation Samples Vaccinated Unvaccinated HBsAg Positive (%) Resident 159 120 39 - Nurses 119 53 66 2 (1.7) Lab. Tech 49 18 31 2 (4.1) Sanitary staff 54 17 37 1 (1.9) Students 119 63 56 -

Table 3: Odds ratio and 95% CI for HBsAg group (4.1%) followed by nurses (1.7%) (Table 2). The according to different variables odds ratios for the nurses, technicians and sanitary staff were slightly elevated, but this was statistically Variables Odds ratio 95% CI p value insignificant (Table 3). Duration of profession 0 – 15 Ref. Among the 5 HBsAg positive cases, 4 cases (80%) (2 16 – 30 1.01 0.22–0.86 0.71 nurses, 1 sanitary staff member and 1 laboratory > 30 1.08 1.01–1.09 0.01 technician) had previous history of jaundice, surgery or Occupation blood transfusion. Out of the 5 HCWs screened 4 were Physician Ref. chronic carrier and one had acute infection. Staff nurses 1.45 0.69–3.5 0.61 Progressing towards the chronic carrier, none of them Sanitary staff members 1.18 0.89–2.78 0.68 found to be positive for HBeAg. Medical lab. technicians 1.89 0.49–4.05 0.67 DISCUSSION According to occupations, the positive rate of HBsAg Hepatitis B infection is a leading cause of morbidity was the highest in the medical laboratory technicians and mortality, not only because of the acute illness but

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also due to its chronic sequelae like chronic hepatitis, 2. Mele A, Ippolito G, Craxi A et al. Risk management of HBsAg cirrhosis and hepatocellular carcinoma, and accounting or anti-HCV positive healthcare workers in hospital. Dig Liver Dis 2001;33:795–802. for more than a million deaths annually worldwide6-8. Besides other modes of infection, nosocomial 3. Gunson RN, Shouval D, Roggendorf M et al. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in health care transmission is one of the major modes of infection workers (HCWs): guidelines for prevention of transmission of and risk factor and it was first emphasized in early HBV and HCV from HCW to patients. J Clin Virol fifties when serum hepatitis cases occurred in health 2003;27:213–230. personnel after the percutaneous exposure to the blood 4. Webster GJ, et al. Molecular epidemiology of a large outbreak of the same patient9. of hepatitis B linked to autohaemotherapy. Lancet 2000;356:379–384. Various epidemiological and cross-sectional studies have reported marked variation in the prevalence of 5. Robert Koch-Institut. On the situation concerning important 10-12 infectious diseases in the year 1999: Part 2: Viral hepatitis. HBsAg among HCWs . A study of CDC (USA) Epidemiologisches Bulletin 2000;28:223–227. estimated the annual risk of HBV infection 2% among of laboratory technicians, 1% among physicians, and 6. Purcell R H. The discovery of the hepatitis viruses. Gastroenterology 1993; 104: 955-63. 0.7% among nurses13,14. In the present study, overall prevalence among HCWs was 1%. The positive rates of 7. Lee WM. Review Article: Hepatitis B virus infection. N Engl J HBsAg in the laboratory technician group (4.1%) were Med 1997;337 (24):1733-45. highest followed by nurses (1.7%) among the 8. Maj MP Carriappa, Brig J Jayaram, Col Rajvir Bhalwar, Col A K occupational groups. This suggested that these groups Praharaj, Lt Col V. K. Mehta, Lt Col L. K. Kapur. Epidemiological differentials of hepatitis B carrier state in the have more chances to be exposed to the needle stick Army: A community based sero-epidemiological study. MJAFI injury or other infectious body fluid from patients than 2004;60:251-254. did the other occupational groups. Further, it was 9. Halder S C. Hepatitis B virus infection and health care workers. observed that, the positive rates of HBsAg were Vaccine 1990;8:24 significantly related to the duration of profession 10. Mahoney FJ, Stewart K. Progress toward the elimination of (Table 1 and 3) as in accordance with other recent hepatitis B virus transmission among health care workers in the 15,16 studies . Thus, specific measures should be United States. Arch Intern Med 1997;157(22):2601-5. implemented to reduce such risk. These may include 11. Sepkowitz KA. Occupationally acquired infections in health strict policies on sharps and considering any blood or care workers. Part II. Ann Intern Med 1996;125(11):917-28. other body fluids being a potential risk17. 12. Gerberding JL. Incidence and prevalence of human In order to prevent the nosocomial infection of immunodeficiency virus, hepatitis B virus, hepatitis C virus, and hepatitis, we advocate precaution and protection from cytomegalovirus among health care personnel at risk for blood exposure: final report from a longitudinal study. J Infect Dis sharp injuries. Health care workers should be made 1994; 170(6):1410-7. aware of hazards, preventive measures and post- exposure prophylaxis to needle-stick injuries. A 13. Hepatitis, proceedings of the seminar held under auspices of the Research society of Sir H.N. Hospital, Bombay on 30th hospital-wide hepatitis immunization programmed Nov. & 1st Dec, 1975. should also be started. 14. Pattison C P, Maynard J E, Berquist D R et al. Epidemiology of Nonetheless, this study has few limitations, firstly, use hepatitis B in hospital personnel. Am J Epidemiol 1975;101:59. of less sensitive techniques, secondly, the design was 15. Catalani C, Biggeri A, Gottard A, Benvenuti M, Frati E, cross-sectional and therefore, casual relationship Cecchini C. Prevalence of HCV infection among health care cannot be ascertained, in spite of all these, this study workers in a hospital in central Italy. Eur J Epidemiol 2004;19 have provided sufficient base for developing a proper (1):73-7. preventive guidelines and educational programs for the 16. Singhal et al., Prevalence of Hepatitis B Virus Infection in care of health care providers. Healthcare Workers of a Tertiary Care Centre in India and their Vaccination Status, J Vaccines Vaccin 2011;2:2 17. Hirschowitz B L, Dasher C A, Whitt F J et al. Hepatitis B Ag & Ab tests of liver function; a prospective study of 310 hospital REFRERENCES laboratory workers. Am J Clin Pathol 1980;73:63. 1. Li G, Li W, Guo F, Xuc S, Zhaod N, Chena S, Liu L: A novel real-time PCR assay for determination of viral loads in person infected with hepatitis B virus. J Virol Meth 2010; 165:9-14.

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WORK-RELATED MUSCULOSKELETAL DISORDERS: A SURVEY OF PHYSIOTHERAPISTS IN SAURASHTRA REGION

Buddhadev Neeti P1, Kotecha Ilesh S2

1Consultant Neurophysiotherapist, Bhavnagar, 2Associate Professor, Preventive & Social Medicine, Government Medical College, Bhavnagar, Bhavnagar

Correspondence: Dr. Neeti P. Buddhadev 607/A – Pattani Plaza, Anantwadi, Bhavnagar 364 001 Email: [email protected] Mobile No.: 9429412184

ABSTRACT

Background: Physiotherapists working in India are at high risk of Work Related Musculoskeletal Disorders (WRMD). The objective of this study was to determine the prevalence, identify the risk factors and coping strategies for WRMDs among physiotherapists of Saurashtra region. Methods: A self administered semi structure questionnaire was sent via e-mail to 34 physiotherapists of Saurashtra region. The questionnaire consisted of demographic information including age and clinical experience; self reports of work related musculoskeletal injuries, perceived job related risk factors and strategies or responses that are adopted for prevention were obtained. The data obtained were analyzed using the Microsoft Excel 2007. Results: The questionnaire was returned by 29 physiotherapists, giving a response rate of 85%. Of 29 subjects, 20 were affected by WRMDs in at least one body part in last one year. Low back (35%) followed by neck (25%) and shoulders (15%) were the most commonly affected region. The risk factors quoted by most of the respondents were managing large number of patients in a day, adoption of constant uncomfortable postures and manual therapy techniques. The most commonly adopted coping strategy identified was decreased patients contact hours (22.2%). Conclusions: Physiotherapists who provide their services in prevention and treatment of musculoskeletal injuries are suffering from occupational musculoskeletal injuries. Incidence of WRMDs is very high. Risk factors and the coping strategies of WRMDs among physiotherapists of Saurashtra region are identified. Further research is required to build up effective preventive or ergonomic strategies.

Keywords: Physiotherapist, Work related musculoskeletal disorders (WRMDs), Occupational injuries

BACKGROUND patients, assisting with mat activities, and lifting heavy equipment.4 These work tasks put therapists at risk for Musculoskeletal disorders (MSDs) can affect the body's both acute and chronic WRMDs. muscles, joints, tendons, ligaments and nerves. Most work-related MSDs develop over time and are caused Other studies into the occupational health issues either by the work itself or by the employees' working affecting physiotherapists in India and abroad have environment. identified a number of key areas of concern. For instance, Cromie et al5 from a survey physiotherapist in Salisk and Ozkan defined WRMDs among the state of Victoria, Australia, found that work-related physiotherapists as musculoskeletal injuries that result pain or discomfort had been experienced by 91% of from a work-related event1 and several studies have respondents, while Bork et al2 identified an incidence documented that work-related musculoskeletal of 61% of work-related musculoskeletal disorders disorders (WRMDs) are frequently experienced by among physical therapy graduates from the University physiotherapists.2,3 of Iowa, USA. Physical therapy can lead to work related This study was designed with the objectives to know musculoskeletal disorders (WRMDs) in Physiotherapist the prevalence, to identify various risk factors and because of nature of their profession. The three most coping up strategies adapted to minimize the effects important risk factors that have been associated with and risks of developing WRMDs. WRMDs are repetitive tasks, uncomfortable postures and high force levels. Physiotherapists also routinely perform activities such as transferring dependent

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NATIONAL JOURNAL OF MEDICAL RESEARCH

METHODS Table 3 shows that private (35%) and outpatient clinic (20%) and home visits (20%) were the most common A self administered semi structure questionnaire was work setting in which WRMDs first occurred. Others sent via e-mail to 34 physiotherapists of Saurashtra were working in rehabilitation center and in academic. region. Initial few email addresses were obtained from the personnel email contacts of authors and the participants were asked to recommend other Table 3: Work Setting at the Time of the Initial physiotherapist of Saurashtra region. The questionnaire Onset of WRMDs (N=20) consisted of demographic information including age and clinical experience; self reports of work related Work Setting (N = 21) Percentage musculoskeletal injuries, perceived job related risk Academic 10.0 factors and strategies or responses that are adopted for Outpatient Clinic 20.0 prevention were obtained. Questionnaire was Private Clinic 35.0 accompanied by a cover letter stating the purpose of Rehabilitation Center 15.0 the study and assuring the confidentiality. The subjects Home Visits 20.0 were allowed two weeks to complete and return the questionnaire via e mail. The data obtained were Physiotherapists were asked about the risk factors that analyzed using the Microsoft Excel 2007. they believe for their WRMDs. The two most common responses were management of large number of RESULTS patients in a day and lifting with sudden maximal effort. Other risk factors that identified for their WRMDs The questionnaire was returned by 29 physiotherapists, were working in same position for long, adoption of giving a response rate of 85%. Most of the uncomfortable posture, not having enough rest, physiotherapists are in the age group of 26-30 years. prolonged sitting, carrying heavy equipments and continuing to work while injured [Table 4] Table 1: Distribution of Physical Therapists by Age and Work Setting (N=29) Table 4: Mechanism of Injury at the Time of the Characteristic Percentage Initial Onset of WRMDs (Multiple Responses=60) Age (years) 21-25 27.5 Mechanism of Injury (N) Percentage 26-30 41.5 Management of large number of 26.7 31-35 20.7 patients in a day (16) 36-40 10.3 Lifting with sudden maximal effort (12) 20.0 Work Setting Adoption of uncomfortable posture 18.4 Academic 20.7 (bending or twisting) (11) Outpatients 17.2 Working in same position for long (07) 11.7 Private Clinic 34.5 Not having enough rest/break during 8.3 Rehabilitation 10.3 the day (05) Home Visits 17.2 Prolonged sitting (04) 6.7 Patient falling or sudden unanticipated 3.3 Of 29 subjects, 20 were affected by WRMDs in at least movement (02) one body part in last one year giving incidence of Carrying, lifting or moving heavy 3.3 WRMDs 69%. 40% of those injured had experienced materials or equipments (02) injury to more than one body area in last one year. The Continuing to work while injured (01) 1.7 low back (35%) was the most common site of injury. The neck (25%) was the second most prevalence site of Table 5: Coping Strategies Used by injury followed by the shoulders (15%), upper back Physiotherapists Consequently to WRMDs (15%), wrist or hand (5%) and elbow or forearm (5%) (Multiple Responses=54) [Table 2] Coping Strategies (N) Percentage Decreased patient contact hours (12) 22.2 Table 2: Incidence by body parts among Consulted a doctor (11) 20.3 Physiotherapists (N=20) Exercise or posture program (9) 16.7 Body areas (N) Percentage Sought physiotherapy treatment (7) 13.0 Low Back (7) 35.0 Modify patient’s position/my position(5) 9.3 Neck (5) 25.0 Taking rest in between treating pts (4) 7.4 Shoulders (3) 15.0 Taking help from assistant / relatives (4) 7.4 Upper Back (3) 15.0 Changed work setting (2) 3.7 Wrists/Hands (1) 5.0 Elbow/Forearm (1) 5.0 Coping Strategies: The coping strategies adopted by physiotherapists with WRMDs are shown in Table 5.

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The two most commonly adopted coping strategies on incidence and risk factors for WRMDs among were decreased patient contact hours (22.2%) and Physiotherapists of Saurashtra region. Consultation with doctor (20.3%). Taking help from assistant or relatives and changing work setting were the two least adopted coping strategies. CONCLUSION WRMD is an important health risk within the physiotherapy profession. This study provides data on DISCUSSION the incidence of WRMDs in physiotherapy profession The aim of this study was to know the incidence and in Saurashtra region. Incidence of WRMDs is very high risk factors for WRMDs among physiotherapist in (69%). Private and outpatient clinic and home visits Saurashtra region. The percentage response for this were the most common work setting in which WRMDs study was 85%. Incidence (last 12 month) of WRMDs first occurred. The incidence of WRMDs among was found to be 69%. This prevalence higher than physiotherapists was highest in low back, neck, incidence of 58% reported by Glover et al7, 40% by shoulders and upper back. Risk factors and the coping West and Gardner8, 61% by Bork et al2 and 62.5% by strategies of WRMDs among physiotherapists of Cromie et al5. The higher prevalence found in our study Saurashtra region are identified. The most common suggests that physiotherapy practice highly predisposes risk factors were management of large number of to WRMDs. This may be a reflection of the conditions patients in a day and lifting with sudden maximal effort. under which physiotherapists practice in India. Further research is required to build up effective preventive or ergonomic strategies that may be applied In this study, the low back pain was reported as the to the clinic to decrease the incidence of WRMDs. most common site of WRMDs. Various studies done internationally, the prevalence of work related low back pain ranged between 22% and 74%.6,7 Our finding is REFERENCES consistent with those of previous studies that have overwhelmingly implicated low back as the body part 1. Salik Y, Ozcan A. Work related musculoskeletal disorders, a most commonly affected by WRMDs among survey of physical therapists in Izmir – Turkey. BMC physiotherapists. Musculoskeletal Disorders 2004; 5:27. 2. Bork BE, Cook TM, Rosecrance JC, Engelhardt KA, The work factors commonly identified by Thomason MEJ, Wauford IJ, Worly RK. Work related physiotherapists in this study as contributing to the musculoskeletal disorders among physical therapists. Phys Ther occurrence of their WRMDs in decreasing order of 1996; 76:827-835. importance were: treating large number of patients, 3. Moulmphy M, Unger B, Jensen GM, Lopopolo RB. Incidence working in same position for long, adoption of of work related low back pain in physical therapists. Phys Ther uncomfortable posture, not having enough rest. 1985; 65:482-486 Previous studies have similarly identified risk factors 4. Holder N, Clark H, DiBlasio JM, Hughes CL, Scherpf JW, for WRMDs.7,8,10 Harding L, Shepard KF. Causes, prevalence and response to occupational musculoskeletal injuries reported by physical The most commonly adopted coping strategies among therapists and physical therapy assistants. Phys Ther 1999; physiotherapists in our study were therapists m 79:642-652 decreased patient contact hours, consulted a doctor, 5. Cromie JE, Robertson VJ, Best MO. Work – related started exercise or adopted posture program, modifying musculoskeletal disorders in physical therapists: prevalence, patient’s position and sought physiotherapy treatment. severity, risks and responses. Phys Ther 2000; 80:336-351. This finding is similar to that of Glover et al.7 6. Mierzejewski M, Kumar S. Prevalence of low back pain among physical therapists in Edmonton, Canada. Diabil Rehabil 1997; 19(8):309-317. LIMITATIONS 7. Glover W, McGregor A, Sullivan C, Hague J. Work – related musculoskeletal disorders affecting members of the Chartered This study is limited by the sampling technique Society of Physiotherapy. Physiotherapy 2005; 91:138-147. employed, as the non probability sampling employed in 8. West DJ, Gardner D. Occupational injuries of physiotherapists our study may prevent generalization of our results. in North and Central Queensland. Aust J Physiotherapy 2001; Like all other cross sectional studies involving recall, 47:179-183. our respondents might have given vague answers to 9. Shehab D, Al-jarallah K, Moussa MAA, Adham N. Prevalence questions asked in this study as they might not have of low back pain among physical therapists in Kuwait. Med remembered the information requested of them easily. Principles Pract 2003; 12:224-230. In an attempt to curtail the influence of this in our 10. Scholey M, Hair M. The problem of back pain in study, we restricted our survey to last 12 month recall. physiotherapists. Physiotherapy Pract 1989; 32:179-190. Despite these limitations, our study has provided data

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

YOGA TRAINING WITH MEDITATION AMELIORATES THE ASTHMATIC ATTACK BY IMPROVING PULMONARY FUNCTIONS: A PILOT STUDY

B Biju1, Geetha N2, Sobhakumari.T2

1Department of Physiology, Amala Institute of Medical Sciences, Thrissur, Kerala 2Department of Physiology, Government Medical College, Thiruvananthapuram, Kerala

Corrspondence: Dr .Biju Bahuleyan Associate professor, Department of Physiology Amala Institute Of Medical Sciences, Amalanagar, Thrissur Kerala - pin 680555 E-mail: [email protected]

ABSTRACT

The concept that yoga is helpful for the treatment of bronchial asthma has created great interest in the medical research field. In order to investigate whether physiological parameters and pulmonary functions were improved in asthmatic patients after yoga training, the present study was conducted on seventy patients with bronchial asthma. The present study was conducted on seventy patients with asthma who were on beta 2 agonist inhalers and yoga therapy for three months. Parameters like pulse rate, respiratory rate, body weight, FVC, FEV1, FEV2, FEV1% and PEFR were compared with controls on beta 2 agonist inhalers alone. Yogic practices resulted in significant improvement in pulmonary functions; decrease in respiratory rate; decrease in pulse rate and body weight (not statistically significant); decrease in frequency of asthma attacks and decrease in frequency of use of inhalers. The disease status in controls deteriorated. Potential explanations for improvement in case group are effect on release of endorphins, balance of ANS and effect on airway smooth muscle dynamics.

Key words: yoga, asthma, pulmonary functions, beta2 agonists.

INTRODUCTION to specific diseases. Among the growing list is cancer, asthma, migraine, peptic ulcer, hay fever etc The term psychosomatic disease is reserved for the group of diseases in which psychological factors are Asthma is considered by many to be a prototype of primarily or predominantly involved in causing, psychosomatic illness. Around 0.5 to 2% of our aggravating or perpetuating the disease. They are also population suffers from asthma. Asthma is considered called psycho- physiological disorders in order to to have a multi-dimensional etiology which includes emphasize the fact that psychological factors produce allergic, infective, climatic, endocrine, and emotional physiological changes which in turn are responsible for factors.1 In most patients with asthma there is a strong the development of abnormal clinical features. The psychological aspect. Indeed many regard asthma as a concept of psychosomatic medicine has gained psychoneurosis and the allergy manifestation as popularity in this decade much more than at any other secondary to psychoneurosis. Psychological stress is time. The psychosomatic disorders commonly involve known to trigger asthma via the vagus nerve.2 A great the autonomic nervous system which controls the deal can be done symptomatically for most patients body’s internal organs. Modern medical and behavioral suffering from asthma. To relieve the bronchiolar studies are revealing that a physical break down under obstruction adrenaline, salbutamol, aminophylline, stress does not necessarily occur due to causes imposed steroid therapy etc can be given. Long term therapy from outside a person such as infections, with these drugs is successful but the patient comes to environmental agents, combined with exhaustion or depend on these drugs.3 Studies emphasize the physical trauma. It can also be due to life experiences, importance of a psychological theory in asthma.4 Hence thoughts, emotions and behavior and personality in the treatment of asthma various psychological structure. Evidence is gradually emerging about interventions have been implemented. Of these psychological factors and personality traits contributing

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NATIONAL JOURNAL OF MEDICAL RESEARCH interventions the role of yoga as a therapy is gaining Pulayanarkotta, Thiruvananthapuram, Kerala. Both the momemtum.5 case and control group were matched for age, sex, f/h of asthma and drugs (beta-2 agonist inhalation therapy). Yoga derived from the Sanskrit word ‘yuj’ means Physiological parameters like pulse rate (PR), union, is a spiritual practice that uses the body, breath respiratory rate (RR), body mass index (BMI) and and mind to energize and balance the whole person pulmonary functions such as FVC, FEV1, FEV2 and The importance of yoga related to medicine is mainly in PEFR were assessed on the first visit. Pulmonary getting a method of mental relaxation in view of the functions were assessed using Medspiror, an electronic tremendous increase in the stress and strain of life, PFT machine which is a dry type of spirometer. After especially in urban areas. Yoga helps to slow down an recording the pulmonary functions of both groups, the overactive mind while, at the same time toning up the patients in the case group were subjected to yoga body, removing toxins and relieving pains, backache therapy, which included breathing exercise or and injuries.6 Nagarathna and Nagendra (1993) pranayama, suryanamaskara, yogasanas (tadasana, conducted a study on the physiological changes in matsyasana, bhujangasana and dhanurasana) and sports teachers following three month of yoga training.7 dhyana. A trained yoga instructor in the holistic The study showed a significant increase in peak medicine department gave yoga training to the case expiratory flow rate (PEFR), Forced expiratory volume group daily one hour for 15 days. The patients were in first second (FEV ) and forced vital capacity (FVC) 1 then asked to do yoga practice, one hour daily at home and a significant decrease in heart rate, respiratory rate, and to keep a record of the practice done. These systolic and diastolic BP recording and body weight. patients were then assessed after three months using Kulkarni and Dater (1997) reported the effects of short Medspiror. term yoga training in both males and females could increase the PEFR.8 Relaxation therapy can Statistical analysis significantly contribute to the standard treatment of The data of both the groups were then statistically asthma in adult patients was reported by Rittz (2001).9 assessed using SPSS of windows version 10. Increase in PEFR in asthmatic patients by sahaja yoga Association among variables was assessed using training was demonstrated by Monacha (2002).10 Pearson Chi-Square test. P value of less than 0.05 was Recently, Sodhi et al. (2009) reported that yoga considered as significant. breathing exercise when used adjunctively with standard pharmacological treatment significantly improves pulmonary functions in patients with bronchial asthma.11 However, the effect of long term RESULTS yoga training along with meditation (dhyana) in patients Both the case group and the control groups were with bronchial asthma has not yet been established. assessed before the onset of study. The yoga Hence, the present study aimed to evaluate the effect of intervention was given only to the case group and yoga training with meditation in patients with bronchial comparison of results before and after yoga was done. asthma. Similarly the control group was also assessed before and after three month. After the period of three months, both the control group and the case group MATERIALS AND METHODS were compared once again. Majority of patients in the control and case groups were belonged to age 40-59 Seventy patients were included in the study with thirty yrs. The difference in the mean age of both groups was five patients in case group and thirty five in control found to be statistically insignificant ( p > 0.05). group. Institutional ethical committee approved this study and written consent was obtained from each patient included in the study. The study was conducted in Dept of Physiology and Dept of Holistic medicine, Table 1: Comparison of PR, RR and BMI between Government Medical College, Thiruvananthapuram, control and case group at the onset and after 3 Kerala. Thirty five non smoking asthmatic patients, 20 months of yoga training male and 15 female patients of 20 to 60 years age Group Onset of study After 3 months group, who were on beta 2 agonist inhalation therapy Pulse rate Control 83.78 ± 9.51 84.51 ± 9.34 reporting voluntarily to holistic medicine out patients (PR) Case 79.89 ± 9.60 ns 77.65 ± 6.88 a department for practicing yoga were included in the Respiratory Control 21.88 ± 3.67 22.97 ± 3.51 study. Patients with h/o respiratory tract infections, any rate (RR) Case 16.40 ± 3.97 a 14.69 ± 2.96 a lung disease other than asthma leading to dyspnea, Body mass Control 24.13 ± 2.65 24.35 ± 2.42 cardiac or any other illness (detected history wise or on index (BMI) Case 24.54 ± 2.96 ns 23.94 ± 2.81 ns clinical examination), current smokers, alcoholics, Values are mean ± SD pregnant and lactating women were excluded from the a p < 0.01 significantly different from control group; ns study. p >0.05 non-significantly different from control group. The control group patients, 20 male and 15 female patients of 20 to 60 years age group, were taken from the Respiratory medicine out patients Department,

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There was no statistically significant difference in the coughing and a sense of suffocation resulting in pulse rate between the two groups before the onset of difficulty in breathing. Causal factors for asthma tend study (table 1). Mean value of pulse rate after yogic to overlap variably from one person to another. On a exercises has decreased to 77.65 compared to its psychological level suppression of negative emotions previous value of 79.89 in the case group. But this such as anger, jealousy, resentment and hatred are often difference was not statistically significant. Highly precipitating causes as are loneliness, longing for significant difference in the pulse rate was noted affection, emotional hypersensitivity, fear of rejection between the case group and control group after 3 etc. In the management of asthma through yoga these months of the study. The case group has a mean pulse psychic factors are brought before the conscious mind. rate of 77.65 and the control group has 84.51. Increase in anxiety can lead to hyperventilation this can thus precipitate or aggravate asthma. Often the result is In the respiratory rate, highly significant difference was still more anxiety and in a vicious cycle, more noted after yoga practice. After three months, the hyperventilation this is further aggravated by inefficient respiratory rate in the case group had a mean value of mechanisms of breathing in asthma whereby increasing 14.69 while that in the control group was 22.97 and this efforts leads to increased collapse of airways.12 difference was found to be statistically significant. While modern medicine aims at immediate relief, yoga

aims at removal of the basic cause. Thus in yoga the Table 2: Comparison of pulmonary function of the attack on any diseased condition is holistic, since it is case group and the control group at the onset and recognized that the mind is central in any diseased after 3 months of study condition, the control and quietening of the mental state would heal the disease to a great extend.13 Yoga Groups Onset After 3 months therapy tries to establish the inner balance by various FVC Control 2.41 ± 0.49 2.22 ± 0.48 means, working from the gross to the subtle. Yoga has b ns Case 2.09 ± 0.55 2.32 ± 0.56 claimed that tension is disease and relaxation is health. FEV1 Control 1.56 ± 0.37 1.38 ± 0.39 All branches of yoga incorporate three major a b Case 1.23 ± 0.34 1.57 ± 0.36 techniques: breathing, exercise and meditation. Some FEV2 Control 1.88 ± 0.35 1.78 ± 0.46 say it work like other mind body therapies and relieves b ns Case 1.66 ± 0.48 1.90 ± 0.47 stress; others believe that yoga promotes the release of FEV% Control 64.37 ± 9.30 61.48 ± 10.74 endorphins in the brain.14 Case 60.06 ± 10.58 ns 68.96 ± 13.97 b PEFR Control 5.70 ± 1.12 4.80 ± 0.84 The physiological parameters taken into consideration Case 3.58 ± 1.4a 4.28 ± 1.28 b in the present study were pulse rate, respiratory rate Values are mean ± SD and body mass index. There was no significant a p< 0.01 and b p < 0.05 significantly different from difference in pulse rate between the case and control control group. NS p > 0.05 non significantly different group at the onset of study. But at the end of three from control group. months, it was seen that highly significant difference in pulse rate was present with a higher pulse rate noted in the control group. Available literature on yogic studies There was no significant difference in BMI between the revealed that the effect on pulse rate varied according control group and the case group at the onset of study. to the type of yoga. In Siddhasana and Virasana, heart The mean BMI of the case group before yoga was rate increases due to increased metabolism.15, 16 While 24.54 and after yoga intervention the mean BMI has after a few months of Hatha Yoga training there was decreased to 23.95. This difference was analyzed improvement in cardiovascular function as shown by statistically and was found to be insignificant. an increase in physical capacity and decrease in heart rate.17 In another study by Ramarao (1990), no change Comparison of pulmonary function of the case group in pulse rate was noted after yoga practice.18 and the control group at the onset and after 3 months of study is depicted in table 2. All the pulmonary In the present study, both the case and control group functions were improved in the yoga trained group. were on beta 2 agonist and their pulse rates had a mean Except for FEV% all the parameters showed value of 79.8 and 83.7. After the intervention of yogic statistically significant difference between the case and practices the pulse rate in the case group decreased control group at the onset of study. After 3 months, from a mean of 79.8 to 77.6. This may be due to yogic FVC and FEV2 showed no significant difference practices like shavasana which caused decrease in between the two groups while FEV1, FEV% and metabolic rate.19 Yogic asanas are similar to physical PEFR showed significant difference between the two training which increase the effectiveness with which the groups. circulation adapts to exercise. Therefore, for a given expenditure of energy the stroke volume of the heart is greater and heart rate is decreased hence decrease in 20 DISCUSSION pulse rate. Asthma is a distressing disorder of the bronchial tubes In the present study, it was also noted that there was a characterized by recurrent attacks of wheezing, significant decrease in respiratory rate in asthmatic

