NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Nitte University Journal of Health Science

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1 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Contents Page No Contents 2 Original Articles Phytochemical and Antimicrobial Activity of the Leaves of Lannea Kerstingii Engl & K. Krause (Anacadiaceae) - Njinga NS, Sule MI , Pateh UU , Hassan HS, Ahmad MM, Abdullahi ST, Danja Ba & Bawa B 4 Locomotor Treadmill Training Program Using Driven Gait Orthosis Versus Manual Treadmill Therapy on Motor Output in Spastic Diplegic Cerebral Palsy Children - Reda S.M. Sarhan, Mohamed Faisal Chevidikunnan & Riziq Allah Mustafa Gaowgzeh 10 A Study to Assess the Level of Attitude Towards Euthanasia Among Health Personnel - Maria Therese A., Rukumani J., Pon Princess Mano, Ponrani & Nirmala 18 Prevalence of Under-Nutrition and Anemia Among Under Five Rural Children of South Karnataka, India - Nanjunda 24 Cross Sectional Study of Attitude, Practice and Knowledge of Oral Hygiene Practices and Dental Treatment in Health Care Professionals in South Canara District.( Karnataka) - Sharath K.S., Manavi Prabhu, Biju Thomas & Shamila Shetty 28 Occurrence of iron Deficiency Anemia Between Over Weight and Normal Weight Adolescents in Selected Schools in Udupi District - Sujatha R. & Reshma 33 Effectiveness of Self Instructional Module on Knowledge of Post Operative Self Care for Mothers Undergoing Elective Caesarean Section in Selected Hospitals, Mangalore - Elizabeth Rajan & Sabitha Nayak 39 Perception Regarding Female Feticide Among Females Attending Out Patient Departments of Selected Hospital of Ludhiana City - Mamta Choudhary 42 Surface Topography of Dental Implants - Vinaya Bhat & S. Sriram Balaji 46 Comparative Evaluation of Antimicrobial Susceptibility Pattern and Virulence Factors Among ESBL and Non-ESBL Producing Escherichia Coli - Shilpa Shenoy, Sumathi K. & A. Veena Shetty 55 A Study of Footprints of Tree-climbing Communities of South India - P. Shivarama Bhat & Arunachalam Kumar 60 Sleep Duration and Sleep Hygiene Practices in Adolescents : Age and Gender Differences - Bindu John 65 Prevalence of Oral Mucosal Lesions and Their Co -relation to Habits in Patients Visiting A Dental School of South Karnataka : A Cross Sectional Survey- 2012 - Mithra N. Hegde, Radhika Jain & Ashwitha Punja 69 The Awareness in Biomedical Waste Management of Nursing Staff at A Tertiary Care Hospital of Mangalore, South India - Rashmi Kundapur, Tanmay Bhat, Sanjeev Badiger & Rajesh Ballal 73 Evaluation of Antimicrobial and Cytotoxic Activity of Electron Beam Irradiated Endodontic Sealer

- A Geethashri, KJ Palaksha, B Mohana Kumar, KR Sridhar,Ganesh Sanjeev, A Veena Shetty 76 Knowledge and Prevalence of Diabetes and Hypertension Among Adults in Selected Villages of Udupi District - Karnataka - Suja Karkada, Navaneetha & Ansuya 81

2 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Page No A Descriptive Study to Assess the Knowledge on Breast Cancer and Utilization of Mammogram Among Women in Selected Villages of Udupi District, Karnataka - Arkierupaia Shadap, Maria Pais & Anusuya Prabhu 84 Evaluation of Salivary Enzymes in Post Menopausal Women with and Without Periodontitis - Santhosh Shenoy B., Prajnya Shenoy, Avaneendra Talwar, Biju Thomas, Sharath K.S. & Shamila Shetty K. 88 Basic Life Support- A Stitch in Time - Muralee Mohan, Rajendra Prasad, S.M. Sharma, Deepthi Shetty & Kalpa Pandya 92 Case Reports Unilateral Bicondylar Hoffa Fracture with A Fracture Shaft and Dislocated Knee and Hip in A Middle Aged Adult : A Rare Case Report - Ashwin Shetty, Sanath Kumar Shetty, Arjun Ballal, Nirmal Babu & Ravindranath Rai 96 Monoarticular Synovitis of Knee Due to Unrecognised Intra-Articular Plant Splinter - Siddharth M. Shetty, Vikram Shetty, Arjun Ballal & Jayaprakash Shetty 99 A Case Report on Stevens-Johnson Syndrome - Babu Dharmarajan, Sanil Varghese & Sachina B.T. 102 Ocular Manifestations of Aplastic Anemia Following Platelet Trasfusion : A Case Report - Divyalakshmi K.S. & Kalpana B.N. 104 A Rare Case of Scrub Typhus Masquerading as Breast Abscess - Pothukuchi Venkata Krishna, Venkata Ravikumar Chepuri, Sudhakar Kanumuri, Raghavareddy Yarram & Sailaja Yadalla 107 Treatment of Ankyloglossia Using Diode Laser – A Case Report - Manavi Prabhu, Sharath KS, Biju Thomas, Santhosh Shenoy B, Shamila Shetty 110 Female Patient with A Variant of Turner Syndrome - Meenakshi A., Prashanth Shetty, Suchetha Kumari, Jayarama Kadandale, Neetha Nandan 113 Resistant Candida Pneumonia in Two Patients with Chronic Kidney Disease - Baikunje S, Upadhyaya VS, Hosmane GB& Rama Prakasha S 117 Review Articles Role of Phytochemicals in Oral Potentially Malignant Disorders : A Review - Ananya Madiyal, Vidya Ajila, Subhas G Babu, Shruthi Hedge, Harini Keshavaiah & Priyadharshini Alva M 120 Embryonic Cysts, Sinuses and Fistulae of Branchial Origin - Arunachalam Kumar 126 A Review of Current Concepts in Bruxism – Diagnosis and Management - Krishna Prasad D, Archana Ashok Swaminathan & Anupama Prasad D. 129 Instructions to authors 137 Nujhs Declaration and Right Transfer Form 140