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NATIONAL JOURNAL OF MEDICAL RESEARCH patients after yoga therapy. By performing yogic medications for a prolonged period with no relief and breathing, the subject while keeping his other skeletal their drug usage was increasing day by day. Further, it muscles relaxed and immobile, exercises a close, was noted that those patients had better education and continuous, voluntary control over his respiratory socio-economic status and hence willing to try out an muscles. The subject may change his ordinary rate of alternative measure in addition to medicines. The 15-18 to 1-2 resp/minute and reduce his ventilation number of attacks of asthma and drug intake was volume a great deal.21 The respiratory centres as a decreased in the case group. The control group, taken group are also under voluntary control and we are able from respiratory medicine outpatient department had to stop our respiration at least for little time at any no significant improvement in pulmonary functions phase of the respiratory cycle. The respiratory centres after three months, further they had to increase drug are continuously in receipt of many type of afferent dosage and number of attacks of asthma reported impulses which cause a cyclical waxing and waning of during this period was more compared to the case its sensitivity. Not only the impulses initiated by pCO2 group. It is important to note that the role of yoga was and pO2 but also the impulses from the stretch assessed as an adjuvant treatment. All subjects had receptors of the lungs and the higher centres, decide been taking beta-2 agonist inhalation and continued the sensitivity of the centre. During the apnoea time, their treatment through out the intervention and follow these impulses increases the sensitivity of the centre to up period. Hence the benefits of yoga are in addition to such a level that finally the voluntary control breaks the benefits of drugs. In specific depressive conditions down. A short period of conscious control of the rate the HPA axis is hypo reactive.27 This causes hypo and depth of breathing as a health-promoting exercise function of the hypothalamic corticotrophin releasing has claimed wide human interest.22 Usually breathing is hormones neurons, which, in failing to modulate the not a conscious event and is regulated automatically by immune inflammatory process, could give rise to bulbopontine respiratory control mechanisms, which increased inflammatory manifestations. The mechanism are further modified by suprapontine mechanisms. In by which yoga acts is by reducing psychological over the conscious being the pneumotaxic centre is activity and emotional instability. Slow breathing which supposed to relay suprapontine messages which is done in yoga, had a broncho-protective and promote voluntary inspiration and expiration.23 During broncho-relaxing effect and a positive endogenous daily practice of pranayamic breathing the basic activity corticosteroid release. Udupa et al. (1972) observed an of bulbopontine complex is modified in such a way as increased adreno cortical activity in practitioners of to slow down its rhythm by voluntarily prolonging the yoga.25 The accelerated adreno cortical functions may phase of inspiration and expiration by stretching to produce varying degrees of stress competence. This their fullest extent, thus making respiratory apparatus increase in corticosteroid level may be a probable cause to work to maximal extent.24 Thus we may hypothesize of decrease in asthmatic attacks in the case group after that by voluntarily practicing pranayamic breathing for the practice of yoga. few weeks the bulbopontine complex is adjusted to Respiration is directly linked with the autonomic new pattern of breathing which is slower than its basal nervous system, which controls physiological arousal. rhythm. Autonomic tone is mediated through cAMP and cGMP Of the 70 patients included in the present study, 24 interactions. Balance between cAMP and cGMP patients had BMI more than 25 in the control and case controls the assembly of proteins into microtubules group. After yoga therapy in the case group no which is necessary to produce contraction of smooth statistically significant difference was noted. But in the muscles.28 The levels of cAMP and cGMP are affected control group fourteen patients had BMI more than 25. by the sympathetic and the vagal nerves. The The remarkable body weight changes as seen with the sympathetic through the beta adrenergic receptors practice of yogic Asanas reported by Udupa et al.25 increase cAMP causing muscle relaxation and through (1972) have not been observed in the present study. A alpha receptors increase in cGMP and causes similar study conducted on the patients doing Shanthi contraction. In asthmatics alpha receptors are increased Kriya has shown significant decrease in body weight and beta receptors are decreased. The sympathetic over probably due to the vegetarian diet.26 In the present activity in stress may be acting through the alpha study, both the control group and case group were receptors causing broncho-constriction and increase in advised to follow strict diet but we do not have airway resistance.29 Relaxation will reduce the blood quantitative data on adherence of the patients to the levels of adrenaline and noradrenaline and increase the diet pattern between the actual sessions or during the level of opoid neuropeptides which modulate the post intervention follow up period. bronchial smooth muscle tone. Animal studies have reported that beta endorphins could influence Before of the onset of study both the case group and bronchial smooth muscle tone.30 Receptors for these control group were compared and statistically neuropeptides are present in some neurons in the significant difference was noted with the asthma more respiratory centres of the brain. Enkephalins also have severe in the case group (table 2). This difference may a role in boosting up the immune system.31 be due to the fact that the case group was taken from Holistic medicine out patients department, where the In the present study, the case group reported an patients reported voluntarily. Those patients were on improvement in symptoms and this can be due to

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NATIONAL JOURNAL OF MEDICAL RESEARCH release of enkephalin during meditation. Yogic process The valuable help of Dr. Ajith TA and Dr. Unmesh has a tremendous influence on the CNS. It helps an AK during the study is gratefully acknowledged. individual to gain control over the ANS, resulting in homeostatic functioning of the body. How ever, there is no definite model of sympathetic activity or REFERENCES relaxation during practice of meditation and there can 1. Sir John Crofton, Andrew Douglas. Blackwell scientific be individual variations. Sirsasana is associated with publications. Oxford London. Respiratory disease. increased sympathetic activity while savasana brings 1980;3:28;456. 32, 33 about a reduction in the sympathetic response. 2. Sathya Prabha.T.N, Murthy.H. Efficiency of naturopathy and Several workers have found an increase in alpha yoga in bronchial asthma – a self controlled matched scientific synchrony in EEG taken during transcendental study. Indian journal of physiology and pharmacology. 2001; meditation, which points to its stabilizing effect on the 45(1); 80-86. nervous system.34 Yoga clearly relaxes the muscles, and 3. Bruce.D.Miller, Where psyche meets soma in bronchial asthma. this deep physical and mental relaxation associated with Psychiatric times, 2002 jan; vol XIX-issue 1. the physiological changes seen in patients after daily 4. Miller.A.L The etiologies, pathophysiology and alternative / yoga seems to have a stabilizing effect on bronchial complementary treatment of asthma. Altern.med.rev. 2001;6(1): reactivity, thus making the vagal efferents less excitable. 20-47. The reduction in psychological hyper reactivity and 5. Aarti Sood Mahajan, R.Babbar. Yoga : a scientific life style, The journal of yoga. October 2003; 2: 10. emotional instability achieved by yoga can reduce efferent vagal reactivity, which has been recognized as 6. Anand.M.P, Non pharmacological management of essential hypertension. Journal of Indian medical association. 1999;97(6): the mediator of the psychosomatic factor in asthma 220-225. leading to bronchodilation. In the present study the highly significant improvement in FEV and PEFR in 7. Nagarathna.H, Nagendra.H.R, Physiological changes in sports teachers following three months of trainng in yoga. Indian the case group was also attributed to the effect of yoga journal medical sciences. 1993; 47(10): 235-238. on vagal efferent activity. Pranayama helps to improve the function of respiration by giving exercise to 8. Kulkarni.V.A, Dater.S.V. Effect of yogasanas and pranayama on PEFR. Indian journal of physiology and pharmacology. muscles of respiration and by its influence on the 1997; 17: 273-276 respiratory centres. Pranayama increases blood 9. Ritz.t Relaxation therapy in asthma. Bahavioural modification. circulation also. As lung tissue becomes more elastic 2001 sept; 25(4)640-66 and the surrounding muscle more flexible, the practice of pranayama can also increase lung capacity. The yogic 10. Manocha.R, Marks.G.B, Kanchington.P, Sahaja yoga in the management of moderate severe asthma-a randomnized practices like kapalabhati and bhastrika are very useful control trial. Thorax 2002, feb; 57(2); 110-5 in strengtening respiratory muscles, esp the diaphragm. These would be valuable in delaying exhaustion in 11. Candy Sodhi, Sheena Singh and P.K Dandona. A study of the effect of yoga training on pulmonary functions in patients with asthma attacks or respiratory insufficiency. Yogic bronchial asthma, Indian journal of physiology and asanas are isometric exercises that involve a pharmacology. 2009; 53 (2): 169-174. coordinated action of synergic and antagonist muscles 12. Lehrer.P, Fieldman.J, Giarchino.N, Sony.A.S. Psychological in bringing about steadiness and flexibility. Another aspects of asthma. Clinical Psychology 2002 jun; 70(3): 690- possible mechanism by which yogic techniques bring 711. relief in asthma in the present study may be by 13. Weller, Stella. Yoga therapy.1995; 91-94, 97-99. decreasing the metabolic rate. It is proved that certain asanas especially shavasana can decrease the metabolic 14. Kowalski.J, Effect of enkephalins and endorphins on cytotoxic activity of natural killer cells and macrophages in mice. rate and hence decrease the oxygen consumption. The European journal of pharmacology. 1997; 326(2); 251-255. decrease in metabolic rate can be by decreasing the 15. Rai.L, Ram.K. Energy expenditure and ventilator response catecholamine secretion and depressing the during virasana – a yogic standing posture. Indian journal of 35 sympathetic function. physiology and pharmacology. 1993; 37(1): 45-50 The result of this study concluded that due to physio- 16. Rai.L, Kant.U, Madan.S.L, Energy expenditure and ventilator psycho spiritual nature of yoga it can be usefully response during sidhasana – a yogic seated posture. Indian applied in the management of asthma. The conclusion journal of physiology and pharmacology. 1994; 38(1): 29-33. of this study is generalisable to subjects with 17. Raju.P.S, Madhavi.S, Prasad.K.V, Comparision of effects of symptomatic asthma who express interest in the non yoga and physical exercise in athletes. Indian journal of medical pharmacological therapies but may not be applicable to research. 1994; 100: 81-87. patients who are antipathetic to this form of treatment. 18. Ramarao.R, Shanthi kriya. Journal-peace 1990; 62; 17-22. Yoga is not the sole treatment for a disease, but where 19. Madan Mohan, Udupa.K.Ananda balayogi. Modulation of cold the disease has already crept in; yoga techniques are pressor induced stress by shavasana in normal adult volunteers. powerful allies in the control of disease along with Indian journal of physiology and pharmacology, 2002; 46(3); modern medicine. 307-312. 20. Astrand P.O, Rhyming.I.A. A normogram for calculation of aerobic capacity from PR during submaximal work. Journal of applied physiology. 1954; 7: 218-221. ACKNOWLEDGEMENT

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21. Bhavani Balasubramanium, M.S.Ransare. Effect of yoga on 29. Singh.V, Wisniewski.A, Britton.J, Tattersfield.A. Effect of aerobic and anerobic power of muscles. Indian journal of pranayama on airway reactivity in subjects with bronchial physiology and pharmacology. 1991; 35(4): 281-282. asthma. Lancet. 1990; 9; 335(8702): 1381-3. 22. Cooper.S.J, Oborne, S.Newton, S.Lewis. Effect of two 30. Hildebran.J.N, Georke.J, Clements.J.A. Surfactant released in breathing exercise – buteyko and pranayama in asthma – a exercised rats lung stimulated by air inflation. Journal of applied randomized control trial. Thorax-2003; 58: 674-679. physiology. 1981; 51: 905-910. 23. Cyril.A, Kerle, Eric Neil, Nnorman Joels. Samson wrights 31. Khanam A.A, Sachdeva.V, Gulenia.R, Deepak.K.K, Study of applied physiology. 1982; 13: 167-169. pulmonary and autonomic functions of asthmatic patients after yoga training. Indian journal of physiology and pharmacology. 24. Jankowska.R.Beta Endorphin concentrations in the sera of 1996; 40(4): 318-24. asthmatic patients. Journal of investigational allergology and clinical immunology. 1996; 6(6): 356-358. 32. Maclean C.R, Effects of trancendental meditation program on adaptive mechanisms: Changes in hormone levels and response 25. K.N. Udupa, Singh. The scientific basis of yoga. JAMA, 1972; to stress after four months of practice. 10: 210. Psychoneuroendocrinology. 1997; 22(4): 227-235. 26. Satyanarayana.M, K.R.Rajeswari. N.Jhansi Rani, Effect of 33. Madan Mohan, Udupa.K, Ananda Balayogi. Modulation of cold santhi kriya on certain psychophysiological parameters: a pressor induced stress by shavasana in normal adult volunteers. preliminary study. Indian of physiology and pharmacology Indian journal of physiology and pharmacology. 2002; 46(3): 1992; 36(2): 88- 92. 307-312. 27. Telles.S, Desiraju T. Autonomic changes in Brahmakumaris raja 34. Murthy K.J, Sahay.B.K, Raju.S. Effect of pranayama on asthma. yoga meditation. Int. journal of psychophysiology. 1993; 15: Lung India. 1984; 2: 187-91. 147-152. 35. Yadav R.K, Das.S. Effect of yogic practices on pulmonary 28. K.V.Krishna Das. Textbook of Medicine. 1998; 3: 941. function of young females. Indian journal of physiology and pharmacology. 2001; 45(4): 493-6.

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VITAMIN A DEFICIENCY AMONG SCHOOL CHILDREN OF BAREILLY: CRUCIAL ROLE OF NUTRITION EDUCATION

Khan Swati1, Mahmood Syed Esam2

1Associate Professor, 2Assistant Professor, Department of Community Medicine, Rohilkhand Medical College & Hospital Bareilly (UP)

Correspondence: Dr. Syed Esam Mahmood Department of Community medicine, Rohilkhand Medical College and Hospital Bareilly-243006 (U.P.) Email: [email protected]

ABSTRACT

Objectives: To find out the prevalence of VAD among urban school children of District Bareilly, to identify the associated biosocial factors and to suggest the suitable measures to prevent xerophthalmia among them. Methods: Six month cross sectional study was conducted among school going children in 2 purposively selected schools in an urban area of Bareilly District. A structured proforma was used to collect the information. Chi- square test was used to analyze data. Results: Of the 800 children examined, the overall prevalence of VAD was found to be 6.37%. The prevalence of VAD was highest in 11-12 years of age group children and lowest in the 3-5 years age group (P-value >.05). The prevalence of VAD was slightly higher among boys as compared to girls (P-value >.05). The prevalence of VAD was significantly higher among the children belonging to lower socioeconomic class as compared to those belonging to upper and middle socioeconomic class (P-value >.05). Nearly 48.5% of children were found to be underweight while 12.25% were overweight. Nearly a quarter of children were found to be anemic. Conclusion: Nutrition education regarding regular intake of plant foods rich in carotene such as green leafy vegetables, yellow fruits, carrots and animal foods containing retinol like fish liver oil, fish, liver, egg, meat, milk, butter, cheese, and use of fortified food like vanaspati, margarine, dried skimmed milk should be strengthened.

Key words: Vitamin A deficiency, urban slum, school children

INTRODUCTION feeding habits among the entire population but young children in particular 5. Vitamin A deficiency disorders (VADD) exists as a public health nutrition problem among preschool-aged Lack of basic amenities like safe drinking water, proper children in 118 developing countries worldwide, with housing, drainage and excreta disposal make the urban the South-East Asian Region harboring the maximum slum population more vulnerable to infection which number of cases 1. VADD early in life include all active further compromise the nutrition of those living in the clinical stages of xerophthalmia including corneal slums 6. VADD can occur at any age however very few xerophthalmia and its potentially blinding sequelae, studies on VAD have also included school children impaired mechanisms of host resistance, increased apart from preschool children. With this background severity of infection, anemia, poor growth and the study was undertaken amongst school going mortality 2. VADD has long been identified as a serious children aged between 3-12 years in an urban area of and preventable nutritional disease. It also contributes Bareilly district to find out the prevalence of VAD, to significantly, even at sub-clinical levels, to morbidity identify the associated biosocial factors and to suggest and mortality from common childhood infection. the suitable measures to prevent xerophthalmia among Studies suggest that ill health and risk of death from them. some infection are also increased even in children who are not clinically deficient but, whose vitamin A body store is depleted 3-4. Though one of the main causes of MATERIAL & METHODS xerophthalmia is poor intake of vitamin A rich foods, it is also associated with poverty, ignorance, faulty A six month cross sectional study was conducted among school going children in an urban area of

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Bareilly District. Ethical committee approval was taken Table 1 - Prevalence of VAD in various age groups before the start of the study. Two schools were selected of the children purposively and informed consent from the school principal and teachers was obtained. A total of 350 Age (yrs) No. of children examined VAD (%) children aged between 3-12 years studying in the 3 & <5 156 7 (4.48) selected schools were surveyed. A structured proforma >5 & <7 133 9 (6.76) was used to collect sociodemographic information and >7 & <9 163 11(6.70) anthropometric and ocular examination by the authors >9 & <11 169 11(6.50) themselves. >11 & <12 179 13(7.26) Total 800 51 (6.37) Socio-economic status of the subject was calculated as Chi-Square(df) 1.25(4), P-value = 0.871 per the modified kuppuswamy socio-economic scale. Education, occupation and income of both the father The prevalence of VAD was slightly higher among and mother were taken in order to calculate the socio boys (7.02%) as compared to girls (5.68%), the economic status of the child. difference being statistically insignificant (P-value Weight of the children was taken with the help of >.05). (Table 2) weighing scale. Weight was measured to the nearest 0.1 Kg and Salter weighing machine (Model no. 235651) Table 2: Prevalence of VAD according to the sex of was used for weight measurement. the child Height was measured against a non stretchable tape Sex No. of children examined VAD (%) fixed to a vertical wall, with the participant standing on Boys 413 29(7.02) a firm/level surface and it was measured to the nearest Girls 387 22 (5.68) 0.5 cm. The children were dressed in light Total 800 51(6.37) underclothing and without any shoes during the Chi-Square(df) 0.0598(1), P-value = 0.4392 measurement. Each measurement was done twice, and the mean of the two readings was recorded. If any pair A higher proportion (48.5%) of children was found to of readings exceeded the maximum allowable be underweight while 12.25% were overweight. Nearly difference for a given variable (e.g. weight, 100 g; a quarter of children were found to be anemic (Table 4) length/height, 7 mm), the measurements were repeated. The same measuring equipments were used throughout the study. Table 3 – Prevalence of VAD in children according to the socio economic status (as per Modified Ocular examination was conducted by an Kuppuswamy socioeconomic scale) ophthalmologist by a bright illuminant torch in natural light as per WHO guidelines. Vitamin A deficiency was Socioeconomic No. of children VAD (%) diagnosed by the presence of bitot’s spot and status examined conjunctival xerosis 7. Anaemia was diagnosed from by Upper 29 0(0.0) pallor of the conjunctiva. Upper middle 72 1 (1.3) Lower middle 339 12 (3.5) Data entry and statistical analysis were performed using Upper lower 253 25 (9.8) the SPSS windows version 14.0 software. Test of Lower 107 13 (12.14) significance (Pearson’s Chi- square test) was applied to Total 800 51 (6.37%) find out the association. p values <0.05 were Chi-Square(df) 17.06(4), P-value*= 0.001 considered significant. *Applying Yates correction

RESULTS Table 4 – Distribution of Children according to the Body Mass Index and Anaemia Of the 800 children examined, 51 (6.37%) had clinical signs of xerophthalmia. The overall prevalence of VAD Body mass index No. (N=800) Percentage was found to be 6.37%. Most of them exhibited Low (<18.5) 388 48.50 conjunctival xerosis and one had bitot’s spot. None had Normal (18.5-25) 314 39.25 any corneal xerosis, corneal scar and Keratomalacia. Overweight (>25) 98 12.25 Anaemia No. (%) The prevalence of VAD was highest in 11-12 years of Present 195 24.37 age group children and lowest in the 3-5 years age Absent 605 75.63 group, the difference being statistically insignificant (P- value >.05) (Table 1). DISCUSSION The prevalence of VAD was significantly higher among The overall prevalence of VAD was found to be 6.37% the children belonging to lower socioeconomic class as compared to those belonging to upper and middle in our study which is higher than that (2.9%) reported by Chauhan et al (2011) 6. Higher prevalence (9.1%) socioeconomic class. (P-value <.05). (Table 3) was reported among school Children in Aligarh by

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Sachdeva et al 8. Surveys conducted in various countries REFERENCES of South-eastern Asia have shown VAD ranging from 1. West Jr KP (2002): Extent of vitamin A deficiency among pre- 8 0.2 % to 15 % in school aged children . A rising trend school children and women of reproductive age. J. Nutr. 132, in the prevalence of xerophthalmia was observed with 2857S– 2866S. the increase in age. Similar trends have been reported 2. Sommer A &West Jr KP (1996): Vitamin A Deficiency: Health, by Sachdeva et al 8. A prevalence of 34% was reported Survival and Vision. New York: Oxford University Press. among school attending adolescents in Nigeria 10. This 3. WHO. Indicators for assessing vitamin A deficiency and their could be attributed to the low intake of Vitamin A rich application in monitoring and evaluating intervention foods such as dark green leafy vegetables/yellowish programmes. WHO/ NUT/96.10 Geneva. WHO.1996. fruits in the higher age groups. Green leafy vegetables 4. WHO. Vitamin Deficiency and Xerophthalmia. Report of a are also good sources of carotene, folic acid, vitamin C, joint WHO/ USAID Meeting Geneva. WHO.1974 Technical iron and calcium contributing to overall improvement Report Series:590. in nutritional status of children. Children aged upto 5 5. WHO. Global prevalence of vitamin A deficiency in population years are given Vitamin A supplementation in our at risk 1995-2005 [Internet]. 2009 [cited 2011 June 6], available country so VAD is less common in the initial 3-4 years from: http:// of life. The prevalence of VAD was slightly higher www.who.int/vmnis/vitamina/prevalence/report/en/ among boys as compared to girls but the difference was 6. Chauhan NT, Trivedi AV, Khan IM, Talsania NJ. Prevalence not statistically significant. Similar trends have been of clinical vitamin A deficiency among primary school children reported by Chauhan et al and Bhattacharya et al 6, 11. in urban slums of Ahmedabad: a cross sectional study. Journal of Clinical and Diagnostic research 2011; 5(8): 1627-1630 The prevalence of VAD was higher among the children 7. WHO. Control of Vitamin A Deficiency and Xerophthalmia, belonging to lower socioeconomic class as compared to Report of a Joint WHO/UNICEF/USAID/Helen Keller those belonging to upper and middle socioeconomic International/IVACG Metting, Geneva. WHO. 1982. class. Similar observation was found in the study done Technical Report Series: 672. by Pal R et al 12. This could be attributed to the fact 8. Sandeep Sachdeva, Seema Alam, Farzana K Beig, Zulfia Khan that children from poor socioeconomic status live in And Najam Khalique. Determinants of Vitamin A Deficiency amongst Children in Aligarh District, Uttar Pradesh. Indian unsanitary surroundings have poor access to basic Pediatrics, 2011 (48): 861-866 health care and unhealthy dietary pattern contributing to poor nutritional status. 9. Singh V, West KP Jr. Vitamin A deficiency and xerophthalmia among school-aged children in Southeastern Asia. Europian A higher proportion (48.5%) of children was found to Journal of Clinical Nutrition 2004;58:1342-49. be underweight while 11.7% were overweight. Previous 10. Ene-Obong HN, Enugu GI, and Uwaegbute AC. Determinants studies reported a high prevalence of under nutrition of Health and Nutritional Status of Rural Nigerian Women. J among rural school children and children in urban HEALTH POPUL NUTR 2001 Dec;19(4):320-330 slums.13-15 11. Bhattacharya RN, Shrivastava P, Sadhukhan SK, Lahiri SK, Chakravorty M, Saha JB. A study on visual acuity and Vitamin Nearly a quarter of children were found to be anemic. A deficiency among primary school students in Naxalbari Anemia prevalence among children of school-going age village, Darjeeling district of West Bengal. Indian Journal of is 37.7% 16. Public Health 2004 ;48 (4) :171-180. 12. Pal R. Vitamin a deficiency in Indian rural preschool-aged Government of India, in 1970, initiated National children. Ann Trop Med Public Health 2009;2:11-4 Prophylaxis Program against Nutritional Blindness to combat and prevent VAD. The program involves 13. WHO Consultation.: Obesity: preventing and managing the global epidemic. WHO Tech. Rep. Ser., 894: 1-37 (2000). supplementation with massive dose of vitamin A as a direct strategy and nutrition education as an indirect 14. Sachdev, H.P.S.: Recent transitions in anthropometric profile of Indian children: clinical and public health implications. N.F.I. long term strategy to combat VAD. After more than Bull., 24: 6-8 (2003) three decades of operation, the program however suffers from poor compliance. Lack of awareness in the 15. Bhargava, S.K., Sachdev, H.P.S., Fall, C.H.D., Osmond, C., Lakshmy, R., Barker, D.J.P., Biswas, S.K.D., Ramji, S., community about the program is one of the possible Prabhakaran, D. and Reddy, K.S.: Relation of serial changes in factors for poor compliance 17. Low awareness of eye childhood body-mass index to impaired glucose tolerance in diseases in an urban population in southern India was young adulthood. N. Engl. J. Med., 350: 865-875 (2004). 18 observed . 16. Kotecha PV, Nirupam S, Karkar PD. Adolescent girls' anemia control programme, Gujarat, India. Indian J Med Res Nutrition education regarding regular intake of plant 2009;130:584-9. foods rich in carotene such as green leafy vegetables, yellow fruits, carrots and animal foods containing 17. Pahwa S, Trilok-Kumar G, Ali S, Toteja GS. Nutrition Education Intervention for Reducing Vitamin A Deficiency in retinol like fish liver oil, fish, liver, egg, meat, milk, a Slum of Delhi, India: Community Based Vitamin A butter, cheese, and use of fortified food like vanaspati, Intervention. South Asian Journal of Evaluation in Practice:1- margarine, dried skimmed milk should be strengthened. 12. Other measures like promotion of breast feeding, 18. Dandona R, Dandona L, John RK, McCarty CA , Rao GN. supply of safe drinking water, maintaining proper Awareness of eye diseases in an urban population in southern sanitation and hygiene, prevention of diarrhea, measles, India. Bull World Health Org 2001: 792. acute respiratory infections and access to basic health services should also be adopted.

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COMPARATIVE STUDY OF PEAK EXPIRATORY FLOW RATE AND MAXIMUM VOLUNTARY VENTILATION BETWEEN SMOKERS AND NON-SMOKERS

Karia Ritesh M1

1Assistant Professor, Department of Physiology, GMERS Medical College & Hospital, Dharpur-Patan, Gujarat

Correspondence Dr. Ritesh M. Karia C-1/5, Doctors’ Quarter, GMERS Medical College & Hospital, Dharpur-Patan, Gujarat, India Email : [email protected] Contact No.: 9033034007

ABSTRACT

Objective: Objectives of this study is to study effect of smoking on Peak Expiratory Flow Rate and Maximum Voluntary Ventilation in apparently healthy tobacco smokers and non-smokers and to compare the result of both the studies to assess the effects of smoking Method: The present study was carried out by computerized software of Pulmonary Function Test named ‘Spiro Excel’ on 50 non-smokers and 50 smokers. Smokers are divided in three gropus. Full series of test take 4 to 5 minutes. Tests were compared in the both smokers and non-smokers group by the ‘unpaired t test’. Statistical significance was indicated by ‘p’ value < 0.05. Results: From the result it is found that actual value of Peak Expiratory Flow Rate and Maximum Voluntary Ventilation are significantly lower in all smokers group than non-smokers. The difference of actual mean value is increases as the degree of smoking increases.

Key Words: Effect of smoking, Peak Expiratory Flow Rate, Maximum Voluntary Ventilation,

INTRODUCTION Prior written permission was taken from Institutional Review Board.(IRB). All the smokers had history of ‘Smoking Is Injurious To Health’ is written in smoking since last 5 years. Smokers are divided in three almost all the tobacco containing products. Despite this gropus9. : tobacco smoking is widely prevalent in developed as well as developing countries8. Smoking has significant Group 1: Mild Smokers –A person who smokes 10 or detrimental effects on various system on the body. less than 10 tobacco products per day Tobacco smoke is mixture of more than 4000 Group 2: Moderate Smokers – A person who smokes compunds7. Out of these many compounds are known more than 10 but less than 20 tobacco products per day to be carcinogenic and toxic. It can cause various pathophysiological effects. It has been identified as the Group 3 : Heavy Smokers – A person who smokes most important risk factor in Chronic Obstructive more than 20 tobacco products per day Pulmonary Disease (COPD)3. It significantly increases progressive deterioration of lung function. Pulmonary The control group (non-smokers) was comparable in Function Test is a test to examine functional capacity age, sex, economic status, socio-physical activity to of lungs and respiratory system. The common study group. The Inclusion and Exclusion criteria were parameters measured in pulmonary function test are as follows. Peak Expiratory Flow Rate (PEFR) and Maximum Inclusion criteria: Voluntary Ventilation (MVV). • Age range: 15 to 45 years • Non smokers: Never smoked MATERIAL AND METHOD • Smokers: Smoking since last 5 years The present study was carried out at Pulmonary Exclusion criteria: Function Lab, department of Physiology, Govt. Medical College, Bhavnagar in 100 male subjects. Out • Evidence of any CVS disease of them 50 were non-smokers and 50 were smokers.

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• History of acute respiratory illness preceding 6 week • Any thoracic or spinal or muscular deformity • History of drug intake like beta blocker, steroid at the time of study • Any lung malignancy The present study was carried out by computerized software of Pulmonary Function Test named ‘SPIRO EXCEL’. Spiro Excel is an instrument designed for lung function screening; the core of the system is the ‘intelligent’ flow meter that, connected through the USB cable, turns any personal computer (laptop or desktop) in a complete spirometric lab.