3 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article PHYTOCHEMICAL AND ANTIMICROBIAL ACTIVITY OF THE LEAVES OF LANNEA KERSTINGII ENGL & K. KRAUSE (ANACADIACEAE) Njinga NS1 , Sule MI2 , Pateh UU3 , Hassan HS4 , Ahmad MM5 , Abdullahi ST6 , Danja BA7 & Bawa B8 1,6Lecturers, Department of Pharmaceutical & Medicinal Chemistry, University of Ilorin, 2 Professor, 4 Senior Lecturer, Department of Pharmaceutical & Medicinal Chemistry, 3 Associate Professor & Dean, Faculty of Pharmaceutical Sciences, Ahmadu Bello University, Zaria, 5 Pharmacist, Dr. Gwamna Awan Memorial Hospital, Kakuri, 7Lecturer, Department of Chemical Sciences, Faculty of Science, Federal University Kashere, Gombe, 8Researche Scholar, National Agency for Food and Drugs Administration and Control (NAFDAC), Nigeria. Correspondence : Njinga N.S. Lecturer, Department of Pharmaceutical & Medicinal Chemistry, Faculty of Pharmaceutical Sciences, University of Ilorin. E-mail : [email protected] Abstract : The phytochemical and antimicrobial activity of the petroleum ether and crude methanol extracts, chloroform and ethyl acetate fractions of the leaves of Lannea kerstingii were investigated. Phytochemical screening revealed the presence of steroids and triterpenes in the petroleum ether extract, steroid, triterpene, flavonoids and tannins in both crude methanol extract and chloroform fraction while the ethyl acetate fraction contained only flavonoids and tannins. The extracts exhibited antimicrobial activities with zones of inhibition ranging from 17.00 to 21.03, 20.10 to 25.24, 25.32 to 34.02 and 22.28 to 27.20 mm for petroleum ether extract, methanol extract, chloroform and ethyl acetate fractions respectively. The minimum inhibitory concentration was between 5 and 10mg/ml, 5mg/ml for the petroleum ether and methanol extract respectively, and between 2.5 and 5 mg/ml, 5mg/ml for the acetate fractions. The minimum bactericidal concentration for all the extracts was 40mg/ml respectively except for chloroform fraction which ranged from 20 to 40mg/ml. The minimum fungicidal concentration for all the extracts was found to be 40mg/ml respectively. This result indicates the broad spectrum antimicrobial potential of L. Kerstingii and justifies the use of this plant in traditional medicine. Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii

Introduction : the living conditions of many millions of people around the Humans have practiced the use of plants for the cure of world. Infections frequently challenge the physician's diseases for centuries[1] and these plants are highly diagnostic skill and must be considered in the differential esteemed all over the world as a rich source of therapeutic diagnoses of syndromes affecting every organ system.[4] agents for the prevention of disease and ailments.[2] The There is continuous increase in the number of multi-drug search for eternal health and longevity and for remedies resistant microbial strains and the appearance of strains against pain and discomfort drove early man to explore his with reduced susceptibility to antibiotics. Examples include immediate natural surroundings and led to the use of many methicillin-resistant staphylococci, pneumococci resistant plants, animal products, minerals etc. and the to penicillin and macrolides, vancomycin-resistant development of a variety of therapeutic agents.[3] This Enterococci as well as multi-drug resistant gram-negative evolving practice is recorded in both folklore and books of organisms.[5] There is an urgent need to control early practitioners. antimicrobial resistance by improved antibiotic usage and Access this article online Despite decades of reduction of hospital cross-infection and search for newer Quick Response Code dramatic progress in their and safer antibiotics.[6] treatment and prevention, Lannea kerstingii is a tree with a height of 12m and 40cm in infectious diseases remain diameter, with a wide-spreading and relatively dense a major cause of death and crown. The bark is smooth to slightly fissured, fissures debility and are spiral around the trunk (spiral grain), pale grey with pinkish, responsible for worsening

Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii 4 - Njinga N.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science white-striped slash.[7] L. kerstingii Engl. and K. Krause aureus NCTC6571, Streptococci faecalis, Bacillus subtilis, (Anacardiaceae) is widely utilized in traditional medicine Corynobacterium ulcerane, Methicillin-resistant by various cultures worldwide; a decoction of the back is Staphylococcus aureus (MRSA), Escherichia coli used to treat swellings,[8] infusion of the back, leaves and NCTC10418, Klebsiella pneumoniae ATCC 10031, bud is used for flatulence, the fruit is used against rickets Salmonella typhi ATCC 9184, Shigella dysenteriae, and scurvy. The plant has been reported for the treatment Pseudomonas aeruginosa NCTC6750, and fungi Candida of diarrhoea,[9] gastritis, rheumatic, sterility, intestinal albicans, Candida tropicalis and Aspergillus flavus. were helminthiasis.[10] obtained from the Department of Phamaceutical Microbiology, Faculty of Pharmaceutical Sciences, Ahmadu Materials and Methods : Bello University, Zaria, Nigeria. All the micro-organisms Plant material collection and extraction (clinical isolates) were checked for purity and maintained in The plant was collected in May, 2011 at Zaria, Kaduna State, slants of agar. Nigeria. It was then taken to the Herbarium of the Department of Biological Science, Ahmadu Bello Cultivation and Standardization of Test Organism University, Zaria for identification. It was identified by A loop full of each of the test organisms were taken from comparison with a herbarium specimen (voucher the agar slant and sub cultured into test tubes containing specimen 1832). After identification, the leaves were 20 ml of sterile nutrient agar (for bacteria) and sabouraud removed and dried under shade. The size was reduced dextrose agar medium (for fungi). The test tubes were then using mortar and pestle, filtered for homogeneity and kept incubated for 24 hours at 37o C for two days (for bacteria) away from light until further use. and 27o C for 2-7 days (for fungi). The growth culture was standardized using sterile normal saline to obtain a density The leaves (100g) was extracted exhaustively using of 106 cfu/ml for bacteria. A sporulated test fungal spores sequential solvent extraction. It was extracted with was harvested with 0.05%Tween80 in sterile Normal saline petroleum-ether followed by methanol using maceration and standardized to 106 spores/ml. method with intermittent shaking and solvents changed every 1 hour. The maceration process was then repeated Preparation of Culture Media several times for exhaustive extraction. The extracts were The prescribed quantities of the dehydrated dried under reduced pressure. The dried methanolic bacteriological culture media was weighed and hydrated extract (20g) was then dissolved in distilled water and with distilled water according to the manufacturers partition using chloroform, and ethylacetate. specification. Where necessary, gentle heat was applied to aid dissolution and the resultant suspensions were Phytochemical Screening dispensed into clean bottles and sterilized at 121o C for 15 Basic phytochemical screening to detect the presence or minutes in an Adelphi bench autoclave. absence of plant chemical constituents such as alkaloids, tannins, saponins, anthraquinones, flavonoids, cardiac Antimicrobial Profile (susceptibility test) glycoside, anthraquinones, steroids and triterpenoe were The antibacterial screening was carried out using agar carried out using standard procedures[11,12] on the diffusion method.[13] The extract was weighed and petroleum ether extract, crude methanol extract, dissolved in DMSO to obtain the initial concentrations chloroform and ethylacetate fractions of the leaves, of L. (40mg/ml) of the different extracts. Overnight culture of kerstingii. the various bacteria in blood agar and the fungi in sabouraud dextrose agar slant media were sterilized to Test Organisms produce inoculums size of 106 cfu/ml. The medium was Reference strains and clinical isolates: Staphylococcus seeded with 0.1 ml of standard inoculums of the micro-

Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii 5 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science organism (Mc-Forland 0.5). The inoculums were sprayed Determination of Minimum Bactericidal Concentration evenly by the use of sterile swab over the surface of the (MBC) medium, the seeded plates were allowed to dry at 37o C and Blood agar was prepared according to manufacturer's 27o C for the bacteria and fungi respectively for 30 mins instruction, sterilized at 121o C for 15 minutes. It was inside incubator. A standard cork borer of diameter 6mm poured into sterile petri-dishes. The plates were allowed to was used to cut a well at the centre of each seeded medium cool and solidify. The contents of the MIC test tubes in the used and 0.1ml of the solution of the extracts was then serial dilution were then sub-cultured on to the prepared introduced into each hole on the surface of the medium of plates and the plates were then incubated at 37o C for 24 each bacteria. In one medium, 0.1ml of DMSO was hours (for bacteria) and 27o C for 2-7 days (for the fungi) introduced to serve as negative control and in another, after which the plates were observed for growth. The plate Spafloxacin and Fluconazole (10 µg ml ) to serve as positive without growth represents the minimum bactericidal control for the bacteria and fungi respectively. The medium concentration. After 24 hours the results were was incubated at 37o C for 24 hours (for bacteria) and 27o C recorded.[14,15] for 2-7 days (for fungi) after which the plates were observed for zones of inhibition. The zones of inhibition Results : were measured with a transparent ruler and the result The leaves of L. kerstingii contained more methanol soluble recorded. phytochemicals (32.44%) followed by petroleum ether (30.2%). The yield of the chloroform and ethyl acetate Determination of Minimum Inhibitory Concentration fractions were found to be 10.05 and 8.5% respectively This was done using broth dilution method.[14] In this (table 1). method, 10ml nutrient broth (prepared according to manufacturers specifications) was dispensed into test The crude methanolic extract and chloroform fraction tubes and sterilized at 121o C for 10 minutes and allowed to were found to contain flavonoids, tannins, steroids and cool. Mc-Forland's turbidity standard scale number 0.5 was triterpenes. The ethyl acetate fraction of the leaves of L. prepared to give a turbid solution. Normal saline was kerstingii was found to contain only flavonoids and tannins. inoculated with each of the test micro-organisms and While the petroleum ether extract contains only steroids incubated at 37o C for 6 hours to make a turbid suspension and triterpenes (table 2). of the micro-organisms. After incubation, dilution of the The petroleum ether, the crude methanol extract and all micro-organism in DMSO was done until the turbidity the other two fractions were inactive against C. ulcerane, P. (1.5x106 cfu/ml) matched that of the Mc-Forland scale by aeruginosa, C. albicans and A. flavus. The crude methanol visual comparison. Two fold serial dilution of the extract in and the petroleum ether extract were also inactive against the broth was done to obtain the following concentrations; S. typhi. All the extracts were active against S. aureus, S. 20mg/ml, 10mg/ml, 2.5mg/ml, 1.25mg/ml and faecalis, B. subtilis, MRSA, E. coli, K. pneumonia, S. 0.625mg/ml. From the suspension of the micro-organism dysentariae and the fungi C. tropicalis. The chloroform in DMSO, 0.1ml was inoculated into the different fraction and the ethyl acetate fraction were also active concentrations of the extract in the nutrient broth. The against S. typhi (Table 3). The zone of inhibition of the broths were incubated at 37o C for 24hrs (for bacteria) and crude methanol extract ranged from 20.10mm (E. coli) to 27o C for 2-7 days (for the fungi) after which the test tubes 25.12mm (S. dysentariae), that of petroleum ether ranged were observed for turbidity. The lowest concentration of from 17.00mm (E. coli and C. tropicalis) to 21.03mm (S. the extract in the broth which shows no turbidity aureus). The chloroform fraction showed high activity represents the MIC. The results after 24 hour were when compared to the ethyl acetate fraction with zone of recorded.

Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii 6 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science inhibition ranging from 25.32mm (S. typhi ) to 34.02mm (B. The MBC of the petroleum ether and the crude methanol subtilis). While that of ethyl acetate ranged from 22.28mm extracts were above 40mg/ml for all the organisms except (S. typhi) to 27.20mm (B. subtilis, K. pneumonia and S. for B. subtilis whose MBC was 40mg/ml for the methanol dysentariae) (table 3). extract. The chloroform extract showed MBC/MFC for all tested organism except for B. subtilis whose MBC was The MIC of the crude methanol and ethyl acetate fractions 20mg/ml. The ethyl acetate showed MBC of 40mg/ml for were 5mg/ml respectively. That of the chloroform extract S. aureus, B. subtilis, E. coli and K. pneumonia and MFC of was found to be 2.5mg/ml for S. faecalis, B. subtilis, K. above 40mg/ml for C. tropicalis (table 5).. pneumonia, S. typhi and S. dysentariae and 5mg/ml for S. aureus, MRSA, E. coli and C. tropicalis respectively while Table 1 : % yield of the different extracts obtained from the extraction of the leaves of Lannea kerstingii. the MIC of the petroleum ether extract was 5mg/ml for S. Fraction Colour Weight % yield aureus, B. subtilis and K. pneumonia and 10mg/ml for S. Petroleum ether extract Dark green 30.02g 30.2% faecalis, MRSA, E. coli, S. dysentariae and C. tropicalis Crude methanol extract Dark green 32.44g 32.44% Chloroform fraction Light green 2.01g 10.05% respectively as shown in table 4. Ethyl acetate fractopm Light green 1.74g 8.5%

Table 2 : phytochemical constituents present in the different extracts of the leaves of Lannea kerstingii Constituents Petroleum Crude Chloroform Ethyl ether methanol fraction acetate extract extract fraction Anthraquinones - - - - Flavonoids - + + + Tannins - + + + Alkaloids - - - - Coumarins - - - - Saponins - - - - Steroids and triterpenes + + + - Cardiac Glycoside - - - - Key: - = not present, + = present Table 3 : Zone of inhibition of crude methanol extract, chloroform and ethyl acetate fraction of the leaves of L. kerstingii. TEST ORGANISM ZONE OF INHIBITION (mm)

Petroluem Crude CH3 OH CHCl3 Ethyl acetate Sparflo-zin Flucona ether fraction extract fraction fraction -zole S. aureus NCTC6571 21.03 20.10 27.30 25.10 27.00 S. faecalis 19.10 21.23 30.10 24.10 32.02 B. subtilis 20.10 25.24 34.02 27.20 47.00 C. ulcerane 0.00 0.00 0.00 0.00 32.11 Methicillin-resistant S. aureus (MRSA) 19.02 22.06 28.41 24.21 37.03 E. coli NCTC10418 17.00 20.10 27.24 26.22 37.10 K. pneumoniae ATCC 10031 20.42 24.10 31.34 27.20 47.02 S. typhi ATCC 9184 0.00 0.00 25.32 22.28 32.23 S. dysentariae 19.30 25.12 32.16 27.20 39.33 P. aeruginosa NCTC6750 0.00 0.00 0.00 0.00 29.22 C. albicans 0.00 0.00 0.00 0.00 32.00 C. tropicalis 17.00 22.03 27.00 24.10 29.21 A. flavus 0.00 0.00 0.00 0.00 34.01

Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii 7 - Njinga N.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 4 : Minimum Inhibitory Concentration of petroleum ether and crude methanol extract, chloroform and ethyl acetate fractions of the leaves of L. kerstingii against Test Organisms TEST ORGANISM MIC(mg/ml) Petroleum Crude Chloroform Ethyl ether extract methanol extract fraction acetate fraction S. aureus NCTC6571 5 5 5 5 S. faecalis 10 5 2.5 5 B. subtilis 5 5 2.5 5 MRSA 10 5 5 5 E. coli NCTC10418 10 5 5 5 K. pneumoniae ATCC 10031 5 5 2.5 5 S. typhi ATCC 9184 2.5 5 S. dysentariae 10 5 2.5 5 C. tropicalis 10 5 5 5

Table 5 : Minimum Bactericidal / Fungicidal Concentration of petroleum ether and crude methanol extracts, chloroform and ethyl acetate fractions of the leaves of L. kerstingii against Test Organism TEST ORGANISM MBC/MFC (mg/ml) Petroleum Crude Chloroform Ethyl acetate ether extract methanol fraction fraction Staphylococcus aureus NCTC6571 40 40 40 40 Streptococci faecalis 40 40 40 40 Bacillus subtilis 40 40 20 40 MRSA 40 40 40 40 Escherichia coli NCTC10418 40 40 40 40 Klebsiella pneumoniae ATCC 10031 40 40 40 40 Salmonella typhi ATCC 9184 40 40 Shegella dysentariae 40 40 40 40 C. tropicalis 40 40 40 40

Discussion : evolutional differences of the plant[21] or the presence of an Methanol was found to be a better extraction solvent than antagonist in the extract. petroleum ether (table 1) which is with conformity with Among the extracts, the petroleum ether fraction is the literature.[16] Flavonoids have been shown to have anti-viral least active. Its activity is solely due to the presence of and antimicrobial activities.[17,18] Tannins may exhibit steroids and triterpenes present in the fraction (table 2). antibiotic activity by complexing extracellular enzymes The chloroform fraction is the most active and its activity is produced by the pathogens or by interference with the be due to the presence of low molecular weight flavonoids, metabolism of the pathogen itself.[19] Thus the tannins, steroids and triterpenes (table 2). The results of antimicrobial activity of the leaves may be due to the this study corresponds with several investigation that presence of flavonoids and tannins (table 2). flowering plants are potential source of antimicrobial The methanol and ethanol extract of the leaves of L. substances.[22,23] kerstingii have been reported to be active against S. aureus, The low MIC of these extracts (table 3) especially the E. coli, P. vulgaris, S. typhi, S. lactis, Shigella sp..[20] This is in chloroform fraction showed the extract's activity against line with the current study in which the methanol extract both Gram positive and Gram negative bacteria which are show activity against S. aureus, E. coli and S. dysentariae associated with different type of infections including but inactive against S. typhi (table 3). This difference may urinary tract infections (S. aureus), and typhoid fever (S. be due to age, physiological variations, environmental typhi). S. aureus is also responsible for a wide variety of conditions, geographic variations, genetic factors and

Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii 8 - Njinga N.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science diseases, including pneumonia, skin and soft tissue Conclusion : infections, and diabetic foot infections.[24] Similarly, P. The leaves of Lannea kerstingii contains phytochemicals aeruginosa is a common pathogen associated with burn which possess antimicrobial activity. This study therefore wound infections, keratitis, and respiratory tract supports the traditional use of Lannea kerstingii for the infections.[25] The extract also showed activity against E. coli treatment of various infectious diseases in Nigeria and (MIC 5mg/ml) which is the commonest cause of urinary different regions of the world, and may serve as a good tract infection and accounts for approximately 90% of first source of novel antibiotics. urinary tract infection in young women.[15] This indicates Acknowledgment : the usefulness of this plant in the treatment of urinary tract The authors are grateful to the Department of Biological infection, respiratory tract infections, diabetic foot Sciences ABU Zaria for Identification of the plant, the infections due to its activity against the organisms causing Department of Pharmaceutical Microbiology, ABU Zaria for these infections. This result gives scientific base and provision of micro-organisms, and to Mr. Abdullahi Makailu credence for the claims of the therapeutic capabilities and Sabo of the Nigerian Institute of Leather and Science folkloric usage of the leaves of Lannea kerstingii for the Technology (NILEST) Zaria, for his assistance with the treatment of various ailments. antimicrobial screening.

References : 1. Lesney MS. Nature's Pharmaceuticals: Natural Products from Plants 15.Usman H, Abdulrahman FI, Ladan AH. Phytochemical and Remain at the Core of Modern Medicinal Chemistry. Today's Chemist Antimicrobial Evaluation of Tribulus terrestris L. (Zygophylaceae) at Work. 2004;13(7):26-31. Growing in Nigeria. Res. J Bio. Sci. 2007;2(3): 244-247. 2. Sharma A, Shanker C, Tyagi L, Singh M, Rao CV. Herbal Medicine for 16. Obi VI, Onuoha C. Extraction and characterization method of plants Market Potential in India: An Overview. Int. J. Plant Sci. 2008;1:26-36. and plant products. In: Biological and Agricultural Techniques. 3. Nair R, Chanda S. Antibacterial activities of some medicinal plants of Ogbulie, J. L, and O. J. Ojiako (eds). 2000; Webs media publications, the Western region of India. Turkish J. Biol. 2007;31: 231-236. Owerri. 4. Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J. 17. Hang T, Jin JB, Cho S, Cyang JC. Evaluation of anti-inflammatory effects Harrison's Principles of Internal Medicine 18th edn. 2012; The of baicalein on dextran sulfate sodium-induced colitis in mice. Planta McGraw-Hill Companies Inc, New York. Medica. 2002;68(2):268-271. 5. Norrby RS, Nord CE, Finch R. Lack of development of new antimicrobial 18. Vessal M, Hemmati M, Vasei M. Antidiabetic effects of quercetin in drugs: a potential serious threat to public health. Lancet. 2005;5: 115- streptozocin induced diabetic rats. Comp. Biochem. Physiol. 119. 2003;135:357364. 6. Sung WS, Lee DG. In vitro antimicrobial activity and the mode of action 19. Okuda T, Yoshida T, Hatano T. Ellagitannins as active constituents of of indol-3-carbinol against human pathogenic microorganisms. Biol. medicinal plants. Planta Medica. 1989;55:117-122 Pharm. Bull. 2007;30: 1865-1869. 20. Adegoke SA, Agada F D, Ogundipe LO. Antibacterial activity of 7. Arbonnier M. Trees, shrubs and lianas of West African dry zones. 2002; methanol and ethanol leaf extracts of Antidesma venosum and CIRAD, MNHN Lannea barteri. African Journal of Microbiology Researc. 7(27), 2013, 8. Doka IG, Yagi SM. Ethnobotanical Survey of Medicinal Plants in West 3442-3447 Kordofan (Western Sudan). Ethnobot Leaflets. 2009;13: 1409-1416. 21. Figueiredo AC, Barroso JG, Pedro LG, Scheffe JJC. Factors affecting 9. Njinga NS, Sule MI, Patteh UU, Hassan HS, Usman MA, Haruna MS. secondary metabolite production in plants: volatile components and Phytochemical and Antidiarrhea Activity of the Methanolic Extract of essential oils. Flavour Frag. J.. 2008;23(4): 213–226 the Stem Bark of Lannea kerstingii Engl. and K. Krause 22. Sandhu DS, Heinrich M. The use of health foods, spices and other (Anacardiaceae). J. Nat. Prod. Plant Resour. 2013; 3(3):43-47 botanicals in the Sikh community in London. Phytother. Res. 2005;19: 10. Koné WM, Kamanzi AK, Traoré D, Betschart B. Anthelmintic activity of 633-642. medicinal plants used in Northern Côte d'Ivoire against intestinal 23. M.P. Guptaa,b,*, P.N. Sol´isa, A.I. Calderon´ a, F. Guinneau-Sinclairc, M. helminthiasis. Pharm. Biol. 2005;43: 72-78. Correab,d, C. Galdamesb, C. Guerraa, A. Espinosaa, G.I. Alvendae, G. 11. Brain KR, Turner TD. The practical Evaluation of Phytopharmaceutical. Roblese, R. Ocampoe. Medical ethnobotany of the Tribes of Bocas del 1975;Wright Scientechnica, Bristol. Toro, Panama. J. Ethnopharmacol. 2005;96: 389-401. 12. Sofowora A. Medicinal plants and traditional medicine in Africa. 2nd 24. Shorr AF. Epidemiology and economic impact of meticillin-resistant Edn. 1993; Spectrum books limited, Ibadan. staphylococcus aureus: review and analysis of the literature. 13. Lino A, Deogracios O. The in-vitro antibacterial activity of Annona PharmacoEconomics, 2007;25:751-68. senegalensis, Securidacca longipendiculata and Steanotaenia 25. Marquart ME, Caballero AR, Chomnawang M, Thibodeaux BA, Twining araliacea- Ugandan Medicinl plants. Afri. Health Sci. 2006;6(1): 31-35 SS, Callaghan RJ. Identification of a novel secreted protease from 14. Vollekova AD, Sochorova R. Isoquinoline Alkaloids from Mahonia Pseudomonas aeruginosa that causes corneal erosions. Invest. aquifolium stem bark is active against Malassezia Sp. Folia. Ophthalmol. Vis. . 2005;46:3761-8. Microbiologica. 2001;46: 107-111.