Spiro Excel is designed in such a way that it is easy and simple to operate and give highly accurate results. With Graph 1: Comparison between actual mean value the help of Spiro Excel it is easy to analyze data and it and predicted mean value of Peak Expiratory Flow gives accurate result without manual calculation Rate according to standardize testing protocol and predictions. Subject Preparation All subjects were physically healthy, without any symptoms. The experimental protocol was explained to all the subjects and written consent was obtained from them. Subject was explained and demonstrated about the procedure to be performed. All anthropometric measurement (age, height and weight) were obtained in the subjects wearing light-weight clothing and barefoot and at room temperature. All vital Data (temperature, pulse, respiratory rate and blood pressure) was collected in sitting position after making subject relax and calm2. General Examination and Systemic Examination (complete RS and CVS examination) was done according to standard protocol. They were allowed to do enough practice, as lung volume depends Graph 2: Comparison between actual mean value on the subject’s making a maximal voluntary effort. and predicted mean value of Maximum Voluntary Full series of test take 4 to 5 minutes. Ventilation Following activities was avoided prior to test which was approved by American Thoracic Society(ATS)4. DISCUSSION - Smoking within at least 1 hr of testing Bajentril AL, Veeranna N (2003) studied that 2-5 years - Consuming alcohol within 4 hr of testing of tobacco smoking tends to a definite tendency to - Performing vigorous exercise within 30 min of narrowing of both the large and small airways and testing significantly lowering lung function1. - Wearing clothing that substantially restricts full chest and abdominal expansion Ferris and Cotes showed a decrease in diffusing - Eating a large meal within 2 hr of testing. capacity in cigarette smokers and this was probably related to a lower pulmonary capillary blood volume in Statical Analysis smokers compared with non-smokers11. The value of PEFR and MVV were compared in the Kim WD (1985) studied that smokers have fewer both smokers and non-smokers group by the ‘unpaired alveolar attachments than non-smokers and that loss of t test’. Data were expressed in mean + SD. Statistical alveolar attachments represents an early stage in the significance was indicated by ‘p’ value < 0.05. destruction of lung parenchyma5. Chatterjee S, Nag SK et al. (1988) studied on 334 RESULTS healthy male non-smokers and 300 healthy male smokers of the age range of 20-60 years and found that Actual value and predicted value of PEFR and MVV value of MVV and PEFR is significantly lower in are shown in Graph 1 and 2. smokers than non-smokers10.

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K. M . Padmavath (2008) studied that MVV showed to provide restriction on the use of or purchase of significant reduction (p<0.0001) in smokers than non- tobacco must be started. This will be helpful to change smokers possibly due to reduction in respiratory muscle policies towards tobacco use, in order to prevent strength6. tobacco induced morbidity and mortality. Graph 1 shows actual and predicted mean value of PEFR (in L/Sec) in control as well as mild, moderate ACKNOWLEDGMENT and heavy smokers. Actual mean value of PEFR in control is 8.85 + 1.84, while predicted value is 9.07 + We are thankful to subjects who give us permission to 1.20. Actual mean value of mild, moderate, heavy and study on them and made this study possible. total smokers are 6.38 + 0.34, 4.53 + 0.28, 2.85 + 0.26, 4.59 + 1.50 respectively. Non-smoker group shows non-significant change in PEFR value than their REFERENCE predicted value. Smokers groups shows significantly 1. Bajentri AL, Veeranna N. Effect of 2-5 years of tobacco lower value than their predicted value. The difference smoking on ventilator function test. Indian Med. Association of actual value and predicted value of PEFR increase as 2003 ; 1017 : 96-7, 108 the degree of smoking increases. 2. Brusasco, R. Crapo and G. Viegi. Series ATS/ERS Task Force: Graph 2 shows actual and predicted mean value of Standardisation Of Lung Function Testing. Eur Respir J 2005; MVV (in L/min) in control as well as mild, moderate 26: 153–161 and heavy smokers. Actual mean value of MVV in 3. J.F. Nunn ; Nunn’s applied respiratory physiology 4th edition ; control is 138.21 + 12.85, while predicted value is 378-83 143.01 + 12.45. Actual mean value of mild, moderate, heavy and total smokers are 102.06 + 6.95, 91.22 + 4. Joshi A,. Correclation of Pulmonary Function Tests with Body 7.78, 76.41 + 8.05, 89.87 + 13.06 respectively. Non- Fat Percentage in young Individuals. Indian J Physio Pharmacol smoker group shows non-significant change in MVV 2008; 52 (4) 383-388. value than their predicted value. Smokers groups shows 5. Kim WD, saettam M, Ghezzo H. Loss of alveolar attachments significantly lower value than their predicted value. The in smokers. A morphometric correlate of lung function difference of actual value and predicted value of MVV impairment. Am Rev. Respir. Dis. 1985, 132 : 814-900 increase as the degree of smoking increases. 6. K. M . Padmavath Comparative Study Of Pulmonary Function Variables In Relation To Type Of Smoking. Indian J Physio Pharmacol 2008; 52 (2) 193-196 CONCLUSION 7. Newcomb PA. The health consequences of smoking cancer : cigarette smoking. Med CI North Am 1992; 76 : 305-31 Therefore, it is concluded that value of Peak Expiratory Flow Rate and Maximum Voluntary Ventilation are 8. Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution Act, 2003 lower in active tobacco smokers than tobacco non- smokers. The actual value of PEFR and MVV is 9. R.W.Colin. Clinical Findings, Sputum Examinations, and Pulmonary Function Tests Related to smoking Habit of 500 decrease as the number of tobacco smoking products women. Chest 1974;66;652-659. increase. Therefore pulmonary function is lower in moderate smokers than in mild smokers and lower in 10. S. chatterjee, Nag SK, Dey SK. Spirometric Standards for Non- Smokers and Smokers of India (Eastern Region). Japanese heavy smokers than in mild and moderate smokers. Journal of Physiology, 38, 283-298, 1988 Lower pulmonary function are associated with greater risk for lung disease, cardiovascular disease, cancer and 11. Van Ganse WF, Ferris BG, Cotes JE: Cigarette smoking and pulmonary diffusing capacity (transfer factor). Am Rev Resp other disease. Dis 105:30, 1972 So, aggressive tobacco control programme aimed to inform the public about the hazards of tobacco use and

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STUDY OF PREVALENCE AND RISK FACTORS OF POSTPARTUM DEPRESSION

Desai Nimisha D1, Mehta Ritambhara Y2, Ganjiwale Jaishree3

1Assistant Professor, Psychiatry, GMERS Medical College & General Hospital Gotri, Vadodara 2Professor & Head, Psychiatry, Govt. medical College & New Civil Hospital , Surat 3Assistant Professor, Community Medicine, P S Medical college, Karamsad

Correspondence: Dr Nimisha Desai Psychiatry OPD, GMERS Medical College & General Hospital Gotri,Vadodara-390021 Email: [email protected], Mobile No.:9427118451

ABSTRACT

Background: The burden of postpartum depression is significant because it remains unrecognized and it not only affects the mother adversely but also has a negative consequence on the family life and the development of the infant. Aim: The present study aims to study the prevalence and risk factors of postpartum depression among mothers attending the well baby clinic for vaccination of their Children. Methods: Around 200 Gujarati women of postpartum period, up to 1year, were randomly selected and assessed using the semi structured proforma including DSM-IV TR diagnostic criteria for depression and predictive index of postnatal depression, to find out risk factors. Results: The prevalence rate of postpartum depression was 12.5%. Women who delivered a girl child were observed to have higher odds of getting PPD [OR 5.487, CI ( 1.563,19.258)], also multigravida [OR 5.391, CI (1.17,24.849)], women having past history of miscarriage [OR 4.613 ,CI(1.299,16.385)], women feeling tense during pregnancy [OR11.716, CI (2.729,50.293)],women who could not confide in partner [10.43 ,CI (3.642,28.219] and absence of someone other than mother and partner in whom the woman could confide [OR 8.909, CI(1.869,42.473)] were found to be the strongest predictors for developing postpartum depression. Conclusion: A significant proportion of Gujarati women had postpartum depression and many psychosocial factors are associated with it.

Key Words: Postpartum depression, Risk factors, Prevalence

INTRODUCTION The first step in preventing postpartum depression is the identification of women who are at risk for Postpartum depression is a nonpsychotic depressive developing it. 1 episode of mild to moderate severity, beginning in or extending into the first postnatal year. Beck described it A recent review of literature found that the following as a thief that steals motherhood 1. A Meta analysis of risks factors are the strongest predictors of postpartum studies mainly based in the developed world found the depression (in decreasing order of effect): depression incidence of postpartum depression to be 12-13 % 2; during pregnancy, anxiety during pregnancy, experience with higher incidence in developing countries 3, 4. of stressful life events during pregnancy, low levels of social support and previous history of depression 6. An Postpartum depression is an important public health earlier Meta analysis of the research had also found the problem, having a significant impact on the mother, the following variables to be predictors of postpartum family, her partner, mother-infant interaction and on depression: Prenatal depression, self-esteem, child care the long term emotional and cognitive development of stress, prenatal anxiety, marital relationship, infant the baby 1. Indian studies also show post partum temperament, marital status, low social support, depression as a cause of significant psychiatric socioeconomic status and unplanned/unwanted morbidity in mothers 3 and malnutrition in infants 5. pregnancy 7. Limited research has been conducted in Hence preventive measures, early intervention and India so far. In a cohort study from rural area of identification can alleviate sufferings of the mother and Tamilnadu, Low income, birth of a daughter when a minimize its potential harmful effects on the newborn. son was desired, relationship difficulties with mother in

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NATIONAL JOURNAL OF MEDICAL RESEARCH law and parents, adverse life events during pregnancy Inclusion criterion: All Gujarati postpartum women and lack of physical help were risk factors for the onset who visited the well baby clinic for the vaccination of of post partum depression 4. Another qualitative study their child in the age range of 18-35 years up to in the community from rural south india shows that the postpartum period of 1 year. following factors were associated with postpartum Statistical Analysis depression: age less than 20 or over 30 years, schooling less than five years, thoughts of aborting current The Prevalence of post partum depression was pregnancy, unhappy marriage, physical abuse during calculated. The frequency distribution of the socio current pregnancy and after childbirth, husband’s use demographic variables was made in order to describe of alcohol, girl child delivered in the absence of living the data. boys and a preference for a boy, low birth weight and a family history of depression 8. A study of mothers in The predictive index for postpartum depression was goa shows economic deprivation, poor marital specifically noted, to assess the predictors of post relationship, the gender of infant as important risk partum depression. factors for occurrence of postpartum depression 3. First the univariate analysis was performed to find the According to Sichel and Driscoll’s ‘EARTHQUAKE association of various predictive factors from the MODEL’, these risk factors can repeatedly weaken a predictive index with the depression as per DSM-IV mother’s fault line placing her in a dangerous position TR gold standard. for an emotional earthquake, such as post partum depression 9. For the purpose of analysis certain of the predictive variables had to be redefined by clubbing some of its This study examines the predictors of postpartum categories into one, as the frequencies earlier were not depression in Gujarati postpartum women so that early sufficient for any analysis. The univariate analysis was detection is possible and intervention can be planned repeated using the clubbed variables and then the well in advance. logistic regression analysis was done using only the independent variables that were significant at the univariate level finally. MATERIALS AND METHODS The logistic regression test was applied using backward The present cross sectional study was conducted at Likelihood Ratio method, with p values of 0.05 for Well-baby clinic of pediatrics department, New Civil entry and 0.1 for the removal of the variable from the Hospital, Surat. 200 Gujarati postpartum women above model, taking depression by DSM as the dichotomous 18 years of age, up to postpartum period of 1 year were dependent variable and "gravida, previous miscarriage, randomly selected and requested to participate in the literacy, any previous termination, any previous still study. After a brief introductory phase explaining the birth, no. of children (one or more), help ever sought nature and purpose of the study, an informed consent for covering, whether the last pregnancy was planned , was taken from the participants. feelings on learning of pregnancy, whether pregnancy was a positive experience , were there any All women were interviewed using semi-structured complications in the pregnancy, did the female feel Proforma based on DSM-IV diagnostic criteria for miserable during her pregnancy, was the female major depression 10 and predictive index for postnatal generally tense during the pregnancy, time with current depression, were specifically inquired to assess the risk partner, can she confide in partner, how were her factors 11. relations with the partner in recent times, was there any Following tools were utilized for data collection. bereavement in her life with respect to her parents, participants' relationship with her mother currently, sex 1) Semi structured proforma including socio- of child, can the participant confide in anyone else demographic and clinical detail apart from her partner and mother " as the 2) DSM IV-TR Diagnostic criteria for Major depressive independent variables. The classification table of the disorder 10 model built finally was able to correctly classify the sample for depression 92.5% times. 3) Predictive index for postpartum depression: It was specifically inquired to assess the risk factors. It was All the statistical analysis was done using the software developed by P.J.Cooper et al in 1996 consisting of 40 Statistical Package for the Social Sciences-version 14 item questionnaire designed to detect the presence of [SPSS 14]. factors that were likely to increase the risk of postpartum depression. The list of questionnaire covers 37 items; the remaining three concerned the RESULTS participant’s age and occupation and her partner’s 200 Gujarati women were studied for their depression occupation. Although the sensitivity and specificity of status and risk factors during their well baby visits. The the predictive index is limited, the index offers a system age ranged from 18-35 years with mean age 23.84 years. for the prediction of postpartum depression that could All women were married at the time of interview. be of use in both research and clinical purpose. 11 Majority of the women (85%) were Hindu. Around

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30% women were illiterate, 50% of women belonged to The odds of multi gravida getting depression are seen joint families, 65.5% had urban background, 62% of to be 5.391 times higher than the primigravida. If there the women had monthly income less than 3000 rupees is any previous history of miscarriage, the odds that and majority (89.5%) were unemployed (housewives). such a female gets depressed is 4.613 times higher than (Table 1) a female without any miscarriage. If a woman is tense during her pregnancy, she has

11.716 times higher odds of getting depressed than the Table 1: Sociodemographic characteristics non tense women. Characteristic Depressed Non- Total The poor relationship with mother although significant n=25 (%) depressed n = 200 at univariate level, was not observed to be a significant n=175 (%) (%) contributor for developing PPD in the logistic model Age after removing the effects of the confounders. It could < 20 years 1 (4) 5 (2.8) 6 (3) be because the females having bad relation with mother 20-24 years 12 (48) 101 (57.8) 113 (56.5) were observed to have warm relations with the partner 25-29 years 10 (40) 49 (28) 59 (29.5) and also they could confide in the partner very well. 30-34 years 2 (8) 18 (10.3) 20 (10) The relationship with the partner and whether the > 35 years 0 2 (1.1) 2 (1) woman could confide in her partner were highly Education associated variables, hence only one of them i.e. can the No Education 9(36) 50(28.5) 59(29.5) woman confide in her partner was taken in the model 1-7 standard 10(40) 48(27) 58(29) finally. The women who could not confide in their Higher secondary 6(24) 61(34.5) 67(33.5) partners were observed to be having odds 10.43 times Further qualification 0 6(3.5) 6(3) higher of having PPD than those who could confide. (Courses after 10th ) Degree/Graduate 0 7(4) 7(3.5) The females who had a girl child are seen to have 5.487 Higher Degree 0 3(1.5) 3(1.5) times higher odds of getting depression than those Domicile having boy child. Urban 15 (60) 116 (66.3) 131 (65.5) If a female does not have anyone, other than her Rural 10 (40) 59 (33.7) 69 (34.5) mother and husband to confide in, the female has Religion 8.909 times higher odds of getting depression as Hindu 19 (76) 151 (86.3) 170 (85) compared to a female who has someone else to confide Muslim 6 (24) 22 (12.6) 28 (14) in. Others 0 2 (1.1) 2 (1) Family Joint 12 (48) 88 (50.3) 100 (50) DISCUSSION Nuclear 13 (52) 87 (49.7) 100 (50) Monthly income All the women in this study were recruited while < 1000 0 2 (1.1) 2 (1) attending the well baby clinic when they had come for 1000-2000 4 (16) 48 (27.5) 52 (26) vaccination of their child. They were not aware about 2000-3000 14 (56) 56 (32) 70 (35) their mental health status. Majority of women (78.5%) > 3000 7 (28) 69 (39.4) 76 (38) were within their first 6 months of postpartum period. Employment In this study we found that the prevalence rate of Unemployed 22(88) 157(89.7) 179 (89.5) depression was 12.5% through a structured clinical Employed 3(12) 18(10.3) 21 (10.5) interview which included DSM-IV TR diagnostic criteria. O’ Hara and Swain [1996] did meta-analysis of The prevalence of postpartum depression was 12.5% 59 studies and estimated that the average prevalence (25/200) through a structured clinical interview which rate of post natal depression was 13% 2. included DSM-IV diagnostic criteria of depression. The women in their first postpartum year were interviewed. Risk factors: 157 (78.5%) women interviewed were within their first Predictive index for postnatal depression was applied 6 months postpartum period, of which 19 were found, to identify predictors of postpartum depression which depressed. From remaining 43 (21.5%) women is already validated tool that could be used in research interviewed, 6 were found depressed. Past history of and clinical practice 11. After doing logistic regression depression was present in 2 cases, of which 1 was analysis strongest predictors identified were pregnancy depressed during interview and the other was not and related factors like multigravida, history of miscarriage, the family history of depression was present in only 4 feeling tense during pregnancy, having girl child cases, of which 2were depressed during interview and 2 ,women not able to confide in their partner and , were not. absence of person other than mother and partner who The results of the logistic regression analysis gives the can be confided in. independent effect of the parameters on the outcome i.e. depression. (Table 2)

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Table: 2 Predictive index factors associated with post partum depression Variable Depressed Not Crude OR (95% Adjusted OR P value depressed CI) (95% CI) (adj OR) Is it the first pregnancy? yes 5 691 1 no 20 1062.6(0.89-9.26) 5.391(1.17-24.85) 0.031 Any previous miscarriage no 14 1531 1 yes 11 225.46(1.96-4.74) 4.613(1.30-16.38) 0.018 Feeling tense during pregnancy no 14 1601 1 yes 11 158.38(2.86-23.83) 11.716(2.73-50.29) 0.008 Sex of the child male 8 1101 1 female 17 653.6(1.37-10.13) 5.487(1.56-19.26) 0.008 Anyone apart from mother and partner who can be confided in yes 4 891 1 no 21 865.43(1.72-22.50) 8.909(1.87-42.47) 0.006 Can confide in partner yes 19 1671 1 no 6 86.59(1.87-7.84) 10.43(3.64-28.22) 0.015 The unadjusted OR(CI) were calculated using WinPepi software.

In this study if there is any previous history of Robertson 6 had reported a high level of anxiety during miscarriage, the odds that such a female gets depressed pregnancy as predictive of post partum depression. is 4.613 times higher than a female without a Relationship related risk factors: miscarriage. This result was comparable to similar finding of the previous study by Playfair and Gower In this study, poor relationship with one’s spouse / (1981) but no such association was noticed by Kumar partner, absence of other person (except mother and and Robson (1984) 12. partner) in whom they could confided were found to be significant predictors statistically. If the women The females who had a girl child are seen to have 5.487 could not confide in partner she has 10.43 times higher times higher odds of getting depression than those odds of getting depression compared to those who having boy child. A similar finding was noted by could confide. Vikram Patel 3, M.Chandran 4and R.J.S.Savarimuthu 8. Vikram Patel 3 and Beck 1, 7 had found that poor Culturally, in our male dominated Indian society, male marital relationship preceded post partum depression. children are preferred and this male-bias is deeply rooted. When a girl child is delivered, the mother may If a female does not have anyone other than mother be subjected to antipathy, criticism and even hostility and husband to confide in, the female has 8.909 times from her spouse and extended family, leading her to higher odds of getting depression as compared to a major depression. If the father is dissatisfied with the female who has someone else to confide in. O’Hara et girl child, post natal depression is more likely to occur. al (1983) and Paykel et al (1980) found that lack of an Women who already had a girl child face greater stress adequate confidant or lower level of social support because of social and family pressure to give birth to a from a confidant are associated with postpartum male child and if the child is a girl again the risk of post depression. 12 partum depression is greater. Such gender bias and the 6 1, 7 limited control, a woman had over her reproductive Robertson and Beck found that inadequate social health may make pregnancy a stressful experience for support is linked to depression in mothers during her and ultimately lead to post partum depression. This pregnancy and post partum period. response is a cogent reminder that child birth is more 84% of depressed women had no other person to than a biological event, and that the personal confide in (except their mother or partner) compared experience of child birth is deeply embodied in the with 48% of non depressed women. (Who confided in socio-moral values of the local culture. a friend / other family member). Thus relationship In this study feeling tense during pregnancy was also with one’s mother / partner and the presence of identified as predictor of post partum depression. If a another person with whom a woman could share their female is tense during her pregnancy, she has 11.716 problems / worries were most important to a woman’s times higher odds of getting depressed. Beck 1, 7 emotional and mental well-being. A good emotional

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support system in the form of one’s mother, partner or 3. Patel V, Rodrigues M, Desouza N. Gender, poverty and friend may prevent women from falling pregnancy to postnatal depression: A study of mothers in Goa, India. Am J psychiatry 2002; 159: 43-7. post partum depression. 4. Chandran M, Tharyan P, Muliyil J, Abraham S. Post partum This study is limited by cross-sectional design, hospital depression in a cohort of women from a rural area of based and small sample size including only Gujarati Tamilnadu, India: Incidence and risk factors. Br J women not represents the general population. Psychiatry2002; 181: 499-504. 5. Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: A CONCLUSION cohort study from Goa, India. Arch dis child 2003; 88: 34-7. 6. Robertson E, Grace S, Wallington T, Stewart DE. Antenatal This study found factors like multigravida, history of risk factors for postpartum depression: a synthesis of recent miscarriage, feeling tense during pregnancy, having girl literature. Gen Hosp psychiatry 2004; 26: 289-295. child and relationship related factors like poor relation 7. Beck CT. Predictors of postpartum depression. An Update. with partner in recent months, absence of person other Nursing Research 2001; 50: 275-285. than mother and partner who can be confided in, were 8. Savarimuthu R.J.S, Ezhilarasu P, Charles H, Antonisamy B, significant predictors for postpartum depression. All of Kurian S, Jacob K.S. Post-Partum Depression in the these potential risk factors can be ascertained during Community: a Qualitative Study From Rural South India. Int J routine pregnancy care; therefore, it is important that Soc Psychiatry 2010; 56: 94-102. antenatal healthcare providers and women themselves 9. Sichel D, Driscoll J W. Women’s moods: What every woman are educated about these risk factors so that early must know about hormones, the brain and emotional health. identification of high risk women for closer follow-up Newyork: William morrow and company, inc; 1999. and intervention is possible. 10. American Psychiatric Association, Diagnostic and statistical manual of mental disorders, fourth edition, text revised. American Psychiatric Press, Washington, DC, 2000. REFERENCES 11. Cooper P.J, Murry L, Hooper R, West A. The development and validation of a predictive index for post partum depression. 1. Beck CT. Postpartum depression: It isn’t just the blues. Am J Psychological medicine, 1996: 26: 627-634. Nurs 2006; 106: 40-50. 12. O’ Hara M, Zekoski E. M. Post partum depression: A 2. O'Hara M, Swain A. Rates and risk of postpartum depression: a comprehensive review in Kumar R, Brockington I.F. (Eds): meta-analysis. Int Rev Psychiatry 1996; 8: 37-54. Motherhood and Mental illness 2 Causes and consequences. London: John Wright; 1988. 17-63.

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ANATOMICAL STUDY OF VARIATION OF VERTEBRAL ARTERY ENTERING THE FORAMEN TRANSVERSARIUM OF CERVICAL VERTEBRAE

Rawal Jitendra D1, Jadav Hrishikesh R2

1Assistant Professor, 2Professor & Head, Dept. of Anatomy, GMERS Medical college, sola, Ahmedabad ,Gujarat

Correspondence: Dr. Jitendra D Rawal, A/1/401, Vishwas city 1, R.C.Technical road, Ghatlodiya, Ahmedabad, Gujarat, India E-mail: [email protected]

ABSTRACT

Introduction: The vertebral artery is unique among the cervico-cephalic vessels by virtue of its position and relationship to the adjacent structures. The advent of new techniques and materials for surgical treatment of lower cervical spinal condition has come along with possible potential complications. As vertebral artery normally passes through transverse foramen of sixth cervical vertebra, these procedures can safely be done on seventh cervical vertebra. Aim: To study the anatomical variation of vertebral artery entering the transverse foramen of cervical vertebrae. Material & Methods: 50 vertebral arteries were dissected in 25 embalmed cadavers, out of which 19 cadavers were male and 6 were female. Vertebral artery was dissected from its origin to its entry into foramen magnum. Results: 4 (8 %) cases were found where vertebral artery entered into transverse foramen of 7th cervical vertebrae out of which 1 was bilateral, and 2 was on left side. In 46 cases (92%) it entered through transverse foramen of 6th cervical vertebrae. Conclusion: In 8% cases as vertebral artery enters through C7 transverse foramina, the relation is important while performing transpedicular fixation or other spinal surgeries.

Key words: Vertebral artery, cervical vertebra, Spine

INTRODUCTION a stable fixation through posterior part without requiring a potential anterior approach. Anatomical The vertebral arteries can be characterized by their variations of the artery path at the segment between the small diameter in relation to great length, asymmetry, second and sixth vertebrae are rare. Upon such segmental branches, and fusion of paired arteries into anatomy, the use of pedicular screws is safe only when one artery, the basilar artery, in the direction of forward performed at the seventh cervical vertebra, in which flow. The vertebral artery arises from the first part of the vertebral artery is not usually present at the subclavian artery and courses within the bony canals of transverse foramen. Nevertheless, in a small portion of the cervical vertebrae, anterior to the cervical nerve people, the vertebral artery is found inside the seventh roots, encircled by veins and nerve elements; then it lies cervical vertebra’s transverse foramen. In such cases on the upper surface of the posterior arch of the atlas there can be increased risk of vertebral artery damage before piercing the dura to enter the cranium. As which can lead to various neurological deficit such as vertebral artery passes through bony canals of the Wallenberg syndrome. This study was undertaken to cervical vertebrae, its relation and variation is important know the variation of vertebral artery entering the for any cervical spine surgery. Posterior stabilization of transverse foramen of cervical vertebra. the cervical spine is commonly used for treating unstable spine resulting from trauma, neoplasia or degenerating conditions. Such procedure is frequently MATERIAL AND METHODS performed by employing lateral mass screws or inter- spinous or sublaminar ligations. These techniques not The study consisted of meticulous dissection of always provide enough stability, sometimes they require vertebral arteries using standard dissection kit. 50 subsequent additional anterior stabilization procedures. vertebral arteries were dissected in 25 cadavers Recently, the transpedicular fixation technique has been obtained from Department of Anatomy, GMERS introduced in order to provide an alternative to obtain Medical college sola, Ahmedabad and other Institutes.

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The cadavers used in this study were obtained after the bilateral in 1 case and unilateral in 2 cases. In unilateral students had finished the dissection of face, triangles of cases variation was present on left side only and on neck and deep dissection of neck. After removal of right side it was normal. larynx, on the anterior surface of the cervical vertebral column, prevertebral fascia is seen. The prevertebral fascia covers the prevertebral muscles (longus colli and Table 1: variation of vertebral artery entering the longus capitis muscle) and lateral vertebral muscles transverse foramina of vertebral artery (anterior, middle and posterior scalene muscles). Each vertebral artery was identified in the root of the neck Vertebral Vertebral Total arising from first part of subclavian artery lying behind artery artery common carotid artery and vertebral vein and passing entering at entering at through a scaleno-vertebral triangle between longus C6 level C7 level colli and scalenus anterior muscle. Rt. Lt. Rt. Lt. Specimens 23 23 1 3 50 Percentage 46 46 2 6 100

DISCUSSION Various studies have been conducted on the variation of vertebral artery passing through transverse foramen of cervical vertebra. The incidence of vertebral artery passing through transverse foramen of C6 vertebra was found to be 6% in the studied population. Bruneau M et al1 studied pathway of vertebral artery by means of MRI and CT angiographic images found variations in 7 % cases. In his study it was also found vertebral artery entering at C3, C4 and C5 level which is Figure 1: Dissected vertebral artery entering at not found in present study. Bruneau et al also described level of C6 transverse process, O – origin of bilateral abnormality 0.8% and unilateral abnormality vertebral artery 12.4% which was more common on left side .In his study he found vertebral artery entering transverse Each vertebral artery was dissected free of its loose foramen of C5 more in number than C7 vertebrae, connective tissue attachments from its origin up to the which is not seen in present study. In present study it transverse foramen of the cervical vertebra. The was found entering at C7 level only. anterior boundary of the foramen of each of the sixth, fifth, fourth and third cervical vertebra was then Yamaki k et al2 described the correlation exist between removed and each artery was mobilized as far as the vertebral artery entering the foramen at abnormal level axis vertebra, using the scalpel handle. The seventh and variation of its origin from subclavian artery, which (C7) and sixth (C6) cervical vertebrae were identified by is not done in the present study. counting from the first thoracic vertebra (T1), identified by locating the first costal arch. Intending to avoid any failure in detecting C7 and C6 from T1, Table 2: Comparisons of Variation of vertebral resulting from the potential existence of a cervical rib, artery entering foramen transversarium of cervical the counting was also performed from the second vertebrae other than C6 cervical vertebra. Authors Incidence of vertebral artery entering through foramen transversarium of various cervical RESULTS vertebrae (in %) The study pertaining to variation of vertebral artery C3 C4 C5 C7 Total entering the transverse foramina of vertebral artery was Bruneau M et al 0.2 1 5 0.8 7 done. Kajimoto BHJ 0 0 0 7.5 7.5 et al 25 cadavers were dissected out of which 6 cadavers Susan S. et al 1 2 5 2 10 were female and 19 were male. From all 50 dissected Present study 000 8 8 vertebral arteries, we found 46 vertebral arteries entering the transverse foramen of the sixth cervical 3 vertebra (92 %) and 4 of them entering transverse Kajimoto BHJ et al in his study described variations of process of seventh cervical vertebra (8%). All vertebral vertebral artery entering the transverse foramen of cervical vertebra to be 7.5%, which is nearer to the arteries entered transverse foramina of cervical 7 vertebrae through C6 and C7 only. Variation was value of present study .