Keywords : antimicrobial, phytochemical, barteri, lannea kerstingii 9 - Njinga N.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article LOCOMOTOR TREADMILL TRAINING PROGRAM USING DRIVEN GAIT ORTHOSIS VERSUS MANUAL TREADMILL THERAPY ON MOTOR OUTPUT IN SPASTIC DIPLEGIC CEREBRAL PALSY CHILDREN Reda S.M. Sarhan1 , Mohamed Faisal Chevidikunnan2 & Riziq Allah Mustafa Gaowgzeh3 1,3Assistant Professors, 2 Lecturer, Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia. Correspondence : Mohamed Faisal Chevidikunnan Lecturer, Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O BOX 90324, Jeddah 21589, Saudi Arabia. E-mail : [email protected] Abstract: Purpose : This study intended to understand and compare the effect of loco-motor treadmill training program using robot-assisted gait therapy (Driven gait-orthosis DGO) and manual treadmill therapy on motor function in children with spastic diplegic cerebral palsy on their gross motor skills related to walking speed, ambulation and endurance. Subjects and Methods : Twelve spastic diplegic cerebral palsy children with the age under 5 years were participated in different ambulation training 3 times per week for 30 - 40 minutes sessions consisting of 2 different treadmill walking programs, for 10 weeks, and were tested pre and post intervention. The outcome measures included were; a timed 10-m walk test, ground walking speed, walking distance, and balance which were measured before and after treatment. Results & Conclusion : The results of this study suggests preliminary findings that children with CP under the age of 5 years can benefit their gross motor function, gait variables after intensive ambulation training using Driven gait orthotis (DGO). Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, Motor Function.

Introduction: children with cerebral palsy has consisted of physical Cerebral palsy (CP) is the most common physical disability therapy, bracing and surgery to lengthen and release tight occurs in childhood. The recent data show that the tendons of contracted muscles and correct muscle incidence of CP is 3.6 on every 1000 live births. As there is contractures4 . no cure for the CP, the motor disability continues Most of the children with CP have ambulatory difficulties. throughout the life and interacts with normal Because normal walking is essential for orthopedic and developmental and aging processes which alter its cardiopulmonary development, and for normal activities presentation over time1 . In spastic CP, spasticity develops of daily living, the achievement of independent, effective, because of the damage to the descending motor nerve and safe gait is therefore the most important goal of tracts and there will be resistance and limitation of normal rehabilitation in children with CP. Their walking energy muscle movements2 . expenditure is increased up to 3 times that of typically Access this article online Thereby it leads to muscle developing children, particularly for children with poorer Quick Response Code contractures which limit locomotor function, classified as level III (reliant on a hand- joint movement and held mobility device for ambulation) or IV (can walk only hence, develop abnormal short distances with a body support walker) by the GMFCS pattern of motor control3 . (Appendix 1). Improving walking function for children with Until recently, treatment moderate to severe walking difficulty is particularly for spasticity of muscles in

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 10 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science important because it has the potential to increase their pathways, as well as damage to central control centers in mobility and positively influence their societal the motor and premotor cortex. Although, exact participation at home, at school, and in the wider mechanisms are not clear, the nervous system is community. The benefits of ambulation are many whether continually adapting to environmental stimuli. This re- with or without assistance like; muscle activity and weight organization is termed as neural plasticity7 . Brain plasticity bearing during walking increase bone mineral density may be intensified by exercise, including movement (Wilmshurst, Ward, Adams, Langton, & Mughal, 1996) and activities, and the effect of motor learning depends on the can decrease the risk of hip subluxation or dislocation intensity and regularity of performing these5 . (Metaxiotis, Accles, Siebel, & Doederlein, 2000). Other Latest developments in clinical neuroscience give lot of benefits gained from ambulation are improved endurance hope that the institution of effective functional therapies of cardiopulmonary system and control of obesity (Chien, on the basis of on enhanced activity can improve the level DeMuth, Knutson, & Fowler, 2006) 1, 5, 6 . of functioning in children with CP8, 9 . Recent concepts of With a growing body of research evaluating the efficacy of motor learning assume that repetitive, task-specific training on treadmill for adults with neurologic disorders, training, enabled by a driven gait orthosis, may be a cost- most notably after injury to spinal cord, clinicians and effective means allowing for an improvement in walking researchers in pediatric CP field have begun to turn their ability 10, 11 . One of the latest solutions in this area is the attention to the potential benefits of treadmill training for Lokomat (Hocoma AG, Volketswil, Switzerland), which was benefitting walking in CP children. This interest is on the designed for adults and shown to facilitate significant basis of the principle that task-specific and repetitive improvements in individuals with injury to spinal cord12–13 . A practice is needed to develop and improve a motor skill paediatric device for children age of 4 years and over has such as walking. Using a mechanical treadmill, with or been available since 2006; however, there are only a few without supporting the body weight, may improve gait in studies assessing body-weight-supported treadmill children with CP because it gives an opportunity to therapy applied to paediatric patients. Robot-assisted intensively and repetitively train the entire cycle of gait and walking training can increase the duration of training and facilitate an improved gait pattern during walking. the intensity for the patients while the therapist's physical Preliminary work suggests that body weight supported strain also can be minimized. treadmill training is feasible in CP children and may Aim of the work: improve their gait variables and general gross motor skills6 . The purpose of the current study was to compare the effect Locomotor treadmill training (LTT) is relatively new of an intensive, loco-motor treadmill training program concept that is used to train the CP children on ambulation using robot-assisted gait therapy (Driven gait-orthosis in a more efficient manner. LTT with or without body DGO) and manual treadmill therapy on gross motor skills weight support, is one method that is followed in the related to ambulation, walking speed and balance in rehabilitation of CP children. The central nervous system children with diplegic cerebral palsy (CP) under the age of 5 (CNS), through mechanisms of brain plasticity, has the years. capacity to learn and adapt. The goal of therapeutic Subjects and Methods: exercise for the re education of muscles and facilitation is Subjects: to get back the body positions and movements voluntary Twelve subjects (7 male and 5 female) with neurological control after injury or disease has affected the motor walking disorders due to spastic diplegic cerebral palsy control mechanism. Motor control may be affected by participated in the study. The participants had an average damage to either or both the afferent and efferent neural weight of 28 kg (SD±4.3), an average height of 89 cm