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Author of Gray’s Anatomy like Susan Standring et al4 and in 2 other cases it was unilateral and on left side. has also mentioned that 10% of vertebral artery enters As in 8% cases the vertebral artery enters through C7 transverse foramina of cervical vertebrae other than C6 transverse foramina, the relation is important while vertebrae. performing transpedicular fixation or other spinal surgeries. In further research, the correlation between The incidence of people with unusual vertebral artery vertebral artery entering the foramen at abnormal level path in its way through low cervical spine is not and variation of its origin from subclavian artery can be neglectful, and should be considered when selecting a studied. Also correlation of path of vertebral artery in transpedicular fixation technique at that region. Panjabi cadaveric dissection and MRI can be studied. et al5 published the first anatomical 3D study in which the ability of human cervical vertebrae’s pedicles to enable transpedicular fixation was proven. So damage REFERENCES: to the vertebral artery is possible while fixing transpedicular screw at all cervical vertebral level is 1. Bruneau M, Cornelius JF, Marneffe V, Triffaux M, George B. possible, also at C7. Anatomical variations of the V2 segment of the vertebral artery. Neurosurgery. 2006; 59(1 Suppl 1): S20-4. The present study is based on 25 cadavers of which 19 2. Anat Sci Int. Yamaki K, Saga T, Hirata T, Sakaino M, Nohno male and 6 female cadavers. So comparison of variation M, Kobayashi S, et al Anatomical study of the vertebral artery in male and female was not possible. Also correlation in Japanese adults. 2006; 81:100-6. based on anthropometric parameter like age, weight 3. Ben Hur Junitiro Kajimoto1, Renato Luis Dainesi Addeo1, and sex could not be made with the variation in the Gustavo Constantino de Campos et al Anatomical study of the path of vertebral artery. vertebral artery path in human lower cervical spine. ACTA ORTOP BRAS 15 2: 84-86, 2007

4. Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical CONCLUSIONS Practice. 40th ed. International edition: Elsevier Churchill Livingstone, 2008; 449. Vertebral artery entered the transverse foramen of 5. Panjabi MM, Duranceau J, Goel V, Oxland T, Takata K. cervical vertebra at C6 level in 92% cases and at C7 Cervical human vertebrae. Quantitative three-dimensional level in 8 % cases. In total 4 cases of vertebral artery anatomy of the middle and lower regions.Spine. 1991; 16:861- entering C7 level it was found that 1case was bilateral 9.

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FREQUENCY AND DISTRIBUTION OF BLOOD GROUPS IN BLOOD DONORS IN WESTERN AHMEDABAD – A HOSPITAL BASED STUDY

Patel Piyush A1, Patel Sangeeta P2, Shah Jigesh V3, Oza Haren V4

1Assistant Professor, Pathology, GMERS Medical College, Sola, Ahmedabad 2Tutor, Microbiology, B.J. Medical College, Ahmedabad, 3Associate Professor, Forensic Medicine, 4Professor and Head, Pathology, GMERS Medical College, Sola, Ahmedabad

Correspondence: Dr.Piyush Ashokbhai Patel Assistant Professor, Department of Pathology, GMERS Medical College, Sola , Nr.Gujarat Highcourt, S. G. highway, Ahmedabad Email: [email protected] Mobile: 9327957088

ABSTRACT

Background: Up till now about 400 red cells antigen have been identified. The majority are inherited by Mendelian fashion. The ABO and Rhesus (Rh) blood group system are most important for blood transfusion purposes, parental testing, legal medicine and in population genetic study. Objective: This study was conducted to determine and compare the frequency of ABO and Rh blood groups in blood donors in secondary care teaching hospital at Western Ahmedabad, Gujarat, India. Materials and Methods: A retrospective study was conducted at Blood bank, GMERS Medical College, Sola, Ahmedabad over a period of seven years from 1st January 2005 to 31st December 2011. Blood group of the blood donors was determined by commercially available standard monoclonal antisera by test tube agglutination technique. Results & conclusion: Out of 5316 subjects, 5076 (95.48%) were male and 240 (4.52%) were female subjects. The commonest ABO blood group present was B (39.40 %) followed by O (30.79 %), A (21.94 %) and AB (7.86 %) in blood donors; while in Rhesus system, 5053(95.05%) donors were Rh-positive and 263(4.95%) donors were Rh- negative. The study has a significant implication regarding the inventory management of blood bank and transfusion services for the patient admitted in our secondary care teaching hospital.

Key Words: Blood groups, ABO, Rhesus (Rh)

INTRODUCTION discovery of other blood group systems, all are deemed as an applications or as a result of Karl’s discovery.4,5 Blood group antigens are hereditary determined and The discovery of the ABO blood groups by Karl plays a vital role in transfusion safety, understanding Landsteiner was an important achievement in the genetics, inheritance pattern, and disease susceptibility. history of blood transfusion that was followed by Nearly 700 erythrocyte antigens are described and discovery of Rh (D) antigen.6,7 organized into 30 blood group systems by the International Society of Blood Transfusion of which Blood groups are genetically determined. The vast ABO and Rh are important.1 majority are inherited in a simple Mendelian fashion and are stable characteristics which are useful in The ABO blood group system is widely credited to paternity testing.8 have been discovered by the Austrian scientist Karl Landsteiner, who found three different blood types in Blood groups are known to have some association with 1900.2 He described A, B and O blood groups for diseases like duodenal ulcer, diabetes mellitus, urinary which he was awarded the Nobel prize in 1930. Alfred tract infection, Rh incompatibility and ABO Von Decastello and Adriano Sturli discovered the incompatibility of newborn.9 fourth type AB, in 1902.3 All human populations share the same blood group The Landsteiner’s discovery opened the door to the systems; although they differ in the frequencies of birth of a wide spectrum of discoveries in the field of specific types. The incidence of ABO and Rh groups immunohaematology, blood transfusion among varies markedly in different races, ethnic groups, and humans irrespective of their natives, unmatched- socio-economic groups in different part of the world.10 pregnancy, legal medicine, anthropology and the

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The frequencies of ABO and Rh blood groups vary Hospital, Sola, Ahmedabad (A secondary care teaching from one population to another and time to time in the hospital) during the 7 year period from January 2005 to same region. The knowledge of distribution of ABO December 2011. and Rh blood groups at local and regional levels are The blood collections were taken from the voluntary helpful in the effective management of blood banks donors at outdoor blood donation camp and in-house and safe blood transfusion services. Identification of blood bank as well as from replacement donors at Rh system is important to prevent the erythroblastosis blood bank. fetalis; which commonly arises when an Rh negative mother carries an Rh positive fetus. Total 5,316 donors were considered medically fit and accepted for blood donation during the study period. Knowledge of the distribution of ABO and Rh blood All were of age between 18-60 years. After blood group is essential for effective management of blood donation, blood group was determined by forward banks inventory, be it a facility of a smaller local blood grouping (cell grouping) by test tube transfusion service or a regional or national transfusion agglutination method. Commercially available standard service. It is, therefore, imperative to have information antisera A, antisera B, and Antisera D were used after on the distribution of these blood groups in any validation at blood bank. Reverse blood grouping population.11 (serum grouping) was performed by test tube Knowledge of blood group distribution is also agglutination method with Pooled known A, B and O important for clinical studies, for reliable geographical cell that are being prepared daily at the blood bank. information and it will help a lot in reducing the Final blood group is confirmed only if both forward maternal mortality rate, as access to safe and sufficient group (cell group) and reverse group (serum group) are supply of blood will help significantly in reducing the identical. Rh negative blood groups were confirmed by preventable deaths. antiglobulin technique. All weak D groups were considered as Rh positive. Apart from their importance in blood transfusion practice, the ABO and Rh blood groups are useful in The donor blood group data were recorded on specially population genetic studies, researching population formed proforma, tabulated, analyzed and compared migration patterns as well as resolving certain medico- with the similar studies by other authors. legal issues, particularly of disputed paternity cases. In modern medicine besides their importance in OBSERVATION & RESULT evolution, their relation to disease and environment is It can be seen from table no. 1 that 95.48 % of being increasingly important.12,13 It is, therefore accepted donors (5073 out of 5316) were male. And imperative to have information on the distribution of only 4.52 % (240 donors) were female. these blood groups in any population group.

Objective: Table 1: Age Groups and Sex Wise Distribution of Accepted donors This study is aimed to determine frequency and distribution ABO and Rh blood group patterns among Age groups Male Female Total blood donors in western Ahmedabad, Gujarat and 18-20 142 1 143 (2.68) compare with other data from similar studies within the 21-30 2181 104 2285 (42.98) India and all over the world. 31-40 2630 134 2764 (51.99) 41-50 105 1 106 (1.99) MATERIAL AND METHOD 51-60 18 0 18 (0.33) The present retrospective study was carried out at Total 5076 (95.48) 240 (4.52) 5316 (100) blood bank, GMERS Medical College and Civil

Table 2: Distribution of ABO & Rh Blood Group Systems ABO Male Female Total Bl. Gr Rh +ve Rh -ve Total Rh +ve Rh -ve Total Rh +ve Rh -ve Total O 1461 101 1562 68 7 75 1529 108 1637 (28.78) (1.98) (30.77) (28.33) (2.92) (31.25) (28.76) (2.03) (30.79) A 1070 43 1113 52 2 54 1122 45 1167 (21.07) (0.84) (21.93) (21.67) (0.83) (22.50) (21.11) (0.84) (21.95) B 1924 79 2003 85 7 92 2009 86 2095 (37.70) (1.55) (39.46) (35.42) (2.91) (38.33) (37.79) (1.62) (39.41) AB 375 23 398 18 1 19 393 24 417 (7.38) (0.45) (7.84) (7.50) (0.42) (7.92) (7.39) (0.46) (7.85) Total 4830 246 5076 223 17 240 5053 263 5316 (95.15) (4.85) (100) (92.92) (7.08) (100) (95.05) (4.95) (100)

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Majority of donor population (5049 donors forming found to have no effect on ABO blood grouping of the 94.97 % of total) was from the age groups of between donor. While looking at the rhesus grouping, on an 21 to 40 yr. This finding is consistent with the other average, 95.05 % accepted donors (5053 donors) were studies.15 Rh positive and remaining 4.95 % (263 donors) were Rh negative. On gender wise examination, 4830 out of The gender wise distribution of ABO and Rh blood 5076 male donors (95.15 %) were Rh positive whereas group systems is described in detail in table no. 2. It remaining 246 male donors (4.85 %) were Rh negative. can be seen that 2095 donors (39.40 %) were detected Regarding female donors, the rates were 92.92 % (223 to be having B blood group followed by O group (1637 female donors) and 7.08% (17femaledonors) donors, 30.79 %), A group (1167 donors, 21.94 %) and respectively. AB group (417 donors, 7.86 %). Sex of the donor was

Table 3: Comparison study on frequency of ABO and Rh phenotypes at different geographical areas (in percentage) Place of Study A BAB O Rh + Rh - Within India Shimoga-Malnad14 24.27 29.43 7.13 39.17 94.93 5.07 Davanagere15 26.15 29.85 7.24 36.76 94.8 5.52 Eastern Ahmedabad17 23.3 35.5 8.8 32.5 94.2 5.8 Punjab18 21.9 37.69.3 9.3 97.3 2.7 Bangalore20 23.85 29.956.37 39.82 94.2 5.79 Chittoor21 18.95 25.797.89 47.37 90.6 8.42 Vellore22 18.85 32.695.27 38.75 94.5 5.47 Present study 21.94 39.40 7.86 30.79 95.05 4.95 Outside India Pakistan19 23.8 38 10 10 89.1 10.9 Nepal23 34 294 33 96.7 3.33 Australia24 38 10 3 49 NA NA Britain25 41.7 8.63 46.7 83 17 USA26 41 94 46 85 15 Niger-Delta27 23.8 20.7 2.8 52.7 93.9 6.12

DISCUSSION population to another. The comparison of frequency and distribution of ABO and Rh group in the blood Majority of the studies within India have described a donors at western Ahmedabad (present study) with the large number of male donors compared to female similar studies carried out within and outside India is donors.15,16 This is because of the fact that in described in table – 3. developing country like India, because of social taboo, cultural habits, lack of motivation and fear of blood While looking at ABO grouping, it can be read from donation, female donors was very less. In addition, table – 3 that the distribution of ABO and Rh grouping large numbers of females from the menstruating age- was comparable to the studies done at Eastern groups are anemic with low weight, so declared unfit Ahmedabad17, Punjab18 and Pakistan.19 All these for blood donation and eliminated by the predonation studies have described ‘B’ as the most frequent and screening and counseling. Hence, general health of ‘AB’ as the least common blood group. The second females needs to be improved by good nutritional diet most common is ‘O’ in present study as well as in study and iron supplements. The fears regarding blood carried out at Eastern Ahmedabad.17 Whereas studies at donation in females needs to be driven out by making nearby areas of Punjab and Pakistan has shown ‘A’ them aware about the advantages of blood donation. being the second most common blood group. 21-40 years age group is the main work force of any of Studies at Southern India15,20,21,22 have described the society. So, they are the most common age group contrast findings with ‘O’ being the most common encountered donating blood. Many of the older people blood group followed by ‘B’, ‘A’ and ‘AB’. In Nepal23, suffer from hypertension, diabetes mellitus, low which is connected to western India, as well as hemoglobin and ischemic heart diseases and hence may Australia24, Britain25 and USA26, ‘O’ and ‘A’ are the abstain from donating or considered unfit during pre- common blood groups that are followed by B and donation counseling. ‘AB’. In Nigeria27 ‘O’ is the predominantly encountered blood group accounting for more than 50 % of donors Knowledge of frequency of ABO Blood Groups is an and AB has least common occurrence. important tool to determine the direction of recruitment of voluntary donors as required for each While looking at Rh grouping, 89-95 % donors all over zone across the country. The distribution of ABO the world are detected as Rh+ve except at Britain and blood group varies regionally, ethically and from one U.S.A. where the frequency of Rh positivity is 83–85

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%. Here it is a well known fact that many of the people other studies of different geographical region of residing at USA have migrated from Britain. India will be useful to health planners while making efforts to face the future health challenges Apart from transfusion service, knowledge of the blood in the region. group system helps to take preventive measures against the diseases which are associated with different blood groups, to prevent the dangerous transfusion reactions REFERENCES and efficient management of blood bank and transfusion services to the needy patients. 1. "Table of blood group systems". International Society of Blood Transfusion (ISBT). Oct 2008, There is known genetic association of specific blood URL:http://ibgrl.blood.co.uk/isbt. groups to certain diseases in certain population. Studies 2. Land steirier K. Zur Kenntnis der antifermentativen, lytischen concerned about possible association between ABO and agglutinierenden wirkungen des Blutserums under lymphe. blood group and cardiovascular diseases have Zentralblatt Bakteriologic. 1900; 27: 357–62. confirmed that persons of group A are affected more 3. Von decastella A, Sturli A. Ureber die iso agglutinine in serum frequently with coronary heart disease, ischemic heart gesunder and Kranaker Menschen” Mfiner Med WSchr. 1902; disease, venous thrombosis and atherosclerosis, while 49: 1090–5. its low in people with blood group ‘O’ which stated to 4. Jolly J G. Medicolegal significance of human blood groups. J have protective effect against these diseases.28,29,30 ‘O’ Indian Med Assoc. 2000; 98: 340–1. group individuals are known to have a 14 % reduced 5. Khurshid B, Naz M, Hassan M, Mabood S F. Frequency of risk of squamous cell carcinoma and 4 % reduced risk ABO and Rh (D) blood groups in district Swabi, NWFP, of basal cell carcinoma when compared to non-O Pakistan. J Sci Tech University, Peshawar. 1992; 16: 5-6. 31 group. It is also associated with a reduced risk of 6. Garratty G, Dzik W, Issitt P D, Lublin D M, Reid M E, pancreatic cancer.32,33 The ‘B’ antigen links with Zelinski T. Terminology for blood group antigens and genes– increased risk of ovarian cancer.34 Gastric cancer has historical origins and guideline in the new millennium. reported to be more common in blood group ‘A’ and Transfusion. 2000; 40: 477–89. least in group ‘O’.35 7. Mollison P L. The genetic basis of the Rh blood group system. Transfusion. 1994; 34: 539–41. So, it is advisable to do blood grouping studies in each 8. Hoffbrand A V and Pettit J E. Blood Transfusion in “Essential region for drafting proper national transfusion policies Haematology”, Oxford UK, Black well scientific Publication. and supplying blood to the needy patients during 2006, 5th Edition: 307–9. emergency. In short, generation of a simple database of 9. Skaik Y, El-Zyan N. Spectrum of ABO and Rh (D) blood blood groups, not only provides data about the groups amongst the Palestinian students at Al-Azhar availability of human blood in case of regional University-Gaza. Pak J Med Sci. 2006; 22: 333–5. calamities, but also serves to enablse insight into 10. Sidhu S and Sidhu L S: ABO blood group frequencies among possibilities of future burden of diseases. the Sansis of Punjab. Coll Anthropol. 1980; 4: 55–58. 11. Enosolease M E, Bazuaye G N. Distribution of ABO and Rh- D blood groups in the Benin area of Niger-Delta: Implication CONCLUSION & SUGGESTIONS for regional blood transfusion. Asian J Transf Sci. 2008; 2 (1): 3–5. 1. The present study concludes that ‘B’ blood group is the commonest blood group amongst the blood 12. Khan M S, Subhan F, Tahir F, Kazi B M, Dil A S, Sultan S. Prevalence of blood groups and Rh factor in Bannu region donors at Western Ahmedabad. This is followed NWFP (Pakistan). Pak J Med Res. 2004; 43 (1): 8–10. by ‘O’, ‘A’ and ‘AB’ blood group respectively. 13. Khaliq M A, Khan J A, Shah H, Khan SP. Frequency of ABO 2. Regarding Rhesus blood group system, Rh positive and Rh (D) blood group in Hazara division (Abbottabad). Pak J donors were 95.05% and Rh negative were 4.95%. Med Res 1984; 23: 102–3. 14. Girish C J, Chandrashekhar T N, Ramesh Babu K, Kantikar S 3. Blood donation by the females was very low and it M. ABO and Rhesus blood group distribution among Malnad needs to be increased by improving health status region blood Donors Research and Reviews in Biomedicine and awareness about blood donation. and Biotechnology [RRBB]. 2011; 2 (3): 25-30. 4. Every individual be ABO grouped at birth since 15. Mallikarjuna S. Prevalence of ABO and Rhesus blood group among blood donors. Indian Journal of Public Health, the antigens are naturally occurring. Groups of Research and Development. 2011. individual indicated on national identity cards, driving licenses and school/office identity cards 16. Giri P A, Yadav S, Parhar G S, Phalke D B. Frequency of ABO and Rhesus Blood Groups: A Study from a Rural Tertiary Care will be of tremendous use in case of acute Teaching Hospital in India. Int J Biol Med Res. 2011; 2 (4): hemorrhage or anaemia in children when urgent 988–990. transfusion of yet to be cross marched blood is 17. Wadhwa M K, Patel S M, Kothari D C, Pandey M, Patel D D. required. Distribution of ABO and Rhesus-D groups in Gujarat, India: a hospital based study. Indan J Ped Oncol.1998; 19 (4): 137–141. 5. It is necessary to conduct similar well designed studies in other states of India in order to 18. Sidhu S. Distribution of the ABO Blood Groups and Rh (D) Factor Among the Scheduled Caste Population of Punjab. determine the blood group frequencies in them. Anthropologist. 2003; 5: 203–204. The data generated in the present study and several

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19. Hammed A, Hussain W, Ahmed J, Rabbi F, Qureshi J A. 28. Khan M I, Micheal S, Akhtar F, Naveed A, Ahmed A & Qamar Prevalence of Phenotypes and Genes of ABO and Rhesus (Rh) R. Association of ABO blood groups with glaucoma in the Blood Groups in Faisalabad, Pakistan. Pak J Biol Sci. 2002; 5: Pakistani population. Canadian Journal of Ophthalmology 722–724. 2009; 44: 582–586. 20. Periyavan A, Sangeetha S K, Marimuthu P, Manjunath B K, 29. Alam M. ABO and Rhesus blood groups in potential blood Seema. Distribution of ABO and Rhesus-D groups in and donors at Skardu (Northern Areas). Pakistan Journal of around Bangalore. Asian J Transfus Sci. 2010; 4 (1): 41. Pathology. 2005; 16: 94–97. 21. Reddy K S N, Sudha G. and Rh (D) blood groups among the 30. Khan M S, Subhan F, Tahir F, Kazi B M, Dil A S, Sultan S, desuri Reddis of Chittoor District, Andhra Pradesh. Deepa F, Khan F & Sheikh M A. Prevalence of blood groups Anthropologist. 2009; 11 (3): 237-238. and Rh factor in Bannu District (NWFP) Pakistan. 22. Das P K, Nair S C, Harris V K, Rose D, Mammen J J, Bose Y 31. Xie J, Qureshi A A, Li Y, Han J, (2010). ABO Blood Group N, Sudarsanam A. Distribution of ABO and Rh-D blood and Incidence of Skin Cancer. PLoS ONE 5(8): e11972. URL: groups among blood donors in a tertiary care centre in South doi|10.1371/journal.pone.0011972. India. Trop Doct. 2001; 31 (1): 47–8. 32. Wolpin B M, Kraft P, Gross M, Helzlsouer K, et al. Pancreatic 23. Pramanik T, Pramanik S. Distribution of ABO and Rh blood cancer risk and ABO blood group alleles: results from the groups in Nepalese medical students: a report. East Mediterr pancreatic cancer cohort consortium. Cancer Res. 2010; 70 (3): Health J. 2000 Jan; 6 (1): 156-8. 1015–23. 24. Australian Red Cross society. All about blood. URL: 33. Amundadottir L, Kraft P, Stolzenberg-Solomon R Z, Fuchs C www.donateblood.com.au/all-aboutblood/blood-types. S. Genome-wide association study identifies variants in the ABO locus associated with susceptibility to pancreatic cancer. 25. Frances TF: Blood groups (ABO groups). In: Common Nat Genet. 2010; 41 (9): 986–90. Laboratory and Diagnostic Tests. Philadelphia: Lippincott. 2002, 3rd Edition: 19–5. 34. Gates M A, Wolpin B M, Cramer D W, Hankinson S E, Tworoger S S. ABO blood group and incidence of epithelial 26. Mollison P L, Engelfriet C P, Conteras M. The Rh blood ovarian cancer. Int J Cancer. 2010; 128 (2): 482–6. Group system. In Blood Transfusion in Clinical Medicine, 9th Edition. Oxford: Black well Scientific Publication.1993; 2008–9. 35. Aird I, Bentall H H, Roberts J A. (1953). A relationship between cancer of stomach and the ABO blood groups. Br 27. Enosolease M E, Bazuaye G N. Distribution of ABO and Rh- Med J. 2011 Apr; 1 (4814): 799–801. D blood groups in the Benin area of Niger-Delta: Implication for regional blood transfusion. Asian J Transf Sci. 2008; 2 (1): 3–5.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

STUDY OF ANGLE OF HUMERAL TORSION IN SUBJECTS OF GUJARAT REGION OF INDIA

Patel Shilpa1, Kubavat Dharati2, Malukar Ojaswini3, Nagar SK4, Parikh Jyoti5, Ganatra Dimple6

1Associate Prof, Baroda Med. College, Baroda 2Assistant Prof., M. P. Shah Med. College Jamnagar, 3Associate Prof. GMERS Gotri Med. College, 4Professor GMERS Gotri Med. College, 5Assistant Prof., Baroda Medical College, Baroda 6Assistant Prof, B. J. Medical College, Ahmedabad

Correspondence: Dr. Ojaswini Malukar Associate Professor, Anatomy Department, GMERS Gotri Medical College, Baroda India Email: [email protected]

ABSTRACTS

Introduction: The longest axes of the upper and lower articular surfaces of the humerus make an angle with each other of little more than 90°. In man however the upper end of the humerus appears to have been rotated laterally, so that the angle between the two axes has been increased to about 164°. This angulation is referred to as the angle of “humeral torsion“. When the two axes are superimposed on each other, they form an angle known as “torsion angle “. Methodology: Present study was conducted on two hundred humeri collected from medical college, Baroda. Out of these 105 were of the right side and 95 were of the left side. The gender of the bones was also determined... Observations: The humeral torsion is greater in the male than in the female and greater on right side than left side humeri possibly because most individuals are right handed. The present study showed no correlation between the torsion angle and the length of the humerus.

Key Words: Angle of humeral torsion, Articular Surface

INTRODUCTION: create the illusion of a twist in the bone and it even runs in such a way as to correctly indicate the direction of torsion. In lower mammals , the longest axes of the upper and lower articular surfaces of the humerus make an angle with Work of Krahl1 shows that torsion has occurred not in the each other of a little more than 90°. shaft of the humerus but at the junction of its proximal epiphysis with the diaphysis. In man, however, the upper end of the humerus appears to have been rotated laterally. So that the angle between Angle of humeral torsion the two axes has been increased to about 164°.This If two ends are viewed from one end, the long axes of the angulation is referred to as the angle of “humeral torsion “. two ends form a right angle in the quadrupeds Thus, the two axes when superimposed on each other form an angle known as angle of torsion. In humans (all primates) the inner surface is rotated to become anterior and the angle increased by 74°thus the Angle of torsion is greater in the male than the female. It is total angle between the two axes becomes 164°. Torsion also greater in adults than children ranges from 135° to occurs through 74°. Hence angle of humeral torsion is 74 165° or more in the male. It is greater in man than in ° anthropoids. Humeral torsion viewed from above: Torsion is directly proportional to the circumference of the humeral shaft but has no correlation with the length of O- original position of long axis of head lying at right the bone. These observations are compared with the angle to long axis of lower end (not drawn) on rotation findings of other workers in different races of inner surface anteriorly the long axis of head lies at new position (N) torsion having occurred through 74°. Humeral torsion denotes twisting of the bone along its long axis. As a result of this twisting the articular axis of Angle of humeral torsion of two ends is viewed from one end is in a plane different from that of the other end. one the long axis of the two ends form a right angle in the quadrupeds. In humerus (all primates) the inner The error of assuming that torsion occurs, in the humeral surface is rotated to become anterior and the angle is diaphysis is a most natural one for the spiral groove does

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NATIONAL JOURNAL OF MEDICAL RESEARCH increased by 74°. Thus the total angle between the two The torsiometer was devised for present study as under. axes becomes 164° torsion occurs through 74° hence The humerus was kept on the osteometric board and angle of humeral torsion is 74°. the two protractors were used. One protractor was kept Material and Methods: There are several methods for at upper end of humerus and the other protractor was measurement of humeral torsion, (Kahl’s 1944)1 the kept at lower end of humerus the center of greater angle of humeral torsion is measured with the help of tubercle was considered as the landmark for the Torsiometer. The torsiometer was devised for present measurement of the angle of torsion. The foot-rule was study as under. kept at the center of the greater tubercle and wherever the foot-rule touches to the both protractor was taken The humerus was kept on the osteometric board and as the angle of torsion. The method of measurement is the two protractors were used. shown in the Photograph 1 & 2. The present study was carried out on 200 dry normal adult human humeri obtained from the collection of bones in the Department of Anatomy Medical College, Vadodara, Gujarat. The bones studied were free of any pathological condition. The humeri were cleaned dried and observed in good daylight. The gender of each specimen was determined by the recognized established practice. The gender of the humeri was determined by the following criteria. V1 –Maximum length-greatest distance between lower end of medial condyle and upper end of humerus using osteometric board. V2 –Tubercles length – Distance between the highest point of the greater tubercles and the lowest point of the lateral condyle using osteometric board. V3 -Antero-posterior diaphyseal curvature – The humerus was placed horizontally on osteometric board and measurement was taken at the highest point of curvature using scale. Figure 1: V4 –Weight using electronic weighing machine.