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 11 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

(SD±6.7), and their age ranged from 3 to 5 years, with an history and lack of patient cooperation5 . average age of 4.2 years (SD±0.7). All children were being Materials: treated as either inpatients or outpatients in pediatric For the experimental group we have instituted the clinics. The subjects were randomly divided into two equal Lokomat Driven gait-orthosis LDGO (Lokomat® Pro Version groups, control group and study group. The control group 4, by Hocoma AG, Volketswil, Switzerland). The Lokomat received manual treadmill therapy and the study group system consists of; a treadmill, a body weight support received intensive, loco-motor treadmill training program system, a harness, a driven gait orthosis. The Lokomat DGO using robot-assisted gait therapy (Driven gait-orthosis is a bilateral robotic gait orthosis that is used in conjunction DGO), and each comprised of six patients. Both groups with a body weight–support system to control a patient's used computerized visual feedback and verbal instructions leg movements in the sagittal plane. The hip and knee of a physical therapist. After explaining the need of the joints of the DGO are actuated by linear drives, which are study to the subject's parties, informed written consent for integrated into an exoskeletal structure with force sensors this study was obtained. The study was approved by the in the hip and knee linear drives. The legs of the patient are Institutional Review Board. moved with predefined hip and knee joint trajectories. A The inclusion criteria for recruiting the subjects were; All passive foot lifter induces an ankle dorsiflexion during the children with cerebral palsy had a pediatrician's diagnosis swing phase. The legs of the patient are moved with highly of spastic diplegia, the subjects were recruited with at least repeatable predefined hip and knee joint trajectories on minimal voluntary control of their lower-extremity muscles the basis of an impedance control strategy. Knee and hip for the ability to respond and to adapt their walking, the joint torques of the subject are determined from force treating physical therapists judge the ability of the subjects sensors integrated in the drives of the DGO3. to voluntarily control their lower extremities (ie, at least For the control group it was trained on a Manual treadmill minimal movement in hip and knee joints was observed therapy consists of; a treadmill, a Biodex unweighing upon instruction), the subjects were having mild spasticity, system with hydraulic lift and a harness. The visual which has been confirmed clinically according to feedback is presented and displayed as line graphs on the Ashworth's scale, the subjects were having Level III or IV of patient monitor and on the monitor for the physical Gross Motor Function Classification System (GMFCS), therapist 9, 10 . subjects were having sufficient cognition should be demonstrated to understand the requirements of the For the evaluation of the outcome we have used the study and all subjects have never received treadmill gait following tools; Walking sheet: 10 meters long, divided at training at any time before the study. The exclusion criteria 1-cm intervals, Recording and displaying system consists were: children treated with botulinum toxin during the last of; Video set, camera and tapes, Color TV and Stop watch, 6 months; children treated surgically within a 1-year period Tape measure, The Bruininks-Oseretsky Test of Motor before the date of the examination; anatomical leg length Proficiency Subset 2 for Balance (Form 1), and 10 meter discrepancy larger than 2 cm (due to the Lokomat system Walk Test (time in sec or msec) limitations); fixed contractures; bone and joint Among the timed walking tests, the simplest to administer deformities; bone-articular instability (joint dislocation); is the ten-meter walk test (10mWT). It is simply a baclofen therapy using an implanted infusion pump; documented measure of the time required for the patient inhibiting casts during the last 6 months; significant to traverse ten meters at his self-selected walking speed. amblyopia and hearing loss; contra-indications for training Properly administered, the test is performed with a flying on a treadmill; any significant endurance impairments due start and finish. Specifically, the patient should be allowed to cardiovascular limitation based on patient's health