Muscular markings present on humerus are prominent in the male gender, while in female gender markings are comparatively smooth. These all are the important measurements that will differentiate the sex of the humeri. Weight was one of the best subjective measures Figure 2: for sexing .The length was measured by placing the Photograph 1 & 2: Method of Measurement used humerus on osteometric board so that the condyles of in the study the inferior end touch on vertical part of osteometric board where Protractor was placed at right angle to Horizontal plane. The angle of humeral torsion is The male bones were 100 and 100 were female humeri 1 measured with the help of torsiometer (Kahl’s 1944) out of 200 dried humeri. Out of two hundred 95 were

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NATIONAL JOURNAL OF MEDICAL RESEARCH left and 105 were right humeri. The data obtained in the and R.P Chaturvadi study were right handed and present study in respect of torsion angle mean of 200 consequently with a more powerful musculature in the humeri the angle of torsion is 70.02 . The mean of 100 right arm, it is possible to explain the greater torsion in male humeri the angle of torsion is 71.20 , mean of 100 the right humeri. female humeri 69.82 , mean of 105 right side humeri the Torsion and rotation are two different phenomena. The angle of torsion is 70.94 & mean of 95 left side humeri angle made by the crossing of the axes of the two the angle of torsion is 68.94. opposite ends when measured erroneously include the 90°rotation which the entire limb undergoes during its development in the uterus. The true angle of humeral RESULT torsion is obtained by subtracting 90° from the measured obtuse angle. This observation was done by Lalit Mehta and R.P Chaturvadi. Such observation Table 1: Observation of the Torsion Angle cannot be done by present study. No. of Bone Mean They also observed that the medially deviated course of Male 100 71.20 the bicipital groove, including the correlation of its Female 100 69.82 angular value (bicipital angle) with the torsion angle is Right Side Bone 105 70.94 in agreement with those of Krahl’s (1948)6 Left Side Bone 95 68.94 observations. However, the values of the torsion and bicipital angle are not the same. This is explained by the The observation of present study is the humeral torsion fact that some degree of torsion 20-30 is present is greater in male than female , and greater on right side (hereditary) even before the ontogenic torsion takes than on left side humeri because most individuals are place. They also show that the circumference of the right handed. shaft is directly proportional to the torsion angle that The present study showed no correlation between the Krahl and Evans (1945)4 observed the inverse torsion angle and the length of the humerus. proportion in the American negroes and direct proportion in the white race. Between the thickness and the torsion angle. The thicker bone shows greater DISCUSSION degree of torsion, as the thickness of the bone is the measure of muscle strength and the torsion is a result of muscular forces. Such observation cannot be done Table 2: A comparison of torsion angle reported by by the present study. Such observation has been different workers shows under this table recorded by Lalit Mehta and R. P. Chaturvedi, T he torsion angle is greater on right (74.35°) than on the left Authors Series Torsion angle (61.8 °) side The present study showed the average Broca (1881)2 Whites 74° angle of the humeral torsion 70.02°. Torsion angle is Mathewset (1993) Salado-indians 69° greater in male is 71.20° than in female is 69.82° , the Martin(1928)3 Australian 45.5° torsion angle is greater on the right 70.94° than on the Martin (1928)3 Paltacalo-indian 48.5° left 68.94° side. Similar observation has been recorded Martin (1928)3 fuegians 53.9 by Lalit Mehta and R. P. Chaturvedi. The bicipital angle Martin (1928)3 peruvians 60.2° is also measured and its direct correlation is found with Martin (1928)3 Swiss 74° torsion angle. the average bicipital angle is 46° with a Chillida (1943) Urgentine 61° range of 15° to 66° and is greater on right (58.5°) than aborigines on the left side (41.6°) Torsion is directly proportional Ayur & upshon Indian (south) 62.1° to the circumference at the humeral shaft but no Krahl & evans4 whitis 75° correlation with the length of the bone. The value of Kate (1969)5 Indian (central) 55° torsion angle, bicipital angle length and circumference Lalit Mehta & Indian 68.5° of humeral shaft are greater on the right side. R.P.chaturvedi (rajasthan) However, the observation of Lalit Mehta and R.P. Present study (2003) Indian (Gujarat) 70.02° Chaturvedi shows that on an average, the right humerus is longer than the left by 0.8 cm and possesses a greater Thus, a comparison of torsion angle reported by torsion angle, the present study shows that on an different workers shows that there is a considerable average the right humeral angle is greater than left side racial variation. Values are subtracted by 90’ (embryonic humeri angle. rotation) wherever obtuse angle has been measured. Krahl and Evans (1945)4 studied the pair of humeri of In the present study, the average torsion angle of the individuals and found that the right humerus is longer right humerus is 70.94°greater than that of the left is than the left and shows greater degree of torsion. 68.94°. Similar observations have been recorded by Lalit Mehta and R.P Chaturvadi and also by Krahl and Gegenbaur (1868) measured the torsion angle in Evans (1945). Assuming that the majority of individuals different age groups while Brocca (1981)2 made a whose humeri have been measured in the Lalit Mehta comprehensive study of the humeral torsion in over

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600 humeri . A correlation between torsion angle and (c) That the torsion occurs between the terminal of the length and thickness of the bone has been reported the bicipital groove namely at epiphyseal cartilage Krahl and Evans, 19454. and that in the finished bone the bicipital groove stands as a clearly visible record which indicate Observation of Vernon E. Krahl is that the spiral angle both the direction and extent of the torsion increases essentially in direct proportion to the process. corresponding torsion angle. The torsion occurs at the proximal epiphysis of the humerus not in the shaft. Le Damany (1903, 1906) , Krause (1909) , Rouffia REFRENCES 4 (1924) Evans and Krahl , these writers write that the 1. Krahl VE. An apparatus for measuring the torsion angle in long twisting of humerus has occurred not in the shaft but bones.1944;22:498. rather at the junction of the diaphysis with the proximal 2. Broca P. La Torsion de1’humreus et la Tropometre. (Redigepar epiphysis. L. Manouvriver) Revue d’Anthrop. 1881; 4: 193-210,385-423. Phylogenetic and ontogenetic surveys of torsion reveal 3. Martin CP. Cause of torsion of the humerus and of the notch that on the anterior edge of the glenoid cavity of the seapula. J. of Anat. 1933;67(1932-1933):573-582. (a) The spiral angle like the torsion angle increases 4. Krahl VE, Evans FG. Humeral torsion in man. Am.J.Phys with age Anthoropo.1945;3:229-253. (b) That the deformation of the bicipital groove is a 5. Kate BR. Humeral torsion Indians. J. Anat. Soc . of India. direct consequence of humeral torsion and is 1969;18:31. proportion to the degree of torsion 6. Krahl VE. The bicipital groove : A visible record of humeral torsion. Anat. Rec.1948;101:319-331.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

A STUDY OF SACRALISATION OF FIFTH LUMBAR VERTEBRA IN GUJARAT

Kubavat Dharati1, Nagar SK2, Malukar Ojaswini3, Trivedi Dipali4, Shrimankar Paras4, Patil Sucheta5

1Assistant Professor, Department of Anatomy, M.P. Shah Med. College, Jamnagar 2Professor, 3Associate Professor, Department of Anatomy, GMERS Medical College, Gotri, Vadodara 4Associate Professor, B. J. Medical College, Ahmedabad 5Professor, Department of Anatomy, GMERS Medical College, Patan, Gujarat

Corresponding Author: Dr. Ojaswini Malukar, 402 Heritage Residency Ellora Park Vadodara Email: [email protected]

ABSTRACT

Introduction: In the lumbosacral region anatomical variations are related with change in the number of sacral vertebra by union of fifth lumbar vertebra or first coccyx with sacrum or deletion of first sacral vertebra. This study is carried to know the prevalence of sacralisation of fifth lumbar vertebra in Gujarat Method: The present study of sacralisation of fifth lumbar vertebra was carried out on 189 dry human sacra of gujarati population,115 male and 74 female. Result: A typical sacrum consisting of 5 segments was observed in 165 (87.3 %) specimen, while sacralisation of fifth lumbar vertebra was seen in 21(11.1 %)cases and lumbarisation of first sacral vertebra was seen in3 (1.3 %)cases. Conclusion: The significant number of sacralisation can have a bearing on counting of vertebral levels specially during planning of spinal surgey, this study can be of use as a prelude to any type of experimental work in biomechanics, for diagnostic and therapeutic purpose in low back pain.

Key words: Anatomic variations, low backpain, Transitional vertebra

INTRODUCTION This study is to know the prevalence of sacralisation of fifth lumbar vertebra in Gujarat region and to The lumbosacral spine not only protects the spinal cord understand the series of morphological changes during and spinal nerves but also support and transmits weight lumbosacral transition that in turn help in diagnostic of the body to the inferior extremity and thus plays an and therapeutic management of illness around important important role in posture. lumbosacral region Lumbosacral transitional vertebrae (LSTV) are congenital anomalies of the lumbosacral region, which includes sacralisation of fifth lumbar vertebra and METHODS AND MATERIAL lumbarisation of first sacral vertebra observed for the The present study includes 189 human sacra of known first time by Bertolotti in 1917. This condition occurs sex (115 male & 74 female) were studied from due to defect in the segmentation of the lumbosacral Department of Anatomy, B.J.Medical college spine during development. Ahmedabad, Government Dental college In sacralisation of fifth lumbar vertebra the transverse Ahmedabad,Medical college Vadodara and process of last lumbar vertebra (L5) becomes larger Government Medical college Surat in Gujarat. All the than normal on one side or both sides, and fuses to the sacra were of adult but precise age was not known. Any sacrum,or ilium and or both. This anomaly is observed increase in the number of elements of the sacrum were in about 3.6 % to 18 % of people and is usually investigated and the identification of the six-segmented bilateral. Although, sacralisation may be as one of the sacrum with five sacral foramina was noted. causes of low back pain (LBP), but is asymptomatic in The sacra consisting of six vertebra, by incorporation many cases (specially bilateral type). Probably low back of the fifth lumbar, were selected. Those with fusion of pain occurs due to chronic faulty biomechanics. In the first coccygeal vertebra were excluded.We used sacralisation, usually L5-S1 intervertebral disc becomes two-fold subdivision of sacralisation.(1) Bi-lateral thin and narrow, this abnormality is found by X-ray sacralisation(2) Uni-lateral sacralisation.

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There was a greater tendency towards the reduction of length of vertebral column. Therefore the incidence of sacralisation is higher than lumbarisation.

Table 2: Classification of sacralisation of fifth lumbar vertebra Sex Unilateral sacralisation Bilateral sacralisation Right Left Total Male 1 0 1 13 Female 2 1 3 4 Figure- 1.1, Transverse process of both side Is Total 3 1 4 17 completely fused (Bi-lateral sacralisation)

DISCUSSION The present study shows that the incidence of sacralisation of the fifth lumbar vertebra among Gujarati population is 11.1 %, which is more in males than female. Based on the literature, sacralisation varied by race and incidence, in our study was close to the Arabs 10 % reported by Bustami (1989)1, 9.2 % reported by Hughes et al (2006), Notwithstanding, the incidence in our study was much lower than that the 18 % among Australian aboriginals, 16 % Indians and 14 % reported by Vandana Sharma(2011)2 in central india Figure – 1.2, Transverse process of Right side is region. The incidence in our study was much higher completely fused (Uni-lateral sacralisation) than that the 3.6 % reported by Moore and Illinosis (1925)3 and 6.2 % reported by Peter et al (1999)4, 7.8 %

reported by Hald et al (1995)5, Natives of Britain 8.1 % Bi-lateral sacralisation (fig-1.1) consists of a bony union reported by Brailsford(1928)6. between the abnormal transverse process and the sacrum on both sides.Uni-lateral sacralisation(fig-1.2) shows a bony union between the abnormal transverse Table 3: Incidence of sacralisation of fifth lumbar process and the sacrum either on right side or left side. vertebra from previous study The various measurements of all the sacra were made Race Incidence References with the help of sliding caliper, divider, thread and steel Australian 18 % Mitchell, 1936 measuring tape(scale). aboriginals Indians 16 % Bustami, 19891 Skeletal variations like sacralisation of fifth lumbar 1 vertebra, lumbarisation of first sacral vertebra, number Arabs 10 % Bustami, 1989 Natives of Britain 8.1 % Brailsford, 19286 of sacral vertebra were recorded. The data were 3 analysed using descriptive statistic and gross anatomy Americans 3.6 % Moore & Illinois, 1925 observation. The occurrence of lumbosacral transitional vertebra is linked to its embryological development and OBSERVATION osteological defects. Embryologically,the vertebra In present study of 189 dry human sacra, 115 (60.8 %) receives contribution from caudal half of one were male and 74 (39.2%) were female sacra.24 cases sclerotome and from the cranial half of succeeding (12.7 %) of lumbosacral transitional vertebra and 165 sclerotome (87.3 %) normal vertebra are found including the sacra These processes are considered to be regulated by the of coccygeal fusion. respective homeobox and paired-box genes, Pax 1 and Pax 9 in the control of cell poriferation during early Table 1: Frequency distribution of sacralisation of sclerotome development. As reveled in mice that were fifth lumbar vertebra and lumbarisation of first deficient for one functional copy of Pax 1, sacral vertebra heterozygosity and homozygosity of the Pax 9 mutation result in vertebral malformations in the Male (%) Female (%) Total (%) lumbar region, such as fused and split vertebrae, as well Subjects(Sacra) 115 74 189 as ossified fusions between vertebrae and neural arches. Sacralisation 14 (12.2) 7(9.5) 21 (11.1) Thus, the cartilage between L5 and S1 vertebrae Lumbarisation 1 (0.7 ) 2(2.7) 3(1.6) calcified to become a” sacralisation” of the fifth lumbar

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NATIONAL JOURNAL OF MEDICAL RESEARCH vertebra, may be caused by some genetic determinants and this probably could be a risk factor of low back of these morphological changes from the somite to pain. vertebrae. This hypothesis was supported by a previous Knowledge of sacralisaiion is not only enlightening for study of Tini (1977)7 as increased incidences of the orthopaedic surgeons, also vital for the (The lumbrosacral transitional vertebrae were observed condition of sacralisation of fifth lumbar vertebra occurring within families. deserves attention of )clinical anatomist, Radiologists, Due to sacralisation of fifth lumbar vertebra, the fusion Forensic experts and morphologists,Architectures. of lumbosacral joint may cause greater difficulty during Hence we are presenting such variation with emphasize labour because of less mobile pelvis and it may be the on its clinical relevance Incorrect numbering during the reason of low back pain problem. planning of spinal surgery may have serious consequences. LSTV does affect the position of the Bertolotti(1917)8 described the relationship between intercrestal line (the line connecting the highest points the low back pain and sacralisation of fifth lumbar of the iliac crests, also called ‘Tuffier’s line’), and on the vartebra. In young patients with back pain the location of the conus medullaris. The intercrestal line possibility of Bertolotti’s syndrome should always be normally corresponds with the level L4/L5 and is taken in account. Some authors proposed that therefore used as a landmark for needle insertion sacralisation of fifth lumbar vertebra may cause symptoms such as lumbar disc herniations, spinal pain, Anatomically and architecturally, the sacralised radicular pain or lumbar scoliosis. But their formation appears stronger and more able to resist pathophysiology or mechanics is still unknown. strain than the usual arrangement Sacralisation is one of the important factors in the emergence of lumbar disc herniation (LDH). LDH frequently occurs at the level above the lumbosacral REFERENCES transitional vertebra rather than at the level of 1. Bustami F. The anatomical features and functional significance transitional vertebra in patient with low back pain. of lumbar transitional vertebra. Jordan Med J 1989;23:49-59 Some evidence suggests that L5-S1 transitions possess 2. Vandana A.Sharma,D. K.Sharma,C.K.Shukla. Osteogenic study altered facet morphology.These alterations are possibly of lumbosacral transitional vertebra in central india related to low back pain situations.The sacralisation region.J.Anat.Soc.India 2011; 60(2):212-217. existing from the time of development,the condition 3. Moore BH, Illinois C. Sacralization of the fifth lumbar vertebra. may be painless for a large number of years and the J Bone Joint Surg 1925; 7: 271-278. history frequently given is pain for a few years only for even much less. 4. Peter H, Wilm B, sakai N, Imai K, Maas R, Balling R. Pax 1 and Pax 9 synnergistically regulate vertebral column development. The various causes for low back pain in sacralisation Development 1999;126:5399-408. have been put forward and these may be summarized 5. Hald HJ,Danz B, Schwab R, Burmeister K,Behren W. as follows: Radiographically demonstrable spinal changes in asymptomatic young men. Rofo 1995; 163: 4-8 1. Actual pressure on nerves or nerve trunks. 6. Brailsford JF. Deformities of the lumbosacral region of the 2. Ligamentous strain. spine. Brit J Surg 1928; 16: 562-627. 3. Compression of soft tissue between bony joints. 7. Tini PG, WISes G, Ainn WM. The transitional vertebrae of the 4. By an actual atthritis if a joint is present. lumbrosacral spine: Its radiological classification, incidence, 5. By a bursitis if a bursa is present. prevelence, and clinical significance. Rheumatol Rehabi 1977;16:180-5. The sacralized transverse process may form a pseudarthrosis with the ilium and degenerative sclerosis 8. Bertolotti M. Contributto alla conoscenza dei vici di differenzarione regionale del rachide con speciale riguards all may appear around the false joint. This may be a site of asimilazzione sacrale della v. lombare. Radiologique Medica low back pain. The lumbar nerve roots may be altered 1917; 4:113-44. when a lumbrosacral transitional vertebra is present

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MEDIAL OPEN WEDGE HIGH TIBIAL OSTEOTOMY FOR VARUS ARTHRITIC KNEES BY DYNAMIC EXTERNAL FIXATOR SYSTEM (DISTRACTION CALLOTASIS)

Shah Mukesh N1, Amin Richa P2, Patel Kunal C2, Amin Prakash V2, Pandit Jyotindra P2

1Assistant Professor, Department of Orthopaedics, GCS Medical College, Ahmedabad 2Harikrupa Accident and Orthopaedic Hospital, Ellis Bridge, Ahmedabad

Correspondence Dr. Mukesh N. Shah Aditya Hospital, A-203/4, Swaminarayan Avenue, 2nd Floor Anjali Cross Road, Vasna Road, Ahmedabad, Gujarat, India E-Mail: [email protected]

ABSTRACT

Introduction: Varus arthritic knee is a major disabling condition in a relatively younger individual. Fixator assisted medial open wedge osteotomy has been found to be a good modality of treatment with promising results. Material & methods: In last 6 years total 52 patients with varus arthritic knee were treated with medial open wedge HTO fixed with external fixator and gradual distraction. The required degree of correction was calculated pre- operatively on a long axis weight bearing films. Distraction of Osteotomy was started at 1 week post operatively and continued till desired degree of correction was achieved. Patients were assessed clinically and radiologically by check X-rays periodically. Fixator was removed after satisfactory consolidation of osteotomy site on x-ray and results were assessed. The follow-up ranged from 3 months to maximum of 6 years. Results: Excellent pain relief was obtained in 43 patients out of 52. Four patients had good pain relief and 3 patients were not satisfied and had persistent symptoms. One patient had loss of correction after removal of fixator and 1 had over-correction. Pin-tract infection was found in 2 patients. None of the patients had non-union of osteotomy or conversion to TKR till last follow-up. Conclusion: Medial open wedge osteotomy with dynamic external fixator has many advantages over other modalities of treatment with promising results. It gives life to varus arthritic knees in younger individuals.

Keywords: Medial Open Wedge, HTO-Ex Fix, Tibia, Osteoarthritis, Total knee replacement

Abbreviations: HTO (High Tibial Osteotomy), TKR (Total Knee Replacement), OA (Osteoarthritis)

INTRODUCTION Apart from routine investigations, pre-operative evaluation of the degree of varus and required degree Osteoarthritis of the knee in relatively younger patients of correction was carried out by taking full-length is a major disabling condition1. Joint Replacement for weight bearing x-rays and by drawing axis of weight OA is the ultimate treatment option but only for those bearing and anatomical axis and calculating desired who are above 60 and not very physically demanding2. degree of correction. If the axis of the varus angle is realigned in young and active patients having arthritic process limited to medial Pre-operative counselling of patients regarding the time compartment1,2,3, with open wedge HTO to unload the up to which the external fixator device to be kept on medial compartment, patients get significant pain relief the legs and need for regular periodical physical & and surgery adds life to the knees1,4,5,6,7. radiological check was done. The present study is to evaluate the results of open Patient with intra-articular pathologies, ligament laxities wedge HTO by Dynamic External Fixator as a and other deformities were excluded from the study. treatment modality to correct the varus deformity and stabilization of osteotomy as compared to other modalities 1,8-12 SURGICAL TECHNIQUE All the patients were operated under spinal anaesthesia and in supine position. Tourniquet control and IITV MATERIALS AND METHODS

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NATIONAL JOURNAL OF MEDICAL RESEARCH guidance were used. The preferable position for locking nut. The patient was then allowed bearing surgeon was on medial aspect of patient’s knee. weight with the help of a walker. Patient’s limb was kept on 2 pillows (for lateral Further follow-ups were done every three weeks at radiography) and in neutral rotation with support which time only spot films were taken to see the below trochanter. The first pin was inserted at the level progress in consolidation of the regenerate & signs of of fibular head in lateral view as near the posterior loosening of pins. cortex of tibia as possible. The second pin was inserted parallel in AP and anterior to 1st pin in lateral view. At the end of 3 months usually the regenerate was fully Distal two pins were inserted in shaft of tibia at the consolidated and patient was allowed full weight junction of middle 1/3 and lower 1/3, after marking bearing using a walker or stick. location of clamp holes on tibia. Osteotomy was done obliquely directed towards head of fibula by a 2 cm Prior to removal of pins, we performed “stress test”. incision over medial cortex, after conforming position The patient was asked to walk full weight bearing by inserting guide-wire under IITV guidance. Care was without support in clinic to observe gait and signs of taken not to break the lateral cortex of the apex of pain or limp. After unlocking the nuts, patient was osteotomy. The Fixator is applied. Completion of allowed weight bearing and walking. The Fixator was Osteotomy was confirmed by slightly distracting the removed with pins in situ & patient is allowed walking osteotomy & observing the opening of the wedge with full weight bearing, if there is pain or limp, the under IITV. Osteotomy is closed again and fixator is fixator is reapplied and maintained for few more days. locked. The wound is closed in layers. Check X-Rays Finally when there was no pain, fixator and pins were were taken immediately post-operatively. Patients were removed in OPD. No cast was given. Six monthly discharged after 5-7 days of surgery. reviews were done with x-rays to see maturation of regenerate, opening of medial compartment and Prior to discharge patient & relatives were taught cartilage healing. At one year another full length x-ray distraction on another fixator device and pin tract care. was taken to see maintenance of re-aligned axis. Fixator was unlocked and distraction was started 1 week after the operation. Distraction was done by 1/4th turn every 6 hours i.e. 1 mm/day. At 2 weeks stitches RESULTS were removed, check x-rays were taken and adequate opening of Osteotomy was confirmed. The MPTA During 2005-2011, 52 patients having varus arthritic (Medial Proximal Tibial Angle) was measured to assess knees were operated by medial open wedge HTO and progress. gradual distraction with fixation by dynamic external fixator. The age of the patients ranged from 35 to 67 X-Rays were repeated at the end of one week, two years. weeks, four weeks, Six weeks and Twelve weeks or the before the removal of fixator On full length X-Ray, we looked for The MPTA (Medial Proximal Tibial Angle) Table 1: Age and sex distribution of Patients was as projected/predicted from the pre-op full length x-ray. The HKA (Hip knee angle) the angle between Age Male (%) Female (%) Total (%) the lines joining centre of femoral head to centre of 35-44 3 (27.3) 8 (19.5) 11 (21.2) knee to centre of ankle which should be between 175 45-50 2 (18.2) 9 (22.0) 11 (21.2) to 178 on lateral view. The mechanical axis of the limb 51-55 2 (18.2) 9 (22.0) 11 (21.2) (line joining centre of femoral head and centre of ankle) 56-60 0 (0.0) 9 (22.0) 9 (17.3) should be passing through the base of lateral tibial 61-64 3 (27.3) 4 (9.8) 7 (13.5) spine. The FTA (femoral tibial angle) should be 65-67 1 (9.1) 2 (4.9) 3 (5.8) between 8 to 14 degrees. Total 11 (100.0) 41 (100.0) 52 (100.0)

Physiotherapy in the form of Knee bending, static Out of 52, 11 patients were males and 41 were females. quadriceps & hamstring and ankle-toe movements were In 41 patients unilateral and in 11 patients bilateral started at the earliest. Non-weight bearing walker was HTO was done. The average operative time was 60 used for walking for 6 weeks. Weight bearing was minutes. allowed after confirming callous formation on X-ray. We encountered pin-tract infection in 2 patients, loss of At the end of 4 weeks check x-rays were done to reduction in 2 patients, micro-fracture at the apex of confirm the distraction gap by calculating MPTA. We osteotomy in 1 patient and over correction in one also looked for signs of pin-tract infection and non patient. None of our patients had infection at union. Gait of the patient and proper execution of osteotomy site, non union or ligament laxity after the physiotherapy was observed. At six weeks, when the surgery. patient was nearing completion of distraction and correction, full length weight bearing film was taken. Minimum follow-up was 3 months & maximum follow-up was 6 years. The evaluations were carried out Once the correction was deemed to be complete, the as per Oxford Knee Score10. The patients were assessed fixator was locked by tightening the central body for pain, walking, stair climbing, gait, range of

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NATIONAL JOURNAL OF MEDICAL RESEARCH movements, flexion deformity, ligament laxity, and There is no bone graft donor site morbidity2,12,15. There radiological evaluation on each follow-up examination. is no need for anaesthesia for removal of implants as The pre-operative score which was in the range of 20 external fixator can be removed on out-door patient to 29, had improved to 40-48 after HTO in majority of basis. Good ligamentotaxis of medial ligaments can be the patients. achieved with distraction open wedge osteotomy. Medial open wedge Osteotomy has been established to

be superior to closed lateral wedge adding life to Table 2: Results as per Oxford Knee Score knees1,16. As there is no change in anatomy of upper tibia, future TKR is not jeopardised1,13,17,18. Medial Oxford Knee Score Patients (%) Open Wedge HTO provides subjective improvements Pre-Operative Score in pain and quality of life. Studies have shown articular 24 1 (1.9) cartilage recovery secondary to improved mechanical 25 5 (9.6) environment by unloading the medial compartment by 26 9 (17.3) open wedge HTO5. 27 10 (19.2) 28 12 (23.1) This surgery is not free from complications at the same 29 15 (28.8) time. Pin tract infection can be distressing and painful. Post-Operative Score This can be prevented by educating the patient for pin- 40 5 (9.6) tract care and sterile cleaning of pins regularly at home. 41 0 (0.0) Use of HA coated pins have less incidence of infection. 42 4 (7.7) Patient has to carry device on leg till the treatment is 43 4 (7.7) over. More frequent follow-up visits & regular 44 4 (7.7) radiological assessment is required during distraction 45 3 (5.8) phase to evaluate correction of varus. Patient should be 46 2 (3.8) counselled properly regarding advantages of the device 47 10 (19.2) like accurate degree of correction and avoidance of 48 20 (38.5) bone Grafting. We feel that still longer follow-ups are required to None of our patients required Total knee replacement evaluate pain relief, maintenance of correction & after HTO. conversion to TKR if at all. Considering above observations, Medial open wedge HTO by external fixator has been found to have promising results in DISCUSSION young individuals with arthritic knee. High Tibial Osteotomy is an established procedure for treating Varus arthritic knees in relatively young, active individuals. The aim of this study is to evaluate REFERENCES advantages of Dynamic External Fixator as a modality 1. Devgan A , Marya KM, Kundu ZS, Sangwan SS, Siwach RC, of fixation of an open wedge osteotomy as compared Medial Opening Wedge High Tibial Osteotomy for to other modalities e.g.: TOMO-fix plate, Puddu plate Osteoarthritis of knee, med J. Malaysia, 2003, 58 (1), 62-67. etc1,5,8,9,11. 2. Spahn G, complications in High Tibial (Medial Opening Wedge) Osteotomy, Arch Orthop Trauma Surg, 2003, 124, Closed wedge and open wedge osteotomies are two 649-53. modalities of high tibial osteotomies. 3. Mayad TF, Minas T, Opening Wedge High Tibial Osteotomy, Open wedge HTO is better than closed wedge HTO as journal of Knee Surgery, 2008,21(1), 80-84. the anatomy ofupper tibia is significantly changed in 4. Franco V, Cerullo G, Cipolla M, Gianni E, Puddu G, Open closed HTO making future TKR difficult. The Wedge High Tibial Osteotomy Techniques in Knee Surgery, conventional way of fixation of HTO with plates has 2002, 1(1), 43-53. many disadvantages as it needs more surgical dissection 5. Parker DA, Beatty KT, Giuttre B, Scholes CJ, Coolican MR, and chances of infection and non-union are high. Also Articular Cartilage changes in Patients with Osteo-arthritis conventional open wedge HTO which needs bone graft after Osteotomy. Am J Sports Med. 2011;39(5):1039-45. also carries donor site morbidity. 6. Bauer GCH, Insall J, Koshino T, Tibial Osteotomy in Gonarthrosis, J Bone Joint Surg, 1969;51 A:1545-62. The fixator assisted medial open wedge high tibial 7. Tuli SM, Kapoor V, High tibial closing wedge Osteotomy for osteotomy has significant advantages. It is relatively a medial compartment osteoarthrosis of knee, J, 2008,42(1), 73- simpler procedure.3 External fixator is easy to apply. 77. Surgical incision is less than 2 cm. The soft-tissue 8. Stepanovic Z, Zivkovic M, Vulovic S, Acimovic L, Ristic B, dissection/surgical incision are limited to osteotomy Matic A, Grujovic Z, High Open Wedge Tibial Osteotomy, site only. There is no major dissection, so future Vojnosanit, Pregl,2011,68 (10), 867-71. replacement is easier as far as skin is concerned13. 9. Raja Izaham RM, Abdul Kadir MR, Abdul Rashid AH, Hossain Accurate degree of distraction, correction of varus is MG, Kamarul T, Finite element analysis of Puddu & Tomofix possible. Correction can also be controlled post- Plate Fixation for Open Wedge High Tibial Osteotomy, Injury, operatively due to modularity of external fixator3,14. 2011, EPUB.

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10. Hauiv B, Bronak S, Thein R, Kidron A, Midterm outcome of 15. Koshino T, Murase T, Saito T. Medial opening-wedge high opening wedge High Tibial Osteotomy for varus arthritic knee, tibial osteotomy with use of porous hydroxyapatite to treat Orthopedic, 2012, 35(2),192-6. medial compartment osteoarthritis of the knee. J Bone Joint Surg Am. 2003 Jan; 85-A (1):78-85. 11. Klinger HM, Lorenz F, Harer T, Open wedge tibial Osteotomy by hemicallotasis for medial compartment osteoarthritis, Arch 16. Majima T, Yasuda K, Katsuragi R, Kaneda K, Progression of Orthop Trauma Surg 2001; 121: 245-7. joint arthrosis 10 to 15 years after High Tibial Osteotomy, Clin Orthop 2000; 381: 177-84. 12. Spahn G, Wittig R (2002) Primary Stability of different implants in tibial opening wedge Osteotomy. A biomechanical study, J 17. Ducat A, Sariali E, Level B, Merti P, Hernigou P, Flecher X, Orthop Sci 7:683-87. Zayni R, Bonnin M, Jalil R, Amzallag J, Rosset P, Servien E, Gaudot F, Judet T, Catonne Y, Posterior Tibial slope changes

13. Briard J; Hurley S; Lin G; Witoolkollachit P; Stanish W, Total after opening and closing wedge High Tibial Osteotomy, Knee Arthroplasty After High Tibial Osteotomy Techniques in Orthop Traumatol Surg Res, 2012,98 (1), 68-74. Knee Surgery: 2011 , 10 (4), 213–217. 18. Nakamura E, Mizuta H, Kudo S, Takagi K, Sakamoto K, 14. Antonescu DN. Is knee Osteotomy still indicated in knee Open-wedge Osteotomy of proximal tibia hemicallotasis, J osteoarthritis? Acta Orthop Belg 2000; 66:421-32. Bone Joint Surg, 2001;83B:1111-5.

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CLINICO-EPIDEMIOLOGICAL CORRELATES OF HOSPITALIZED H1N1 PNEUMONITIS CASES IN A TEACHING HOSPITAL OF WESTERN INDIA DURING 2009- 2010 PANDEMIC

Patel Bhavin D1, Srivastav Vipul S2, Patel Ameekumari B3, Modi Bhautik P4

1Resident, Dept. of Medicine, 2Professor and Head, Dept. of Medicine, 3Resident, Dept. of Pathology, 4Resident, Dept. of Community Medicine, Surat Municipal Institute of Medical Education & Research (SMIMER), Surat, Gujarat, India

Correspondence: Dr. Bhavin Patel Resident, Dept. of Medicine, SMIMER, Surat - 395010 e-mail : [email protected] Mobile : 09427427206

ABSTRACT

Introduction: In late March and early April 2009, an outbreak of H1N1 influenza a virus infection was detected in Mexico. The first case of this flu in India was found at the Hyderabad airport on 13 May. As of 15 November 2009, 15411 cases of swine flu have been confirmed and 523 deaths been reported in India. Methodology: This cross-sectional study includes all adult, confirmed H1N1 positive patients in Category “C” admitted in “Swine Flu Ward” of SMIMER hospital, Surat, during the H1N1 pandemic 2009-2010. Detailed clinical evaluation and laboratory investigations were done in all 40 enrolled patients. Results: Out of total admitted 40 H1N1 positive and category C patients, 9 patients expired and 31 patients cured and discharged. Mean age of expired patients and of cured patients was 32 years and 36 years respectively. Most common symptom was fever (100%) and cough (92.5%). Breathlessness was significantly more common (p value<0.05) in patients who expired as compared to patients who got cured. Mean SGPT and SGOT was three times higher in non-fatal cases as compared to non-fatal cases. In 88.89% of the fatal cases shows higher SGPT and SGOT level more than upper normal limit which was statistically significant (p value<0.05). Conclusion: Fever was most common symptom followed by cough, headache/bodyache, throat pain, breathlessness and running nose. Poor prognostic factor were Breathlessness on admission, delay more than 2 days, cyanosis on admission, hepatic dysfunction, low platelet count.

Key words: Influenza, H1N1, Pandemic, SGPT, SGOT

INTRODUCTION The first convincing record of an influenza pandemic was of an outbreak in 1580, which began in Russia and The symptoms of human influenza were clearly spread to Europe via Africa. In Rome, over 8,000 described by Hippocrates roughly 2,400 years ago.1 people were killed, and several Spanish cities were Since then, the virus has caused numerous pandemics. almost wiped out. Pandemics continued sporadically The most extensive and severe outbreaks are caused by throughout the 17th and 18th centuries, with the influenza A viruses, in part because of the remarkable pandemic of 1830–1833 being particularly widespread; propensity of the H and N antigens of these viruses to it infected approximately a quarter of the people undergo periodic antigenic variation. Influenza A has exposed.6 16 distinct H subtypes and 9 distinct N subtypes, of which only H1, H2, H3, N1, and N2 have been The most famous and lethal outbreak was the so-called associated with epidemics of disease in humans. Spanish flu pandemic (Type A Influenza, H1N1 Influenza B and C viruses are similarly designated, but subtype), which lasted from 1918 to 1919. It is not H and N antigens from these viruses do not receive known exactly how many it killed, but estimates range subtype designations, since intratypic variations in from 20 to 100 million people. It is 10 to 25 times more influenza B antigens are less extensive than those in than total number of HIV patients currently present in influenza A viruses and may not occur with influenza C India (Currently around 2.4 million HIV positive virus.2,3,4,5 people in India).7 This pandemic has been described as

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“The greatest medical holocaust in history” and may patients in Category “C” admitted in our “Swine Flu have killed as many people as the Black Death.6 Ward” during the H1N1 pandemic 2009-2010. In late March and early April 2009, an outbreak of Inclusion Criteria: H1N1 influenza a virus infection was detected in Patients fulfilling all of the following criteria were Mexico with subsequent cases observed in many other enrolled in the study countries including India. On June 11, 2009, WHO 1. Patients of age ≥18 yrs, meeting the clinical raised its pandemic alert level to highest level phase 6 case definition of swine flu9 indicating widespread community transmission in at 2. Patients falling in “Category C” swine flu least 2 continents. April 15, 2009, and April 17, 2009, cases 10 the Centers for Disease Control and Prevention (CDC) 3. Patients giving consent to participate in the confirmed the first two cases of human infection with a study. pandemic influenza A (H1N1) virus in the United Exclusion Criteria: States.8 1. Age <18 years The first case of this flu in India was found at the 2. Cat A & Cat B Patients10 Hyderabad airport on 13 May, when a man traveling 3. Refusal to participate in study. from US to India was found H1N1 positive. The According to the above inclusion criteria, 40 patients of transmission of the flu increased dramatically the Category “C” H1N1 influenza were enrolled in to the beginning of August, with the first death due to swine study. Detailed clinical evaluation was done in all the flu being reported in Pune on 4 of August 2009. An enrolled patients. Respiratory specimens (throat / nasal intense public panic and media attention put this swabs-2) were collected on admission, as per the CDC epidemic in limelight like never before. As of 15 guidelines.11 This was tested by RT-PCR to detect November 2009, 15411 cases of swine flu have been H1N1 virus at the Regional Microbiology Laboratory at confirmed and 523 deaths been reported in India. Case the Government Medical College Surat. clustering had been observed around Delhi, Pune and Bangalore cities with 80% cases being reported from 14 Routine laboratory investigations were done on major cities. admission. Hb, PCV, Platelet count were done in automated cell counters in pathology lab of SMIMER During acute influenza, virus may be detected in throat hospital. PSMP was seen manually by the Pathologist. swabs, nasopharyngeal washes, or sputum. The virus Patients were followed up to recovery / final outcome. can be isolated by use of tissue culture—or, less commonly, chick embryos—within 48–72 h after Data analysis: inoculation. Other laboratory tests generally are not helpful in the specific diagnosis of influenza virus The information thus collected was entered on a excel infection. Leukocyte counts are variable, frequently spreadsheet and analyzed with the help of SPSS being low early in illness and normal or slightly elevated software, Epi info software and appropriate statistical later. Severe leucopenia has been described in tests for significance. overwhelming viral or bacterial infection, while Ethical Considerations: leucocytosis with >15,000 cells/L raises the suspicion of secondary bacterial infection. Permission was obtained from the Institutional Ethical Committee of the Surat Municipal Institute of Medical This pandemic affects Surat, city located in the south Education and Research, Surat before commencing of Gujarat, state located in the western part of India. In the study. Confidentiality of the data collected was Surat Municipal Institute of Medical Education and maintained strictly throughout the study. Research (SMIMER), 40 patients were diagnosed H1N1 positive and admitted during this pandemic in 2009. This study was conducted to study the clinic- RESULTS epidemiological correlates among these 40 patients. Total 40 patients were found positive and admitted from 1st September, 2009 to 30th September, 2010. METHODOLOGY Out of them, 9 patients expired. Admission rate and mortality was highest among 18-30 years (77.78%) age Study Type: group, suggesting high fatality rate among young adults. This is a cross-sectional observational study conducted Mean age of 32 years was reported among expired over 1 year in Department of Medicine of Surat patients (range 22 years to 49 years). Mean age of 36 Municipal Institute of Medical Education and Research years was reported among cured patients (range 18 (SMIMER) in Surat city of Gujarat, a western state of years to 60 years). India. Surat city is one of the most rapidly growing The evidence of benefit from antiviral therapy was cities of India and has a large number of industries strongest when treatment is initiated within 48 hours which are manned mainly by migrant labourers. This after the onset of illness (pvalue <0.05) in comparrision study includes all adult, confirmed H1N1 positive with patient starting antiviral after 48 hours of onset of illness. None of the patient who expired had received

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NATIONAL JOURNAL OF MEDICAL RESEARCH antiviral treatment within 2 days of onset of illness, Mean platelet count was low in fatal cases as compared suggesting that delay in starting treatment associate to non-fatal cases. And this difference is statistically with poor outcome. There is no significant association significant(p-value < 0.05). of death due to H1N1 influenza with delay in initiation of antiviral therapy after 2 days or next subsequent days. Initial treatment by general practitioners and Table 2: Symptomatology in H1N1 Positive delayed diagnosis and referral to higher center, may be patients possible explanations for late start of Oseltamivir in suspected or confirmed influenza A (H1N1) patients. Symptoms Non fatal Fatal No. of 100% deaths occurred 5 days after onset of illness. cases cases patients Mean survival period(Defined as period from onset of (%) (n=31) (%) (n=9) (%) illness to death)in fatal cases 8.33 days. (n=40) Fever 31(100.00) 9(100.00) 40 (100.00) Cough dry/ with 24 (77.42) 2 (22.22) 26 (65.00) Table.1 Baseline characteristics and disease expectoration history of 2009 pandemic influenza A (H1N1) virus Headache/body 22 (70.97) 8 (88.89) 32 (80.00) infected ache Throat Pain 20 (64.52) 6 (66.67) 26 (65.00) Non-Fatal Fatal Breathlessness* 15 (48.39) 9 (100.00) 24 (60.00) Characteristics cases cases(n=9) Running 12 (38.71) 4 (44.44) 16 (40.00) (%)(n=31) nose/Sneezing Age Group Nausea/vomiting 6 (19.35) 1 (11.11) 7 (17.50) 18-30 years 12 (38.71) 7 (77.78) Diarrhoea 3 (9.68) 1 (11.11) 4 (10.00) 31-40 years 8 (25.80) 0 (0.00) Abdominal Pain 3 (9.68) 0 (0.00) 3 (7.50) 41-50 years 9 (29.03) 2 (22.22) Conjunctivitis 2 (6.45) 0 (0.00) 2 (5.00) >50 years 2 (6.45) 0 (0.00) Muscle pain 1 (3.22) 1 (11.11) 2 (5.00) Mean Age(Yrs)-(Range) 36 (18-60) 32 (22-49) Haemoptysis 1 (3.22) 1 (11.11) 2 (5.00) Gender (*p value<0.05) Male 14 (45.16) 5 (55.56) Female 17 (54.83) 4 (44.44) Time interval from onset of illness to admit in Thrombocytopenia was seen in 55.55% in fatal cases as SMIMER Hospital compared to non-fatal cases (29.03%). Mean SGPT 1-4days 19 (61.29) 3 (33.33) and SGOT was three times higher in non-fatal cases as 5-10 days 12 (38.71) 5 (55.55) compared to non-fatal cases. In 88.89% of the fatal >10 days 0 1 (11.11) cases shows higher SGPT and SGOT level more than Referral from general 67.74% 100% upper normal limit which was statistically significant practitioner/physician (p value<0.05). Mean bilirubin was 1.45 in fatal cases Time interval from onset of illness to start slightly higher than non-fatal cases. 44.45% of fatal treatment cases were having elevated total bilirubin. There was no <2 days 7 (22.58) 0 (0.0) significant difference of serum creatinine and blood 2-4 days 8 (25.81) 4 (44.44) urea in fatal and non-fatal cases. There was no 4-6 days 7 (22.58) 3 (33.33) significant difference in mean random blood sugar >6 days 9 (29.03) 2 (22.22) between fatal and non-fatal cases. Mechanical ventilation 2 (6.45) 9 (100.00) Duration of Hospital stay <3 days 0 5 (55.56) DISCUSSION 3-5 days 5 (16.13) 0 In our study, out of 40 patients, 45.24% patients were 5-10 days 25 (80.64) 2 (22.22) male while 54.76% were female, which is compare to >10 days 1 (3.20) 2 (22.22) the Saurashtra study12 where 51.5% were male and 48.5% were female. There was apparently equal As seen in Table 2 Breathlessness was significantly affection of both female and male. The difference more common (p value<0.05) in patients who expired between the number of male and female patients was as compared to patients who got cured. While statistically not significant in our study. (p>0.05) remaining symptoms were almost equal in both groups. The median age in our study was 33 years. 67.5% As seen in table 3, there was no significant difference patients were young (age <40years). In Saurashtra of mean hemoglobin between fatal and non-fatal cases. study12 median age was 28 years and around 61% Mean WBC count was on upper normal limit in non- patients were young (age <45 years). The higher fatal cases. In non- fatal cases leucopenia was seen in incidence in younger age group was statistically 12.9% cases, while leucocytosis was seen in 45.16% significant as compared to the incidence in older age cases. In fatal cases leucopenia was seen in 22.22% group. cases, while leucocytosis was seen 22.22% patients.

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Tabel 3: Laboratory and radiographic findings on hospital admission in influenza (H1N1) infected patients Observation Non-fatal cases (n=31) Fatal cases (n=9) p value Hemoglobin gm/dl(mean±SD) 11.90±2.13 12.54±2.61 0.48 Leukocyte count(mean±SD) 9200±4427.26 6611.11±3307.73 0.11 Platelet count (mean±SD)/mm3 217064±95340 145770±36863 0.03* SGPT(mean±SD)U/lit 44.22±47.16 208±201.93 0.0001* Elevated alanine aminotransferase (>40 U/ltr) SGPT 38.71% 88.89% 0.02* SGOT(mean±SD) 49.58±55.70 424.55±710.28 0.004* Elevated aspartate aminotransferase (>40 U/ltr) SGOT 29.03% 88.89% 0.004* Total bilirubin(mean±SD)mg/dl 0.91±0.41 1.45±0.57 0.002* Elevated total bilirubin (>1.2 mg/dl) 16.12% 44.45% 0.18 Serum Creatinine(mean±SD)mg/dl 1.01±0.50 0.8±0.31 0.24 Serum Creatinine >1.4mg/dl 16.12 11.11% 0.8 Blood urea(mean±SD)mg/dl 34.70±22.14 33.55±10.32 0.88 Blood urea>40mg/dl 22.58% 22.22% 0.66 Random blood sugar(mean±SD)mg% 109.54±34.02 116±36.71 0.62 * p-value < 0.05

The median age of fatal case in our study was 28 years. haemoglobin in our study. As compared with China 77% patients were from age group of 25-44 years. In study total WBC count on higher side. This may be due Saurashtra study12 median age of fatal case was 29. 40% to number of critical patients were more in our study as patients were from age group of 25-44years. compared with china study. Both leucopenia and leucocytosis noted in our study. As compared with In our study mortality rate was 22.5% while in Saurashta, China and USA study16 Leucopenia seen in Saurashtra study12 mortality was 25.91% which was less number of patients. While leucocytosis seen more similar to our findings. In California study13 mortality as compared to other study. This may be due to was 7%. The higher mortality may be attributed to a development of secondary bacterial infection at home selection bias as we had taken only category “C” or privet hospital to presentation at SMIMER hospital patients in our study. more in our patients as compared with other study. In our study mean hospital stay was 5.37 ±2.5. In Delhi Mean lymphocyte counts were slightly on higher side as study14 duration of stay was 6.4±2.9. The difference compare with china study. While lymphopenia seen may be because in Delhi study only ICU indoor slightly on lower side as compared with Saurashtra and patients were included, while we had included all China study. patients. Mean platelet counts were almost similar with China In our study 42.5% patients were presented to hospital study. While thrombocytopenia seen more as compared within 4 days of onset of symptoms and 57.5% patients with other study. While incidence of Thrombocytosis were presented after 4 days of onset of symptoms. In less as compared with other study.15,16 Saurashtra study12 48.6% patients were presented to Derange LFT seen in almost half of patients in our hospital within 4 days of onset of symptoms and 51.4% study. Elevated SGPT level seen slightly more as patients were presented after 4 days of onset of compared with USA study16 and less as compared with symptoms which was similar to our findings. Saurashtra study.12 While abnormal SGOT level was Clinical features and examination: seen more or less similar as compared with Saurashtra and USA study. Elevated Serum bilirubin level seen In our study most common symptom was fever (100%) almost one forth patient in our study, which is 12 and cough (92.5%) which was similar to Saurashtra comparable with Saurashtra study. and California study13. Headache-Bodyache (80%) were common in our study, while it was less common in Saurashtra(21.5%) and California study13 (33%). CONCLUSION Throat pain was found on 65% patients which was almost similar to Saurashtra study. Presence of Out of 40 patients, 45.24% were male and 54.76% were breathlessness was slightly more in our study(60%) as female. Majority of patients were young age group, compared to Saurashtra (53.3%) and California 47.5% patients from age group between 18-30 years. study(56%). There is significant difference in number Male and female were equally affected. We had high of cases cured and expired having breathlessness at the mortality rate (22.5%) in our study as we included only time of admission. GI symptoms like nausea-vomiting category “C” patients. Fever was most common were present in 17.5% patients, abdominal pain in 7.5% symptom followed by cough, headache/bodyache, of patients, and diarrhea in 10.0% patients. throat pain, breathlessness and running nose. This was consistent with other studies. Vomiting, abdominal As compared with Saurashtra and China study15, there pain, jaundice and diarrhoea were seen less common in was no significant difference between mean levels of our study. Delay more than 48 hours from onset of

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NATIONAL JOURNAL OF MEDICAL RESEARCH symptoms to starting of treatment was associated with 8. Swine influenza A (H1N1) infection in two children -- higher mortality and morbidity. Poor prognostic factor Southern California, March-April 2009. MMWR Morb Mortal Wkly Rep 2009; 58:400-402. were Breathlessness on admission, delay more than 2 days, cyanosis on admission, hepatic dysfunction, low 9. http://india.gov.in/outerwin.php?id=http://mohfw- platelet count. h1n1.nic.in (Accessed on 25/11/2011) 10. Ministry of Health & Family Welfare Pandemic Influenza A (H1N1),Guidelines on categorization of Influenza A H1N1 cases during screening for home isolation, testing treatment, REFERENCES and hospitalization (Revised on 05.10.09) Available at : 1. Beveridge, W I (1991). "The chronicle of influenza epidemics". www.mohfw-h1n1.nic.in/.com (Accessed on 25/11/2011) History and Philosophy of the Life Sciences 13 (2): 223–234. 11. http://mohfw-h1n1.nic.in/documents/PDF/Annexure- 2. Lamb RA, Choppin PW (1983). "The gene structure and XVII.pdf (Accessed on 25/11/2011) replication of influenza virus". Annu. Rev. Biochem. 52: 467– 12. Chudasama RK, Patel UV, Verma PB, Amin CD, Shah HM, 506. Banerjee A, Patel RR. Characteristics of Fatal Cases of 3. Bouvier NM, Palese P (September 2008). "The biology of Pandemic Influenza A (H1N1) from September 2009 to influenza viruses". Vaccine 26 Suppl 4: D49–53.. January 2010 in Saurashtra Region, India. Online J Health Allied Scs.2010;9(4):9 4. Ghedin, E; Sengamalay, NA; Shumway, M; Zaborsky, J;

Feldblyum, T; Subbu, V; Spiro, DJ; Sitz, J et al. (October 2005). 13. Janice K. Louie, MPH Meileen Acosta, Kathleen Winter; "Large-scale sequencing of human influenza reveals the Factors Associated With Death or Hospitalization Due to dynamic nature of viral genome evolution". Nature 437 (7062): Pandemic 2009 Influenza A(H1N1) Infection in California; 1162–6. JAMA, November 4, 2009—Vol 302, No. 17

5. Lynch JP, Walsh EE (April 2007). "Influenza: evolving 14. Samra T, Pawar M, Yadav A. Comparative evaluation of acute strategies in treatment and prevention". Semin Respir Crit Care respiratory distress syndrome in patients with and without Med 28 (2): 144–58. H1N1 infection at a tertiary care referral center. Indian J Anaesth 2011;55:47-51 6. “Pandemic (H1N1) 2009 - update 76”.Global Alert and

Response (GAR). World Health Organization. 2009-11-27. 15. Bin Cao, M.D., Xing-Wang Li, M.D., Yu Mao, M.D., Jian Available at Wang, M.D; Clinical Features of the Initial Cases of 2009 http://www.who.int/csr/don/2009_11_27a/en/index.html. Pandemic Influenza A (H1N1) Virus Infection in China; The (Accessed on 25/11/2011) new England journal of medicine; 24 December , 2009

7. Modi B, Patel P, Patel S. A Profile of Patients Registered at 16. Seema Jain, M.D., Laurie Kamimoto, M.D., M.P.H., Anna M. Anti Retroviral Therapy (ART) Centre at Surat Municipal Bramley, M.P.H., Hospitalized Patients with 2009 H1N1 Institute of Medical Education & Research (SMIMER) in Surat Influenza in the United States, April–June 2009 The new City, Gujarat, India. SAARC Journal of Tuberculosis, Lung England journal of medicine; November 12, 2009 Disease And HIV/AIDS 2011;VIII(2):11-16 .

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

SUSCEPTIBILITIES OF ESBL-PRODUCING ENTEROBACTERIAECEAE TO ERTAPENEM, MEROPENEM AND PIPERACILLIN-TAZOBACTAM

Shah Kinal1, Mulla Summaya A2

1Consultant Microbiologist, Global Baroda Hospital, Vadodara 2Professor & Head, Department of Microbiology, Government Medical College, Surat

Correspondence: Dr. Kinal Shah Email: [email protected]

ABSTRACT

Objectives: The susceptibilities of ESBL-producing E.coli and K. pneumoniae to ertapenem, meropenem and piperacillin-tazobactam.53 strains of E.coli and K. pneumoniae were studied. Methods: They were originally resistant to ceftazidine. Minimum inhibitory concentration of the strains towards ertapenem, meropenem and piperacillin-tazobactam were determined by Vitek-2 compact system. Results: The MICs of all ertapenem and meropenem for all isolates were <0.5 μg/ml and <0.25 μg/ml respectively and MIC of piperacillin-tazobactam was between 4 to 16 μg/ml. ESBL-producing organisms were more susceptible to ertapenem and meropenem. They were susceptible to piperacillin-tazobactam thus in our hospital ertapenem, meropenem and piperacillin-tazobactam are drugs of choice for them.

Keywords: Ertapenem, ESBL, Meropenem, E.coli, K .pneumonia.

INTRODUCTION Laboratory strains of Gram negative bacteria (Escherichia coli and Klebsiella penumoniae) Production of extended spectrum β-lactamases (ESBL) previously shown to produce ESBL were studied. by gram negative bacteria has become a major issue in ESBL producer was defined as an organism showing the fields of clinical microbiology and infectious disease <15mm zone of inhibition by disc diffusion towards in past 5 years (1-3). Extensive use of third generation ceftazidime. Subsequently it was proven to be an cephalosporins has contributed to the evolution of ESBL produced by the double disc diffusion method ESBL (Extended Spectrum β Lactamase). These showing an increase of > 5mm in the presence of plasmid mediated group of enzymes are the products clavulonic acid. MIC of the laboratory strains were of point mutations at the active site of TEM, SHV, determined by Vitek 2 Compact system against OXA enzymes. Etrapenem, Meropenem and Piperacillin-tazobactam Worldwide debate regarding the feasibility of according to manufacturer’s instruction. prescribing third and fourth generation cephalosporins for treatment of patients infected with ESBL producing bacteria. Therapeutic options are few and include RESULT aminoglycosides, quinolones, piperatazobactam4 and We studied ESBL producing bacteria isolated from carbapenem 5. urine, pus, sputum, blood, high vaginal among 53 In order to establish a clinical treatment protocol in our ESBL producer 26 isolates of E. coli and 27 isolates of institution we measured the MIC (Minimum Inhibitory Klebsiella pneumoniae. Concentration) of Etrapenem & Meropenem and Among the antimicrobial agents tested, the three piperacillin tazobactam against ESBL producing strains carbapenems: ertrapenem, imipenem and meropenem of enterobacteriaceae. and pipera-tazabactam were overall the most consistently active in vitro against E. coli and K. MATERIALS & METHODS pneumoniae. We compared MIC of Etrapenem, Meropenem and Graph 1 shows susceptibility of K. pneumoniae to 18 Piperacillin-tazobactam against various ESBL antimicrobial agents. Graph2 shows susceptibility of E. producing gram negative aerobic bacteria. coli to 18 antimicrobial agents.

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Figure 1: ESBL K. pneumoniae susceptibilities to ertapenem and other antibiotics. (Lighter bar represents percentage of isolates sensitive to antibiotics. Darker bar represents percentage of intermediately sensitive antibiotics.)

The MIC of ertrapenem, imipenem and meropenem pneumoniae are susceptible to quinolone such as were < 0.5, < 1 and < 0.25μg/ml and MIC of pipera- levofloxacin, ESBL producing E. coli and K. tazabactam was in the range of < 4 to 16 μg/ml. pneumoniae are 100% and 81.48% sensitive to amikacin (aminoglycoside) respectively. 96.15% and In regard susceptibility of ESBL producing organisms 100% resistance to cefepime respectively and 100% to other antibiotic, 3% E.coli and 18.51% K. resistant to ceftazidine for all clinical specimens.

Figure 2: ESBL E.coli susceptibilities to ertapenem and other antibiotics. (Lighter bar represents percentage of isolates sensitive to antibiotics. Darker bar represents percentage of intermediately sensitive antibiotics.)

DISCUSSION inducible or constitutive non-transferable. The second type of β-lactamases is the plasmid-mediated ESBLs The β-lactamases are a large family of enzymes which are constitutively expressed and transferable [3]. representing the major mechanism of resistance of Cotransfer of resistance against aminoglycosides, bacteria against β-lactam antibiotic. More than 340 β- trimethoprim, sulfonamides, tetracyclines, [1,3] lactamase enzymes have been detected until 2004 . chloramphenicol and quinolones is common on ESBL ESBL production by gram negative bacteria has plasmids. become a major problem in clinical practice in last few years due to extensive use of the β-lactam antibiotic. There is ongoing debate about the optimal treatment of The chromosomally mediated β-lactamases are patients infected with ESBL producing bacteria and the

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NATIONAL JOURNAL OF MEDICAL RESEARCH actual in vivo activity of various third and fourth phenomena. We did not test the antibiotics with generation cephalosporin antibiotic against these additional β-lactamase inhibitors or combinations. bacteria. A strict recommendation [8] has been published rejecting the use of third and fourth generation cephalosporins against ESBL producing CONCLUSION bacteria resulting vastly increased use of carbapenems [2] or non β-lactam agents. Uncomplicated urinary tract Meropenem and ertapenem remain good choices for infection caused by ESBL producing bacteria could the treatment of infections suspected to be due to possibly be treated with cephalosporins, as the ESBL producing E.coli and K. pneumoniae. concentration achieved in urine is very high but this Piperacillin-tazobactam also has a very good assumption must be clinically evaluated. Cefepime use susceptibility in our study and it is not an effective for systemic infections caused by ESBL producing drug. So, piperacillin-tazobactam can be drug of choice bacteria may fail 4 due to selection of ESBL producing for ESBL producing E. coli and K. pneumoniae. bacteria during treatment and several studies have documented clinical failures. Therefore cefepime act against ESBL-producing is not recommended unless REFERENCES given in high dose (> 4g/day) and combined with 1. Jacoby GA,Muoz-Price I.S: Mechanisms of disease: the new aminoglycoside or quinolone [2]. Prospective studies of beta –lactamases. N EngI J Med2005;352:380-91 efficacy of third or fourth generation cephalosporins 2. Rupp M E,Fey PD:Extended spectrum beta-lactamase (ESBL)- for such infection will probably never be conducted producing Enerobacteriaceae. Drugs 2003;63:353-65. 8 due to the aforementioned recommendations and 3. Shah AA, Hasan F, Ahmed S,Hameed A: Extended spectrum would probably even be considered unethical today. beta-lactamases(ESBLs): characterization,epidemiology and detection.Crit Rev Microbial 2004;30:25-32. Currently, carbapenems are regarded as the preferred agents for treatment of infection caused by ESBL or 4. Coudron PE, Hanson ND, Climo MW: Occurrence of 2,4 extended-spectrum and AmpC beta-lactamase in blood stream AmpC producing bacteria . However, chromosomally isolates of K. pneumoniae: isolates harbor plasmid-mediated mediated extended-spectrum serine protease (group FOX-5 ad ACT-1 AmpC beta-lactamases. J Clin Microbial 2F) and metallic β-lactamases active against 2003;41:772-77. carbapenems are not uncommon. In short, increased 5. Nordman P,Poirel L: Emerging carbapenemases in Gram- utilization of carbapenem against ESBL producing negative aerobes. Clin Microbial Infect 2002;8:321-31. bacteria will possibly lead to improved patient 6. Livermore DM, Sefton AM,ScottGM:Properties and potential outcome. of ertapenem. J Antimicrob Chemother 2003;52:331-44. In our study, both ertapenem and meropenem showed 7. Higgins PG,Wisplinghoff H,Stefanik D,Seifert H: In vitro very low MICs against ESBL producing organisms. activities of beta-lactamase inhibitors clavulanate, sulbactam,and tazobactam alone or in combination with beta- We found that piperacillin-tazobactam was also lactams against epidemiologically characterized multidrug- effective against ESBL producers, and its effectiveness resistant Acinetobacter baumanii strains. Antimicrob Agents is 96.29% for K. pneumoniae and 100% for E. Coli. Chemother 2004;48:1586-92. These findings correlate to the Asia-Pacific region 8. National Committee for clinical Laboratory Standards: study [11] reporting that most ESBL strains were still Performance Standards for Antimicrobial Susceptibility Testing: sensitive to piperacillin-tazobactam, but already more Approved Standard M100-S9. Waye, National Committee for resistant to ticaricillin-clavulanate. Thus, in our Clinical Laboratory Standards, 1999. hospital, tazobactam appears to be much more 9. Chitnis S,Chitnis V,Hemvat N, Chitnis DS: In vitro effective ESBL inhibitor, and piperacillin-tazobactam is susceptibility to meropenem and other antimicrobial agents among Gram-negative bacilli isolated from hospitalized patients becoming drug of choice for infection suspected to be in central India. Chemotherapy 2006;52:43-45. caused by ESBL-producing bacteria. Piperacillin tazobactam is cost effective than carbapenem. So, here 10. Erdem I,Kucukercan M,Caran N: In vitro activity of combination therapy with cefepime, piperacillin-tazobactam, or in our Hospital it has become a drug of choice. One meropenem with ciprofloxacin against multidrug-resistant should consider it as a better option specially for non Pseudomonas aeruginosa strains. Chemotherapy 2003;49:294- affordable patients. 97. There are several limitations to our study. First, only 11. Bell JM,Turnidge JD,Jones RN: SENTRY Asia-pacific Participants. Prevalence of extended-spectrum beta-lactamase- relatively small number of E. coli and K. pneumoniae producing Enterobacter cloacae in the Asia –pacific region: isolated were tested. However, we believe that this results from the SENTRY Antimicrobial surveillance Program, number is quite representative of the overall studied 1998 to 2001. Antimicrob Agents Chemother 2003;47:3989-93.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

CHOICE OF OPERATIVE TECHNIQUE FOR EMERGENCY CASES OF SIGMOID VOLVULUS IN A TERTIARY CARE HOSPITAL OF GUJARAT

Patel Upendra1, Bhautik Modi2

1Assistant Professor, Department of Surgery 2Resident, Department of Community Medicine, Surat Municipal Institute of Medical Education & Research, Surat

Correspondence: Dr. Upendra Patel 1Assistant Professor, Department of Surgery, Surat Municipal Institute of Medical Education & Research, Surat - 395010

ABSTRACT

Introduction: Sigmoid volulus is by far the most common type of volvulus, accounting for 75 to 90 % of all volvulus. Most common presenting symptom is abdominal pain and constipation. . It may be initially managed by sigmoidoscopy or rectal tube insertion but where fear of compromised vascular supply of the sigmoid colon is associated, immediate laparotomy after resuscitation must be undertaken to avoid gangrene and septic shock. The primary objective of the study is to demonstrate the most suitable procedure for management of patients with sigmoid volvulus needing emergency surgery. Methodology: All patients presenting with volvulus and needing emergency operative intervention during 1 years duration from January 2010 to December 2011 were included in this study. Total 41 patients were included in the study of which 25 presented with gangrenous sigmoid colon on laparotomy and viable sigmoid colon was present in the remaining 16 cases. Comparison is done with respect to mortality and early morbidity associated with different operative procedures. Results: Highest mortality i.e. 33.3% observed among patients who underwent primary resection and anastomosis without proximal colostomy. Wound infection was more common following all forms of stoma procedure. Conclusion: Hartmann’s procedure goes a long way in decreasing mortality due to sigmoid volvulus in the emergency setting.

Key Words: Volvulus, Sigmodoscopy, Detorsion, Hartman’s Procedure, Resection and anastomosis

INTRODUCTION chronic constipation, which leads to a long redundant sigmoid colon with narrowing of the mesentery. Volvulus refers to torsion of a segment of the alimentary tract, which often leads to bowel Volvulus of the sigmoid colon is commoner in obstruction. The most common sites of volvulus are Africans, Asians, and South Americans. This has been the sigmoid colon and cecum. Volvulus of other attributed to their consumption of high roughage diet.2 portions of the alimentary tract, such as the stomach, It is common in India, Eastern Europe and gallbladder, small bowel, splenic flexure, and transverse Scandinavia.3 colon, are rare.1 Most common presenting symptom is abdominal pain Sigmoid volvulus occurs when the last part of the large and constipation while vomiting is usually a late bowel just before the rectum (the sigmoid shaped symptom. Usually, huge abdominal distension is sigmoid colon) twists on its self. It is by far the most present and erect abdominal skiagram reveals omega common type of volvulus, accounting for 75 to 90 % sign which is a distended loop of sigmoid colon filling of all volvulus. Sigmoid volvulus accounts for up to 8 the entire abdomen with its base in the left iliac region. % of all cases of intestinal obstruction. It is commoner It may be initially managed by sigmoidoscopy or rectal in the elderly, patients with chronic illnesses, those in tube insertion but where fear of compromised vascular long term institutions like nursing homes, and patients supply of the sigmoid colon is associated, immediate with mental illness. It can also been seen in children laparotomy after resuscitation must be undertaken to under the age of ten. Men are more often affected than avoid gangrene and septic shock. Even following women.2 Common to all patients with this condition is conservative detorsion, elective sigmoidectomy is

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NATIONAL JOURNAL OF MEDICAL RESEARCH advocated due to high rates of recurrence. Various with primary anastomosis without proximal surgical procedures for sigmoid volvulus in the colostomy. emergency setting are available with conflicting results Comparison is done with respect to mortality and early emanating out of various studies regarding superiority morbidity associated with these operative procedures of one procedure over the others. viz, Hartmann’s procedure, primary colonic resection The primary objective of the study is to demonstrate and anastomosis and primary resection and the most suitable procedure for management of anastomosis with proximal transverse loop colostomy. patients with sigmoid volvulus needing emergency Permission was obtained from the Institutional Ethical surgery. Also, a comparison is done with respect to Committee of the Surat Municipal Institute of Medical mortality and early morbidity associated with various Education and Research, Surat before commencing of operative procedures viz, Hartmann’s procedure, the study. Confidentiality of the data collected was primary colonic resection and anastomosis and maintained strictly throughout the study. Data entry primary resection and anastomosis with proximal and analysis was done using Microsoft Excel. transverse loop colostomy.

METHODOLOGY RESULTS This study was done at department of Surgery of Surat Total 41 patients were included in the study of which Municipal Institute of Medical Education and Research 25 presented with gangrenous sigmoid colon on (SMIMER), teaching hospital of Surat, city located in the laparotomy and viable sigmoid colon was present in southern Gujarat. All patients presenting with volvulus the remaining 16 cases. Out of these patients, 22 and needing emergency operative intervention during (53.65%) were males and 19 (46.34%) were females; 1 years duration from January 2010 to December 2011 54% patients were over 60 years of age and only 12% were included in this study. Patients who presented patients were under 40 years of age. Average duration with sigmoid volvulus where de-rotation was possible of presentation following onset of obstructive with rectal tube placement were excluded from the symptoms was 4.4 days. study. Total 41 patients were included in the study of which 25 presented with gangrenous sigmoid colon Table 1 shows presence of co morbidities among the on laparotomy and viable sigmoid colon was present patients included in the study. in the remaining 16 cases. Surgical decision making regarding choice of surgical procedure depended Table 1: Co morbid conditions presents in the upon the presence of gangrenous gut, time of patients of Sigmoid Volvulus who had undergone presentation following onset of obstructive features, emergency surgery (n=41) (multiple answers) extent of proximal colonic dilatation, co morbidities Number of patients Co-morbid conditions and surgeon’s preference. (%) Out of 25 patients with gangrenous sigmoid colon, 15 Hypertension 12 (29.26) underwent Hartmann’s procedure (sigmoidectomy Diabetes Mellitus 8 (19.51) with closure of rectal stump and proximal end Neuropsychiatric disorder 14 (34.14) colostomy) and 10 patients underwent sigmoidectomy Osteo-arthritis 9 (21.95) with end to end anastomosis and proximal transverse COPD/Asthma 3 (7.32) loop colostomy. All patients underwent proximal gut None 4 (9.75) decompression after sigmoidectomy to decrease abdominal distension and enable better abdominal Outcome was analysed in all groups by assessing closure. complications, blood requirement and operating time. Operating times, intra-operative and postoperative Out of 16 patients with viable sigmoid colon, 10 blood requirement increased in patients who underwent Hartmann’s procedure and 6 underwent underwent primary anastomosis with/ without sigmoidectomy with primary end to end anastomosis proximal colostomy. of the colon. In all patients who underwent resection

Table 2: Outcome following Surgery Outcome following Gangrenous Gut (n=25) Viable Gut (n=16) surgery Hartman’s(n=15) Resection anastomosis with Resection and Hartman’s proximal Colostomy (n=10) anastomosis (n=6) (n=10) Mortality 3 2 2 1 Wound infection 5 4 1 4 Burst abdomen 1 1 1 1 Colostomy retraction 1 - - 1 Anastomotic leak - - 2 -

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NATIONAL JOURNAL OF MEDICAL RESEARCH

Highest mortality i.e. 33.3% observed among patients general condition. One of the most important factors who underwent primary resection and anastomosis involved in success of resection and primary without proximal colostomy. Wound infection was anastomosis is the surgeon’s ex- perience.10 more common following all forms of stoma procedure. In our hospital, like most other institutes in India, the Incidence of burst abdomen was also highest (16.6%) same sets of surgeon are deputed for emergency in patients who did not have a proximal colostomy and surgery for a period of 24 hours. Also, emergencies are underwent primary anastomosis following handled mainly by emergency surgeons and residents, sigmoidectomy. Anastomotic dehiscence was seen in the junior most tiers of surgeons in the institute. Thus, nearly 33.3% in this group. Two patients who surgical skill and experience also becomes an important underwent Hartmann’s procedure initially needed issue in the success of anastomosis done under less relaparotomy due to colostomy retraction in the early than optimal conditions. Another factor is surgeon postoperative period. All patients who underwent fatigue. As evident in the results, 78% of surgeries primary resection and anastomosis and had started beyond midnight. But after a surgical day anastomotic leak were later converted to Hartmann’s spanning over 18 hours and often comprising more procedure but only one of them survived, the rest than six major emergency surgeries, surgeon fatigue succumbing to sepsis. also has a major bearing on the quality of the

anastomosis. In this study, it was found that there was DISCUSSION anastomotic leak in all 2 of the 6 primary anastomosis Depending upon patient’s condition and choice of (without colostomy) done beyond midnight. Thus, surgeon, any of the available treatment options can be keeping this factor of surgeon fatigue in mind, even in selected for patients presenting with sigmoid volvulus. cases of viable gut, in most patients operated beyond But non-operative de-torsion with sigmoidoscopy or midnight, Hartmann’s procedure was done, limiting rectal tube insertion followed by early elective mortality to the least. sigmoidectomy is preferred in the emergency conditions to prevent recurrence.4,5 CONCLUSION Surgeon should limit his choice to Sigmoid volvulus is a surgical emergency. If possible, mesosigmoidoplasty or sigmoidopexy in emergency conservative (non-operative) de-torsion with elective surgery where gut is viable to avoid the high risk of sigmoidectomy is the procedure of choice. If anastomotic leak associated with resection and emergency surgery is indicated, Hartmann’s procedure anastomosis in the emergency setting.6 But the should be the procedure of choice especially if done recurrence rate is high after this procedures. beyond midnight by less experienced surgeons towards Sigmoidectomy with or without anastomosis has gained the end of an operative schedule. Thus, Hartmann’s agreement as definitive treatment of sigmoid volvulus by procedure goes a long way in decreasing mortality due most of the authors.7,8 to sigmoid volvulus in the emergency setting.

The average days of presentation are 4.4 days after REFERENCES onset of obstructive symptoms in our study. Thus, the chances of patients having advanced disease and 1. Sigmoid volvulus. Available at : http://www.uptodate.com/ increased incidence of ischemic and gangrenous bowel contents/sigmoid-volvulus Last accessed on 7/5/2012 is more. Also, most patients were elderly and with 2. Sigmoid volvulus. Available at : http://www.abdopain.com/ comorbidities thus increasing the risk of complications sigmoid-volvulus.html accessed on 7/5/2012 3. Shepherd JL — The epidemiology and clinical presentation of and morbidity/mortality following surgical sigmoid volvulus. Br J Surg 1969; 56: 353-9. intervention. 4. Welch GH, Anderson JR — Acute volvulus of the sigmoid It has been documented previously by various studies colon. World J Surg 1987; 11: 258-62. that in the presence of gangrenous gut, Hartmann’s 5. Gibney EJ — Volvulus of the sigmoid colon. Surg Gynecol procedure is the surgical intervention of choice as Obstet 1991; 173: 243-55. primary resection and anastomosis is associated with an 6. Akgun Y — Mesosigmoplasty as a definitive operation in treatment of acute sigmoid volvulus. Dis Colon Rectum 9 unacceptably high mortality. Comparing mortality rate 1996;39: 579-81. of different procedures in our study, mortality was 7. Kuzu MA, Aslar AK, Soran A, Polat A, Topcu O, Hengirmen S— highest i.e. 33.33% in those undergoing resection and Emergent resection for acute sigmoid volvulus – results of 106 primary anastomosis only followed by 20% in patients consecutive cases. Dis Colon Rectum 2002; 45: 1085-90. undergoing Hartmann’s procedure with gangrenous 8. Dulger M, Canturk NZ, Utkan NZ, Gonullu NN — Manage- gut, 20% in those undergoing primary anastomosis ment of sigmoid colon volvulus. Hepatogastroenteroly 2000; 47: with a proximal colostomy and least in patients 1280-3. undergoing Hartmann’s procedure with viable 9. Bagarani M, Conde AS, Longo R, Italiano A, Terenzi A, Venuto G — Sigmoid volvulus in west Africa: a prospective gut(10%). Also, the increased mortality in the group study on surgical treatments. Dis Colon Rectum 1993; 36: 186- undergoing resection and anastomosis with proximal 90. colostomy may be explained by the increased operating 10. Raveenthiran V — Restorative resection of unprepared left- time and blood requirement intaoperatively and colon in gangrenous vs viable sigmoid volvulus. Int J Colorectal postoperatively in compromised patients with poor Dis 2004; 19: 258-63.

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NATIONAL JOURNAL OF MEDICAL RESEARCH ORIGINAL ARTICLE

PREVALENCE AND ASSOCIATED FACTORS OF BACK PAIN AMONG DENTISTS IN SOUTH GUJARAT

Patel Harshid L1, Marwadi Mehul R2, Rupani Mihir3, Patel Piyanka4

1Assistant Professor, Pathology Department, Gujarat ADANI Institute of Medical Sciences, Bhuj, Kutch, Gujarat 2Resident, Department of Medicine, 3Resident, Department of Community Medicine, SMIMER, Surat 4Consulting Dental Surgeon, Surat

Correspondence: Dr. Priyanka Patel Dental Surgeon, Krishna Dental Clinic, Surat Email: [email protected]

ABSTRACT

Introduction: Dentistry is a high risk profession for developing back pain because high visual demands result in prolonged and affixed as well as uncomfortable postures. Objectives: This study has been conducted to measure prevalence of pain related to dental work among dentists in Surat city and to identify the aggravating and relieving factors associated with the pain. Methodology: In this cross sectional study, 154 randomly selected dentists were interviewed. Results: Prevalence of pain was 63.6 percent. Back was the commonest site for pain. Prolong sitting was reported to be the most common aggravating factor for pain while correcting working post relieve pain in most. Most of the dentists did not take any treatment for pain which may adversely affect the condition and increases the severity of the pain. Regular daily exercise as well as physiotherapy are helpful to relieve pain but very few doing it regularly. Some dentists took pain killers while very few consulted orthopedic surgeons for treatments.

Keywords: Musculo-skeleton pain, dentist, exercise, posture

INTRODUCTION most common and troublesome of complaints; its exact causes are legion and an exact diagnosis is often A wide variety of deleterious work environmental difficult.7 factors are proved to affect the physical health of dentists or even aggravate their preexisting disorders.1-3 Some investigations have shown that the prevalence Studies have shown that dentists report more frequent and location of pain and other symptoms may be and worse health problems3 particularly musculoskeletal influenced by posture and work habits, as well as other 4 6 pain. There is increasing evidence that unique working demographic factors. conditions in dentistry can significantly affect the Several dental procedures require the dentist to assume health of dentists. and maintain positions that may have potential Musculoskeletal pain, particularly back pain, has been disadvantages for their musculoskeletal system.8 Their found to be a major health problem for dental work with patients is often performed with their arms practitioners. 4-6 abducted and unsupported and the cervical spine flexed forward and rotated lead to high prevalence of pain in Dentists commonly experience musculoskeletal pain back, neck and shoulder region.5, 9 during the course of their careers. While the occasional backache or neck-ache is not a cause for alarm, if The study has been conducted to measure prevalence regular pain or discomfort is ignored, the cumulative of pain related to dental work among dentists in South physiological damage can lead to an injury or a career- Gujarat and to identify the aggravating and relieving ending disability. The dentists are at high risk of neck factors associated with the pain. and back problems due to the limited work area and impaired vision associated with the oral cavity. These METHODOLOGY working restrictions frequently cause a clinician to assume stressful body positions to achieve good access The study was conducted in the month of January and visibility inside the oral cavity. Furthermore, dental 2011. Taking a population of 600 dentists as registered procedures are usually long and require much more to local Indian Dental Association branch and concentration during work. Back pain is one of the prevalence of 80% of neck/back/shoulder pain among

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NATIONAL JOURNAL OF MEDICAL RESEARCH dentists6 the sample size was found to be 139 (using seven (95.9%) dentists out of 49 had got pain after Epi-info 2002 software). For the calculation starting dentistry. (Table 2) confidential limit of 95% and allowable error of 10% Only four participating dentist reported that the pain was considered. was started during their under graduate study. For the Considering certain non response, 160 dentists were rest, pain was started after completing their graduation. randomly selected from register of IDA. All selected dentists were contacted and explained Table 2: Distribution of pain according to site of pain about the study details. Informed verbal consent was among dentists (n=98) sought from all dentists and personnel interview was conducted for those who agreed for participation. A Site of pain No. of Dentist (%) pretested pre-coded questioner was used to record Neck pain 22 (42.9) information obtained during interaction with Back pain 74 (75.5) participants. Shoulder pain 22 (22.5) Pain in wrist 2 (2.04) The data was analyzed using Epi Info 2002 software Pain in leg 1 (2.04) (Database and statistics software for public health professionals. July 2002). Statistical significance was Ten dentists stated that they were feeling continuous said to be established when p value is < 0.05 at 95% pain during the whole day while remaining 89.8% had confidence interval. intermittent pain which was precipitated and or aggravated by certain factors. Prolong sitting posture was the most common factor (95.9%) which aggravate OBSERVATION AND DISCUSSION the pain. Out of selected 160 dentists 154dentists agreed to On asking to describe severity of their pain, 42 (40.8%) participate in the study. Profile of the study dentist categories their pain in to mild category as pain participants is described in table 1. didn’t demand change in their working posture. 44 (44.9%) dentist classify their pain in to moderate Mean age of participants was 29.4 years with standard category as the pain made them to change posture deviation of 6.38. Mean weight of participants is 62.3 while working. The remaining 14 (12.2%) categories kg with standard deviation of 10.6. Current study their pain in to severe pain as it compelled them to take revealed that 98 (63.6%) dentists had at least one kind rest in between. of occupational pain either neck or back or shoulder or combination of it. Certain factors help the participants to relieve their pain which includes correct posture (46.9%), pause for few

minutes (32.7%), muscle relaxing exercise (24.5%), Table 1: Profile of dentist participated in the study analgesic drugs (10.2%), complete rest for a day (4.1%), etc (Table 3). Similar to this study, a study in Glasgow No of dentists (%) also found that improving or correcting posture can Gender definitely help to relieve the pain.11 Female 46 (29.9) Male 108 (70.1) Age group (years) Table 3: Factors aggravating or relieving pain (n=49) <30 110 (71.4) >30 - 40 36 (23.4) Factors No. of Dentist (%) >40 8 (5.2) Pain aggravating factors Weight (Kg) Prolong sitting 94 (95.9) <=50 22 (14.3) Rotation 14 (14.3) >50 - 60 50 (32.5) Lifting Heavy object 10 (10.2) >60 - 70 54 (35.1) Driving 4 (4.1) >70 28 (18.2) Trauma 2 (2.0) Experience (years) Pain relieving factors <=5 90 (58.4) Correct posture 46 (46.9) >10 14 (9.1) Pause in working 32 (32.7) >5 - 10 50 (32.5) Exercise 24 (24.5) Presence of pain Analgesic drug 10 (10.2) Yes 98 (63.6) Short sitting 2 (2.0) No 56 (36.4) Ortho belt 2 (2.0) Rest 4 (4.1) Back, neck and shoulder are the most common sites of pain and it was reported by 75.5%, 42.9% and 22.5% Only few dentist remained absent in their clinical work dentists respectively. Occurrence of pain at these sites due to pain. Six dentists remained absent for one day 10, 6 was reported by many studies in the past. Forty and 10 for more than 2 days.

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Medical treatment and physiotherapy exercise play important role in management of such musculo- REFERENCES skeleton pain. Among the 98 study participants, 49% had never taken any treatment of their work related 1. Myers HL, Myers LB (2004) ‘It’s difficult being a dentist’: stress pain (table 4), which reveled ignorance in the and health in the general dental practitioner.Br Dent J 197, 89– participants. Ignorance of pain in early stage and 93. continuous exposure to aggravating factor ultimately 2. Puriene A, Janulyte V, Musteikyte M, Bendinskaite R(2007) convert mild and moderate pain in to sever disabling General health of dentists. Literature review. pain. Regular exercise was found to be effective in 3. Szymanska J (2002) Disorders of the musculoskeletal system preventing and relieving dental work related pain.12 among dentists from the aspect of ergonomics and prophylaxis. Ann Agric Environ Med 9, 169–73. 4. Shugars D, Miller D, Williams D, Fishburne C, Srickland D. Table 4: Measures taken by study participants to Musculoskeletal pain among general dentists. General Dentistry 1987;4:272-6. relieve pain (n=49) 5. Murtomaa H. Work related complaints of dentists and dental Treatment No. of Dentist (%) assistants. Int Arch Occup Environ Health 1982;50: 231-6. No treatment 48 (49.0) 6. Marshall ED, Duncombe LM, Robinson RQ, Kilbreath SL. Drugs 16 (16.3) Musculoskeletal symptoms in New South Wales dentists. Aust Exercise 30 (30.6) Dent J 1997;42:240-246. Physiotherapy 26 (26.5) 7. McRea R. Clinical orthopedic examination. 3rd edition. Other 12 (12.2) Churchill Livingstone, Longman Group, London, UK. 1990. 8. Powell M, Smith JW. Occupational stress in dentistry: The RECOMMENDATION postural component. Ergonomics 1964 (Suppl): 337-340. 1. Dentist should avoid working in bent position. 9. Shugars DA, Williams D, Cline SJ, Fishburne C. Straight posture while working helps to prevent Musculoskeletal back pain among dentists. General Dentistry development of pain as it maintains the normal “s” 1984; 32: 481-85. shape of the spinal cord and reduces stress on 10. Khalid A. Al Wzaan et al.. Back & Neck Problems Among inter vertebral discs. Dentists and Dental Auxiliaries The Journal of Contemporary Dental Practice, Volume 2, No. 3, Summer Issue, 2001) 2. Education of correct posture should be part of under graduate dental education. 11. Students of university of Glasgow dental school, a study on 3. Dentists should be encouraged to take regular back pain, 0105932c & 0105741c elective report 2005). breaks. 12. Shrestha BP, Singh GK, Niraula SR, Work Related Complaints 4. Dentist should do regular exercise especially among Dentists, J Nepal Med Assoc 2008;47(170):77-81. relaxation exercise during their practice

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NATIONAL JOURNAL OF MEDICAL RESEARCH SHORT COMMUNICATION

COMPARISON OF EFFICACY OF DIAL FLOW MICRODRIP SETS FOR HYPERVISCOUS FLUIDS

Shiraboina Madanmohan 1, Ramachandran Gopinath2

1Resident, 2Professor & Head, Anaesthesiology & Intensive care, Nizams Intitute of medical sciences, Hyderabad

Correspondence: Dr.Madanmohan Shiraboina Flat no-502, Krishnakalyan residency , Sree colony , Neredmet X Roads, Secunderabad-500056, Andhra Pradesh, India Email:[email protected] Mobile No.:9885261503

ABSTRACT

Thie current study was conducted with an objective to compare efficacy of dial flow microdrip sets for hyperviscous fluids. Four different sets and two hyperviscous fluids were used to eliminate bias. The study was done by suspending buret sets which was attached with microdrip dial flow sets and set rate was 100 ml/min. we noted the time to flow 100ml. 3 sets were delivered fluid as per set rate with insignificant p value. Micro drip dial flow sets can be used for hyperviscous fluids.

Key words- Microdrip dialflow sets, Hyperviscous fluids, efficacy

BACKGROUND purchase and maintain2,a large number of pumps. In this study, we used micro drip dial flow sets [precision Accurate fluid infusion (such as Hyper viscous fluids), Flow controller (dial type) can be set for 5-250 ml/hr- and drug administration is crucial for the optimum attached to I.V set and ideally suited for gravity management of a critically ill patients. Continuous and infusions ]1 to know efficacy of these sets in delivering controlled intravenous delivery of common hyper viscous solutions. These micro drip sets are medications, such as inotropic agents, vasodilators, cheaper and easy to use. we did this study in air aminophylline, insulin, heparin, sedatives like propofol (allowed the fluid to flow in to a tub) ,for this reason – etc. via infusion pump is the preferred mode of therapy no ethics committee approval and patients consent in acute care1 .But infusion pumps are not available in required for us. all locations of hospitals and also cost is high to

Table-1: Comparison of HES and Gelofusine in One Hour No. Mean Std. Std. 95% confidence interval Minimum Maximum deviation Error Lower Bound Upper Bound Amount of HES In 1 8 60.50 1.60 0.56 59.15 61.84 58.00 63.00 One Hour 2 8 60.12 0.99 0.35 59.29 60.95 59.00 62.00 3 5 83.60 5.59 2.50 76.65 90.54 75.00 90.00 4 4 60.25 1-25 0.62 58.24 62-25 59.00 62.00 Total 25 64.96 9.84 1.96 60.89 69.02 58.00 90.00 Amount of 1 8 59.87 1.26 0.44 58.83 60.91 58.00 62.00 Gelofusine In One 2 8 60.00 1.30 0.46 58.90 61.09 58.00 62.00 Hour 3 5 81.4 5.45 2.44 74.62 88.17 75.00 90.00 4 4 59.75 1.70 0.85 57.03 62.46 58.00 62.00 Total 25 64.20 9.12 1.82 60.43 67.96 58.00 90.00

MATERIALS AND METHODS To eliminate manufacturers variation, 4 different Sets- 8 of Alfa,8 of Mediflow ,5 of Ramsons and 4 of Softy , To test efficacy of dial flow sets for hyper viscous were used for each fluid(total-50). 100ml of measured solutions, we used two Different hyper viscous fluid was taken in to a buret set and These sets were solutions namely , 6% pentastarch [0.15-0.19 cps], tested by Suspending from an I/V stand allowed to Gelofusin [0.13-0.17 cps] (cps-centipoies units)3 used.

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NATIONAL JOURNAL OF MEDICAL RESEARCH flow into air. Set the rate at 100 ml/hr and noted the time for Emptying of buret. RESULTS Data was analysed using SPSS version 13 (SPSS Inc, Table 1 show observations obtained during one hour. Chicago, IL).

Fig 1: Time required for infusion of 100ml fluid according to different type of fluid

CONCLUSION 1. Clinical Pharmacy and Pharmacology Section Newsletter. Available at www.sccm.org/ (Accessed on 12th May 5, 2012. We conclude that micro drip dial flow sets can be used 2. Benjamin P. H. Kemper1,Marie¨ l Koopmans2,Ronald J. M. M. to deliver hyper viscous fluids with set rate but there is Does. (j)Quality Engineering, 2009;21:471–477. a difference between different manufacturers. 3.Abdalla Abdelsamad Abdalla , Umsalama M.Ahmed et al, Physiocchemical characterisation of Traditionally Extracted Pearl REFERENCES Millet Starch(jir), J.Appl.Sci.Res., 2009;5(11):2016-2027.

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NATIONAL JOURNAL OF MEDICAL RESEARCH CASE REPORT

TRANSIENT APPEARANCE OF BLASTS IN PERIPHERAL SMEAR IN PAEDIATRIC PATIENT WITH ACUTE ALEUKEMIC LEUKEMIA

Vaghasiya Viren L1, Parikh Hina S2, Patel Divyesh V3, Taviad Dilip S4

1Asst. Professor, 2Associated Professor, 3Resident, 4Tutor, Pathology Department, Government Medical College, Vadodara

Correspondence: Dr. Viren L. Vaghasiya 20, Keshav Park society, Vavol Gandhinagar, Gujarat-382016 India Email: [email protected]

ABSTRACT

Acute leukemia can present as leukemic blast in peripheral blood & bone marrow or in some cases in only in bone marrow. Here we present unique case of paediatric acute leukaemia which shows blast cells in peripheral blood transiently and without any definitive treatment blast cell disappear from peripheral blood. So diagnosis made previously was questioned, but later on when bone marrow examination was performed it turn out to be acute leukaemia. We haven’t found any reference of similar phenomenon in similar clinical settings

Key Words: Transient, Peripheral blood, Aleukemic leukemia

INTRODUCTION On admission CBC was performed which show total WBC count of 18,800/cumm and 22% Blast cells Acute leukemia is malignant proliferation of (figure 1). Child was treated symptomatically along with hematopoietic precursor cells. Most common form of antibiotic therapy, no steroids were given but two unit paediatric leukemia is acute lymphoblastic leukemia.1 of blood transfused to patient to relieve symptoms of By definition when there is more than 20% blast cells anemia. Next day follow up CBC report shows total in peripheral blood or bone marrow (mostly at both count of 4000/cumm and there is no/rare atypical sites), acute leukemia is diagnosed.2 Sometimes cells. Repeated CBC shows similar results and serum peripheral blood show less number of blasts cells or no LDH level was 255 U/L(normal range: 135-225 U/L). blast cells but bone marrow fulfils criteria for acute Bone marrow aspiration was done which shows leukemia in those cases it is called sub-leukemic or hypercellular marrow with predominant cell population aleukemic leukemia respectively. Transient appearance were blast cells (figure 2). Patient was referred to cancer of blast cells in peripheral blood has been described in institute for further treatment. neonate with Down’s syndrome.3 We come across the case which show blast cells in peripheral blood on day 1 of admission, followed by their conspicuous absence DISCUSSION in follow up CBC without start of any definitive therapy, Which make initial diagnosis under question. The acute leukemias are group of disorder arising from But later on when bone marrow examination neoplastic transformation of hematopoietic stem cells. performed it turn out to be acute leukaemia. They can be either acute myeloid or lymphoid leukemia depending upon differentiation of stem cells. In

paediatric group of patient, acute lymphoblastic History leukemia is the most common malignancy accounting for about 30% of all pediatric malignancy.1 Usually A 5 yr old male child presented to pediatric OPD with blood and bone marrow both show blast cells in acute complains of pain while walking since 1½ month and leukemia, but when peripheral blood show less number inability to stand and bend from waist. He also of blast or no blast and bone marrow fulfil criteria for complained of low grade intermittent fever since 15 acute leukemia, it is called subleukemic or aleukemic days. He does not have hepato-splenomegaly or leukemia respectively. Here we present case with lymphedenopathy. Patient does not have any facial feature of overt leukemia and aleukemic leukemia at features or anomalies suggesting Down’s syndrome. different time frame. Incidence of childhood acute

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NATIONAL JOURNAL OF MEDICAL RESEARCH leukemia is about 2.0 per 100000 men/women per year. organomegaly/lymphedenopathy and leucocytosis, 85% of them are acute lymphoblastic leukemia. Highest diagnosis may be mistaken as arthritis and true incidence is between 1-5 yr however T cell ALL occurs diagnosis may be delayed.1 at older age (9-14yr).1 Diagnosis can be established by peripheral blood and bone marrow examination. However diagnosis of acute leukemia is not sufficient as treatment and prognosis differs significantly among these groups of neoplasms. Further classification requires cytochemistry, flow cytometry, cytogenetic and moleucular biologic analysis depending upon case. In our case we initially observe blast cells in peripheral blood in a quantity to meet diagnostic criteria for acute leukemia but follow-up peripheral smear examination after blood transfusion on subsequent day show no/rare blast with only other noticeable change is decrease in total WBC count. The same finding persists even after repeated peripheral blood examination. So naturally first report is questioned as either diagnostic error or sampling error. But as severe persistent bone pain cannot be explained by any other condition and Figure 1: First blood smear showing single blast based on finding of blast once on peripheral blood, cells (right lower corner) and single lymphocyte bone marrow examination is done which turn out to be (upper left) leukemic marrow. In our opinion, it may be similar condition as leukemoid reaction where marrow under stress releases some of their constituent cells prematurely in peripheral blood. Bone marrow of person having aleukemic leukemia put to stress transiently blast may appear in peripheral blood. However we cannot find any reference of such phenomenon as transient appearance of blast in peripheral blood followed by their disappearance without any definitive treatment.

CONCLUSION Transient appearance of leukemic blast in peripheral blood in child with aleukemic leukemia may happen. Especially patient with clinical features can not be explained by other disease have to be evaluated by bone marrow examination to rule out leukemia so that diagnosis can not be delayed.

Figure 2: Bone marrow slides show majority of REFERENCE nucleated cells are blast cells 1. Whitlock J, Gaynon P. Wintrobe’s clinical hematology, 12th edition, Philadelphia:Lippincott wiliams and wilkins; 2009. p1889. Clinical symptoms are due to bone marrow failure or 2. Vardiman J, Porwit A, Brunning R, et al WHO classification of infiltration of leukemic cells. Fatigue, lethargy, tumors of haematopoietic and lymphoid tissue, 4th edition, persistent fever, bruising, bleeding and bone-joint pain Lyon: IARC; 2007.p18. are the most common presenting features. Other 3. Transient leukemia in newborns with Down syndrome, Pediatr features include organomegaly, lymphedenopathy, Blood Cancer. 2005;44(1):29-32. symptoms of CNS involvement (headache, vomiting and cranial nerve palsy), mediastinal mass (T cell ALL). When there is only bone pain not associated with

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NATIONAL JOURNAL OF MEDICAL RESEARCH CASE REPORT

A RARE CASE OF ABERRANT MIGRATION OF PRIMORDIAL GERM CELLS – YOLK SAC TUMOR OF UTERUS

Tandon Rakesh1, Chugh Ashima2, Patel Harsh2, Aggarwal Deepti2

1Professor & HOD, 2Resident, Department of Pathology, SBKS MI & RC, Vadodara

Correspondence: Dr Ashima chugh UH-7, Medical campus, PGIMS, Rohtak Email:[email protected], Mobile No.:8980979583

ABSTRACT

Yolk sac tumor of uterus is a very rare tumor seen in young women. It is thought that these tumors arise in the uterus as a result of aberrant migration of primordial germ cells. We present a case of 12 year old female with complaints of lump & pain in abdomen. CT report suggested germ cell tumor of ovary. Cytology report suggested teratoma. The mass was excised & sent to our pathology department for histopathological examination. The mass was 14X14X8 cm. On C/S a cyst was seen arising from the posterior wall of uterus measuring 10X7X3 cm. On gross examination ovary appeared normal. We reported Yolk sac tumor of uterus with heterologous differentiated mesenchymal components – (T3aNxMx) Stage IIIA. The section from the ovary did not show any remarkable pathology. Alfa fetoprotein was also raised in this patient.

Key words – Teratoma, Yolk sac tumor , Alfa fetoprotein

INTRODUCTION GROSS EXAMINATION Yolk sac tumor is a rare and highly malignant germ cell Received cystic globular soft tissue mass weighing 300 tumor. It accounts for about 10% of malignant germ gms, measuring 14x14x8 cm. External surface was cell tumors. Most yolk sac tumors of the female genital nodular, variegated. On cut section brownish tract occur in the ovaries. Rare cases have been hemorrhagic fluid mixed with necrotic material came reported in the vulva4, the cervix and the out.There were heterogeneous areas comprising of endometrium5. Yolk sac tumors arising in the pelvis solid , cystic, cartilaginous, bony areas with presence of outside of the ovary, like our case, are distinctly hair.There was a large cyst measuring 10x7x3 cm. The uncommon. Yolk sac tumor of uterus is a very rare mass was arising from the uterine posterior wall.Uterus tumor seen in young women. It is thought that these with cervix measuring 5x4x3 cm with extensive tumors arise in the uterus as a result of aberrant necrosis and hemorrhage. Also attached to mass was migration of primordial germ cells1 ovary with fallopian tube. Ovary was measuring 3x2x1

cm, fallopian tube was measuring 3 cm long. On cut section both appeared normal.Also received separate CASE REPORT soft tissue bits with clots and necrotic material aggregating 18x18x3 cm. We present a case of 12 year old female with complaints of abdominal pain, abdominal enlargement and abdominal mass. The female came to gynaec OPD. MICROSCOPIC EXAMINATION: Radiological investigations were done. They suspected teratoma or germ cell tumour of ovary. Then the All the sections showed histomorphology of Yolk sac surgeon aspirated the ascitic fluid & it was sent for Tumour showing tumour cells arranged in reticular cytological examination. Teratoma was suspected in pattern with clear, amphophilic cytoplasm and atypical cytology. Then alpha fetoprotein was also done which hyperchromatic nuclei. Characteristic schiller Duval was raised. Surgeons decided to excise the mass. On Bodies was seen. There was abundant extra cellular the operation table, a huge mass was seen originating hyaline deposition in the stroma with presence of from the posterior wall of uterus. Both ovaries heterologous differentiated mesenchymal components appeared normal. The mass was sent for such as cartilage and bone. There was also presence of histopathological diagnosis. cuboidal/columnar lined cystically dilated glands with extensive areas of necrosis and haemorrhage in the

background - Overall features were that of Yolk sac

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NATIONAL JOURNAL OF MEDICAL RESEARCH Tumour of uterus. The sections from uterus showed of the early embryo. The occurrence of this tumour at uterine smooth musculature with presence of yolk sac an extragonadal site is extremely rare. Ungerleider et al2 tumour. The sections from cervix showed presence of cited from literature 17 cases of this tumour at yolk sac tumour. The sections from ovary and fallopian extragonadal site 10 cases in the vagina, 2 cases in the tube didn’t show any remarkable pathology. pelvis, one each in the broad ligament, retroperitoneum, maxillary sinus, cervix, brain and at

the same time reported the first case in the region of the vulva. Our case is very rare. Till now to the best of our knowledge rarely any yolk sac tumor with mesenchymal differentiation has been reported in uterus. The mesenchyme like components of these tumors have pleuripotent properties; it usually presents in the form of spindle cells in a well vascularized myxoid background.3 The most common differential diagnosis suspected on cytology is teratoma. The yolk sac tumor with pleuripotent mesenchymal componenets raise the suspicion of teratoma. But increase alfa-fetoprotein differentiates between the two. CT scan suggested germ cell tumor of the ovary. The surgeons also suspected the same. The surgical treatment for yolk sac Fig 1:The section shows part of yolk sac tumor tumor in young women is unilateral salpingo-ophrectomy with originating from the myometrium(4X, H &E) limited debulking of extraovarian tumor. Bilateral tumors are rare, and it is not necessary to biopsy a grossly normal contralateral

ovary6. If they appear uninvolved, the contralateral ovary and uterus need not be removed even in patients with advanced disease. While doing salpingo-ophrectomy surgeons noticed that the mass was originating from posterior wall of uterus. Both the ovaries appeared normal. Exploration of the remainder of the abdomen revealed smooth and unremarkable abdominal peritoneum, liver surfaces and diaphragms and normal appearing pelvic and para-aortic lymph nodes.

REFERENCES 1. Sternberg's dignostic surgical pathology, 4 th edition, Stacey e. mills, D. Carter, J. Greenson, H. Oberman, V. Reuter, M. Stoler, 2004,Vol-3, P- 2183-2188. Fig 2: The section shows rounded or festooning 2. Ungerleider RS, Donaldson SS, Warnke RA, Wilbur JR. pseudopapillary processes with central vessels Endodermal sinus tumor. The Stanford experience and the first (schillar duval bodies). Few cells showing hyaline reported case arising in the vulva. Cancer 1978; 41:1627-1634. droplets. ( 20X, H&E) 3. Rosai and ackerman's surgical pathology, 9th edition, 2004,Vol – 2, p-1684.

4. Traen, K., H. Logghe, et al. (2004). "Endodermal sinus tumor DIAGNOSIS of the vulva: successfully treated with high-dose chemotherapy." International Journal of Gynecological Cancer Yolk Sac Tumour of Uterus – T3a Nx Mx -Stage IIIA 14(5): 998-1003. 5. Spatz, A., D. Bouron, et al. (1998). "Primary yolk sac tumor of T3a- Tumour invading serosa the endometrium: a case report and review of the literature." Nx - Lymph node can not be assessed Gynecologic Oncology 70: 285-288. Mx-Distant Metastasis can not be assessed 6. D. Pectaside,E. Pectasides, D. Kassanos, “Germ cell tumors of the ovary” Cancer Treatment Reviews,Volume 34, Issue 5, August 2008, Pages 427–441 DISCUSSION Endodermal sinus tumour is so called because of its histological similarity to the extra-embryonal structures

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NATIONAL JOURNAL OF MEDICAL RESEARCH CASE REPORT

AN UNUSUAL CASE OF UNILATERAL ATLANTO- OCCIPITAL ASSIMILATION WITH SKULL ASYMMETRY

Rajani Sangeeta J1, Suttarwala Ila M1, Rajani Jitendra K2

1Associate Professor Anatomy Medical College Baroda Vadodara 2Professor and Head, Oral Pathology Dharmsihn Desai Uni., Faculty of Dental Science, Nadiad, Gujarat

Correspondence Dr. Sangeeta Jitendra Rajani 2, Sakhar Co-operative Society, Harni Warashiya Ring Road, Near Shiv Vatika, B/H Omkar Hospital, Vadodara, Gujarat, India. E-mail address: [email protected], Telephone no.: +91 9427320670

ABSTRACT

A congenital fusion of the atlas to the base of occiput is defined as assimilation of Atlas. This condition is due to failure in segmentation and separation of the most caudal occipital sclerotome and first cervical sclerotome during the first week of fetal life. This is a case of unilateral fusion of left half of atlas with corresponding occipital bone and atlas is rotated and inclined. Skull showed asymmetries in various skull features on left side like change in size of neurovascular foramina, shifting of position of styloid process, reduction in size of middle cranial fossa along with corresponding petrous bone. Hence knowledge of position of various features of skull, beneficial to the clinicians, surgeons, neurologist and radiologist.

Key words: Assimilation; Atlas; Occipitalization

INTRODUCTION OBSERVATION AT ATLANTO-OCCIPITAL REGION A congenital fusion of the atlas to the base of occiput is defined as assimilation of Atlas. It is also known as The entire left half of the atlas vertebra [anterior arch, occipitalization of atlas, occipitocervical synostosis and articulating facet and posterior arch] was assimilated atlanto-occipital fusion. It is one of the most frequent with the occipital bone. Right half was free from fusion osseous anomalies of Atlas and it is very important in but its anterior arch remained attached to left half of clinical practice as it shows multiple variations and anterior arch and site of union between two parts seen combinations. The atlas vertebra partially or totally with prominent anterior tubercle and two halves of the fuses with the occipital bone. Complete fusion is more posterior arch of the atlas were discontinuous, an common than the incomplete while multiple variations interval between them seen [Fig 1YA]. Left Superior of partial assimilation have been reported and may articular facet was fused with occipital condyles, while involve any aspect of atlanto-occipital articulation.The inferior articular facet fused with tubercle (of transverse most probable cause of the occipitalisation is a ligament) and looks like a fused mass protruding into congenital disorder.This condition is first, described by the foramen magnum [FM], large facet of irregular Rokitansky in 1844 and Schuller in 1911 demonstrated shape noted on it [Fig 1 ‘a’]. Both transverse processes this anomaly on roentgen graphically and the incidence were normal in appearance, but foramen of this anomaly is ranges from 0.08-3% of the general transversarium [FT] was larger on left with thin costo- population 1. We present a skull which shows unilateral transverse bar, and its tip was fused with jugular fusion of left half of atlas with occipital bone along process [Fig 1BA] and a gap was created [between with asymmetries in various features of skull. jugular process and costo-transverse bar] this probably gave exit for ventral ramus of 1st cervical nerve [Fig 2A

RA]. The fused left atlas possessed five openings, three CASE REPORT anterior and two posterior. Anteriorly, hypoglossal canal and two very small foramina were located During the osteology demonstration class for between fused anterior arch and basilar part of occipital undergraduate medical students, we noticed a skull with bone [Fig 2A]. Hypoglossal canal was separated from fused first cervical vertebra (Atlas).This skull was of jugular foramen by thin plate of bone. Posteriorly, one adult as socket for upper third molars with synostosis canal for vertebral artery was located just behind the of spheno-occipital synchondrosis, noted. fused lateral mass and opens in to the FM and it was

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NATIONAL JOURNAL OF MEDICAL RESEARCH small in size as compare to FT. Posterior to it, a small [Fig 3B WA], it extended downward for few mm and foramen was noted, which probably gave exit for dorsal was separated from occipital condyle by a well marked ramus of 1st cervical nerve [Fig.2B]. Anterior part of fossa can be called as fossa for vertebral artery [Fig upper surface of left posterior arch was grooved and 1BkA]. Bilateral condylar canals were absent. being continuous with canal for vertebral artery. Atlas appeared to be rotated to left in a vertical axis and Protruding mass on its superior aspect showed a hence anterior tubercle was in line with hamulus of left groove, which runs forward from vertebral canal [Fig pterygoid lamina. This rotation shifted articular facet 3A YA], probably vertebral artery has taken this course for odontoid process of axis on right [Fig 1 WA]. to reach anterior. Such foramen for vertebral artery was Unilateral fusion led to an inclination towards the left absent on right side. Sagittal and transverse diameters of 8.3mm. Instead of external occipital crest there was of FM were 26mm and 27.5mm respectively. prominent tubercle just 10.3mm behind the FM noted Protrusion reduced left half of FM. Irregular shaped [Fig 3B YA]; this could be due to the abnormal pull on tubercle, anterior to left transverse process was noted Ligamentum Nuchae.

Fig 1: Fig 2: Fig 3: F Fig 1: Adult skull, shows two YA show fusion of anterior arch and gap in posterior arch, ‘a’ is irregular facet on inferior articular facet. BA indicates fusion of tip of transverse process and BkA shows the position of fossa for vertebral artery while WA shows the position of facet for odontoid process Fig 2A: RA indicates gap between Costotransverse bar and jugular process & 3 YA show positions of hypoglossal foramen [thick] and two small foramina medial to it. Fig 2B: Two BkA show position of vertebral canal [thick arrow] and small foramen posterior to it Fig 3A: YA indicate the protruding mass in FM and groove on it Fig 3B: WA is the irregular tubercle anterior to left transverse process; two yellow circles show the position of styloid process and RL show the comparative distance between transverse process and mastoid process. YA locates the position of tubercle instead of occipital crest. BkA indicates the left sided occipital bone depressed. Fig 4: Interior of skull showing small and compromised left half and two BkL indicate comparative length of petrous bone and two BA show the positions of left sigmoid sinus groove and jugular fossa Note: BA- blue arrow, BkA – black arrow, WA – white arrow, YA- yellow arrow, RA – red arrow, RL- red line, BkL- black line,

Fig 4:

OTHER OBSERVATIONS side. Squamous part of occipital bone was depressed on left side [Fig 3B BkA]. Distance between transverse Inclination, rotation and unilateral fusion were process and mastoid process was remarkably reduced responsible for various asymmetries in features on left [Fig 3B RL], the left transverse process was moved

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NATIONAL JOURNAL OF MEDICAL RESEARCH away from styloid process [Fig 3B]; this probably to the odontoid projection into the FM and repeated disturbed the anatomy of various structures of that flexion and extension of the neck leads to a gradual region. Further we noted that small sized stylomastoid increasing degree of ligamentous laxity and instability foramen and short carotid canal on left. On intracranial with aging. The first neurological signs and symptoms examination, the grooves for transverse and sigmoid usually occur after second decade of life 5,6. sinuses and jugular fossa were larger on left side [Fig 4 Transverse process is very important landmark for BA]. The size of left middle cranial fossa was smaller head and neck surgeons, when it is inclined and fused along with short and wide Petrous bone [Fig 4 BkL]. to occipital bone, there may be confusion in reaching All these observations suggest that patient might have various structures and also this led to asymmetry in left torticollis with comparatively less developed neck structure and shape of apertures for the vessels and muscles and facial muscles, absent atlanto-occipital nerves around the FM 7,8. Such condition is associated joint movements and compromised brain size on left with some other skeletal malformations such as basilar side. invagination, occipital vertebra, spina bifida of atlas, fusion of the axis and third cervical vertebra and atlanto-axial subluxation 2,9, but here we can not rule DISCUSSION out the other associated conditions, except occipital While going through the literature we have not come vertebra [which is absent here], as no other details are across exactly similar description of any two cases of available of the specimen. assimilation of atlas, this may be because assimilation may involve any aspect of fusion. Our case shows unilateral atlanto-occipital fusion on left associated with REFERENCES asymmetries in features. 1. Surekha Jadhav, Manoj Ambali, Raosaheb Patil, Megha Doshi, In the development of basilar occiput and atlas, the Priya Roy. Assimillation of tlas in Indian dry skulls. JKIMSU. 2012; Vol 1: 102-106 rostral half of the first cervical sclerotome combines with the caudal half of the last occipital sclerotome to 2. Vineeta Saini, Royana Singh, Manimay Bandopadhyay, Sunil kumar Tripathi, Satya Narayan Shamal. Occipitalization of atlas: form the base of the skull. While the caudal half of the its occurance and embryological basis. IJAV. 2008;2:85-88. first cervical sclerotome combines with the rostral half of second cervical sclerotome to form 1st cervical 3. A Macalister. Notes on the development and variations of the atlas. J Anat Physiol.1893 july; 27 (Pt 4): 519-542 vertebra and odontoid process 2. In small number of cases the disruption of this merging process may result 4. H.L.H.H. Green. Un usual case of Atlantooccipital fusion. in atlanto-occipital assimilation. In our case median 1930; http://www.ncbi.nim.nih.gov vertical division of anterior arch seen, in such cases 5. Brad Mckechnie. Occipitalization of atlas. Dynamic there has been either no nucleus in the anterior arch Chiropractic. 25 March 1994; Vol 2 Issue 07. and that ossification has taken place by an inward 6. Anu Vinod RANADE, Rajalakshmi RAI, Latha Venkatraya extension from the lateral mass or anterior arch PRABHU, Mangala KUMARAN, Mangala M. PAI. Atlas developed from double centers of ossifications 3,4. The assimilation: a case report. Neuroanatomy. 2007; 6: 32–33 standard dimensions for FM range between 28-38mm 7. Satheesha Nayak.Asymmetric Atlas Assimilation And Potential and 25-40mm for the sagittal and transverse diameters Danger To The Brainstem: A Case Report. The Internet respectively. Spinal cord compressions never occur Journal of Biological Anthropology. 2008;Volume 1 Number 2 when the sagittal diameter is 18 mm or more 1,5. We 8. M. Senator,S. Gronkiewicz. Anthropological analysis of the presume that protruding mass in FM and border line phenomenon of atlas occipitalisation exemplified by a skull from twardogóra (17th c.) southern Poland. International reduced diameter might not have caused compression Journal of Osteoarchaeology. of Medulla Oblongata or spinal cord but reduced http://onlinelibrary.wiley.com/doi/10.1002/oa.1236/abstract diameter might compress vertebral vessels, 1st cervical (Article first published online: 19 JAN 2011) nerve and may give physiological symptoms like 9. Yassermetwally. Atlanto-occipital Assimillation. Online news dizziness, seizures and syncope and neurological paper of Prof. Yassermetwally; march 6 2010 filed under symptoms. This neurological compression is also due neurological section; http://yassermetwally.wordpress.com.

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NATIONAL JOURNAL OF MEDICAL RESEARCH CASE REPORT

A CASE REPORT ON CARCINOMA OF JEJUNUM

Patel Upendra1, Shrimali Gaurishankar2

1Assistant Professor, Department of Surgery, Surat Municipal Institute of Medical Education & Research, Surat 2Microbiologist, General Hospital, Mehasana

Correspondence: Dr. Upendra Patel 1Assistant Professor, Department of Surgery, Surat Municipal Institute of Medical Education & Research, Surat - 395010

ABSTRACT

A 69 years old male presented with features of acute intestinal obstruction. At exploratory laparotomy, a mass was felt in jejunum. The growth with adequate margin and mesenteric lymph nodes were removed. The jejunal growth was diagnosed as adenocarcinoma on histopathology, which is a rare tumour of small intestine. He was planned adjuvant chemotherapy. He is in complete remission 6 months after follow-up.

Key words: Jejunum, Adenocarcinoma, Radiotherapy, 5-Flourouracil

INTRODUCTION were seen in straight x-ray abdomen in erect posture. Carcinoma of jejunum is one of the rare types of Surgery - As patient presented with acute intestinal carcinoma. Small intestinal adenocarcinoma accounts for obstruction, emergency laparotomy was done after 0.3% of all malignancies of the gastrointestinal tract and parenteral hydration. During operation, lower midline 30% to 50% of all malignancies of the small intestine.1 incision was given. An annular constricting Growth Main drawback of Jejunal cancer is that it is characterised involving the jejunum almost completely occluding by hidden and non-specific symptoms. Despite a lumen was seen 30 cm distally from duodeno-jejunal thorough history, physical examination, and complete flexure. The jejunum proximal to the stricture was diagnostic work-up, the correct diagnosis of small hypertrophied. No secondary deposit was seen in the intestinal malignancy is established pre-operatively in liver or in peritoneum. A resection and end to end only 50% of cases and exploratory laparotomy is often anastomosis with removal of mesenteric glands was required.2 Patients usually present with intestinal performed. Postoperative period was uneventful. He obstruction. The tumours are usually not accessible to was discharged and referred to the department of examination with the endoscope. The difficulty of early radiotherapy. diagnosis of carcinoma jejunum is reflected in difficulty Histopathology - The resected segment showed in curability.3 And ultimately leads to more suffering of the moderately differentiated mucin secreting infiltrative patients. This is why carcinoma of Jejunum requires more adenocarcinoma jejunum (Fig 1, H&E x 100), with attention and need to explore by additional researches. metastasis in 4 out of 11 mesenteric lymph nodes. Carcinoma had penetrated the muscle coat of the small intestine and had extended into the serosa. Lympho- CASE REPORT vascular tumour emboli and perineural invasion were A 69 years old male presented as a surgical emergency seen (stage-Dukes’C). Surgical line of resection was free with symptoms of sudden severe abdominal pain, of lesion. absolute constipation, distension and repeated vomiting. Postoperative routine haematological and biochemical He had no previous history of constipation, pain parameters were normal. His chest x-ray and abdomen or passage of mucus, bleeding per rectum ultrasonogram of abdomen were normal and did not before this acute incidence. show any evidence of metastases. Serum Examination – On examination, he was mildly dehydrated carcinoembryonic antigen (CEA) level was 7ng/ml. with tachycardia (pulse 110/ minute), but blood Chemotherapy and follow-up — His disease stage was pressure was normal. His abdomen was distended and T3N1M0. He was planned adjuvant chemotherapy with tender. Liver and spleen were not palpable. Other single agent capecitabine for six cycles. He is in systemic examinations were normal. complete remission at 6 months follow-up. Investigation - Multiple fluid and gas filled bowel loops

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NATIONAL JOURNAL OF MEDICAL RESEARCH anatomically fixed flexion site, (b) fluid intestinal contents pass in a short period restricting carcinogen exposure, (c) contents are alkaline minimising bacterial flora, (d) high IgA level, etc.4 Majority of the tumours were infiltrate in the serous membrane or deeper. Radical surgery with lymph node dissection is the cornerstone of treatment. Adjuvant chemotherapy with different combination of 5-fluorouracil(5-FU), leucovorin, adriamycin, paclitaxel, oxaliplatin, etc, have been tried in several studies particularly in advanced diseases.5,6 Capecitabine is a prodrug of 5-fluorouracil with relatively safe toxicity profile and widely used in colorectal malignancy. Intratumoural concentration of active molecule 5-FU is much higher with capecitabine. Fig 1: Tumour Cells Arranged in Glandular Pattern Moreover, due to oral administration compliance is and in Solid Sheets and the Background Reveals much better with this drug. So, the above elderly Abundant Mucin Deposition patient with poor general condition and performance status was treated with capecitabine and he tolerated it well. DISCUSSION Malignant lesions in small intestine are mainly REFERENCES lymphomas. Carcinoma in jejunum is quite rare.1 1. Ugurlu MM, Asoglu O, Potter DD, Barnes SA, Harmsen WS, Clinical presentations mainly consist of anaemia, Donohue JH. Adenocarcinomas of the jejunum and ileum: a dyspepsia, anorexia, intestinal obstruction, ileus, gastro- 25-year experience. J Gastrointest Surg 2005; 9: 1182-8. intestinal haemorrhage. Macroscopic classification of 2. Lee HJ, Cha JM, Lee JI, Joo KR, Jung SW, Shin HP. A case of carcinoma jejunum is not yet clear. Annular stenotic jejunal adenocarcinoma diagnosed by preoperative double type lesions are most frequent. Since clinical balloon enteroscopy. Gut Liver 2009; 3: 311-4. presentations of small intestinal adenocarcinoma are 3. Good CA. Tumors of small intestine. AJR Am J Roentgenol vague and non-specific, they are usually diagnosed in 1963; 89: 685. advanced stages. The rarity of this tumour and the 4. Lowenfels AB. Why are small bowel tumours so rare? Lancet difficulties with endoscopic examinations in small 1973; i: 24-6. intestine may also attribute to the delayed diagnosis. As 5. Cornelison TL, Goldberg JM, Piver MS. Taxol and platinum a result, survival is generally poor, with most series chemotherapy in the treatment of pancreatic and jejunal car- reporting five-year survival rates of 20-30%.1 However, cinoma. J Surg Oncol 1995; 59: 204-8. double balloon enteroscopy (DBE) is a safe and 6. Chen CW, Wang WM, Su YC, Wu JY, Hsieh JS, Wang JY. effective method to make pre-operative histological Oxaliplatin/5-fluorouracil/leucovorin (FOLFOX4) regimen as diagnosis of jejunal cancer in suspected cases2. The an adjuvant chemotherapy in the treatment of advanced jejunal pathogenesis is not clear. Reasons for rarity of adenocarcinoma: a report of 2 cases. Med Princ Pract 2008; 17: carcinoma in jejunum may be due to (a) there is no 496-9.

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NATIONAL JOURNAL OF MEDICAL RESEARCH

INTRUCTION FOR AUTHORS

About the Journal National Journal of Medical Research (NJMR) is a quarterly published peer-reviewed national journal indexed with Spcopemed, NewJour, IndexSholar, WHO HINARI, IndMedica, Index Copernicus International, eJManager and many other agencies.. The journal allows free access (Open Access) to its contents. Submission of manuscript and review is completely free. However authors of accepted articles are being charged with nominal printing / publication fees.

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Volume 2 Issue 2 April – June 2012 : NJMR : print ISSN: 2249 4995 eISSN: 2277 8810