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 12 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science several meters of ambulation immediately before and after allowed free movement of the lower extremities. the ten-meter walkway to ensure that there are no periods The subjects of the study group were fitted with a bilateral of acceleration or deceleration within the timed event robotic orthosis that is used in conjunction with a body- itself. Additionally, clinicians should walk behind the weight support system to control the patient's leg patient rather than at his or her side or in front of him or her movements in the sagittal plane. The DGO's hip and knee to ensure that they are not pacing the patient at a speed joints are actuated by linear drives, which are integrated in other than the patient's true, self-selected walking speed. an exoskeletal structure. A passive foot lifter induces an Methods of Evaluation: ankle dorsiflexion during the swing phase. The legs of the Age, Sex, height, weight and body mass index (BMI) were patient are moved with highly repeatable predefined hip done according to standardized methods. Gait evaluation and knee joint trajectories on the basis of an impedance was performed as follows; the walking sheet was control strategy. Knee and hip joint torques of the patient positioned on the floor of the gait evaluation area and are determined from force sensors integrated in the drives fastened on both sides. The children were asked to walk as of the DGO3 . normally as they used to, from the start to the end of the The treating physical therapists judged the ability of the walkway. This was repeated three successive times. Then, subjects to voluntarily control their lower extremities (ie, at the subjects were videotaped along the ten-meter long of least minimal movement in hip and knee joints was the sheet. The videotape was then played back on the TV observed upon instruction). The subjects then walked on for the measurement of the temporal and distance gait - the treadmill to become familiar with treadmill and parameters, as follows: determine their self-selected walking speed (Their • Stride length: The distance between two successive preferred speed), then the treadmill was stopped, and placements of the same foot. appropriate amount of unweighting of each subject was • Cadence: The number of steps taken per minute. adjusted. The treadmill speed was set for each subject • Velocity: The distance covered in a minute. (Whittle, individually according to his/her preferred speed. The 1993) average speed was 0.55 m/s (SD±0.08 m/s) with the lowest possible body-weight support (where knee buckling was The Balance evaluation was done using the Bruininks- still prevented for passively behaving subjects). The oseretsky Test of Motor Proficiency Subset 2 for balance. impedance for the DGO control program was set to Each test was repeated two times, after which the final maximum (ie, the “guidance force” was set at 100%). Then score was calculated. All evaluation procedures were the subjects were weighed on the previously calibrated conducted by the same investigator for each patient before Tefal Electronic Device (weight scale), this weight was used and after the suggested period of treatment. to calculate the support needed for each subject. The The following steps were taken before starting the investigator was positioned next to the treadmill to guard treatment; upon arriving to the treatment area, all the the subjects from falling. Treatment for both groups subjects were given an overview of the treatment continued for ten successive weeks, thrice a week. Each procedure and were also instructed on how to safely step session lasted about 30 - 40 minutes3 . onto and off the treadmill. The subjects of the control Results : group were fitted with the harness with support across the Twelve subjects (n=12) were participated in this study and buttocks, around the thigh and around the rib cage, while the statistical comparison between values obtained before allowing free movements of the arms, the harness and after training were done using “t tests”. Results are suspended from an overhead support and the support presented as means ± standard deviation (SD) and the

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 13 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science differences were considered significant by keeping the As it is shown in the table 3, the mean value of velocity in confidence interval at 5% (p<0.05). the study group before treatment was 36.03 ± 4.495 cms/sec which was increased to 41.8 ± 3.705cms after 10 As shown in table 1, the mean value of the stride length in weeks of treatment. The mean difference was 5.75, which study group before treatment was 59.4cms, which represented a highly significant difference (p < 0.001). In increased after the suggested period of treatment to the control group, the mean value of velocity has increased 66.0cms. The improvement was 11 %, which revealed a from 38.45 ± 4.272cms to 39.67 ± 3.637cms after highly significant difference (t =7.92, p < 0.001) and the application of the traditional physical therapy program, mean value of the stride length in control group before with a mean difference of 1.22, which was shown as treatment was 59.0cms, which increased after the statistically not significant (p<0.032). suggested period of treatment to 61.4 Cm. The improvement was 4 %, which revealed a non significant From the table 4, it can be shown that in the study group, difference (t = 2.714, p < 0.025). the mean values of the grades of stability before and after treatment were 14.6 ± 0.966 and 16.4 ± 2.75 (grades), As shown in Table 2, the mean values of cadence in the respectively where the mean difference was.1.8 grades, study group before and after the suggested period of which was statistically highly significant (p< 0.001). treatment were 74.16 ± 7.386 and 80.92 ± 6.369( in Meanwhile, the mean values of these grades in the control steps/min ), respectively. The mean difference was 6.76, group before and after treatment were 15.3 ± 1.494 and which was statistically highly significant (p < 0.001) 16.6 ± 1.577(grades) respectively, showing a mean whereas the mean value of cadence in the control group difference of 1.3 (grades) which was also statistically increased from 74.96 ± 7.295(in steps/min) to 79.57 ± significant (p < 0.005). 8.135 (in steps/min) after treatment, which indicated a non-significant improvement (p < 0.815). APPENDIX 1. The Bruininks-Oseretsky Test of Motor Proficiency Subset 2 for balance. (Form 1) Action Duration Point Score Total Trial 1 Trial 2 Score Standing on preferred leg on floor 10 seconds maximum per trial ( ) seconds ( ) seconds 0 1 2 3 4 0 1 2 3 4 Standing on preferred leg on balance beam 10 seconds maximum per trial ( ) seconds ( ) seconds 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Standing on preferred leg on balance 10 seconds maximum per trial ( ) seconds ( ) seconds beam-eyes closed 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 Walking forward on walking line 6 seconds maximum per trial ( ) steps ( ) steps 0 1 2 3 0123 Walking forward on balance beam. 6 seconds maximum per trial ( ) steps ( ) steps 01 2 3 4 0123 Walking forward heel-to-toe on walking line 6 seconds maximum per trial ( ) steps ( ) steps 0123 0123 Walking forward heel-to-toe on balance beam. 6 seconds maximum per trial ( ) steps ( ) steps 0 1 2 3 4 0123 4 Stepping over response speed Stick on balance beam 10 seconds maximum per trial ( ) steps ( ) steps 0123 01 Adopted from Bruininks (1987)

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 14 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

TABLES: Table1 : Shows mean values of stride length (in cms) in both Table 2: Shows mean values of cadence (in steps/min) in both study and control and study group after treatment control groups before and after treatment. Comparison Study Control Comparison Study Control Pre After Pre After Pre Post Pre Post Mean 59.4 66.0 59.0 61.4 Mean 74.16 80.92 74.96 79.57 SD 5.92 5.436 6.342 7.662 SD 7.386 6.369 7.295 8.135 MD 6.6 2.4 MD 6.76 0.39 t 7.92 2.714 t 6.002 0.241 p < 0.001 0.025 p < .001 <0.815

Table 3: Shows mean values of gait velocity (in cms /sec) in both Table 4: Shows mean values of Stability (in grades) in both study study and control groups before and after treatment. and control groups before and after treatment. Comparison Study Control Comparison Study Control Group Pre Post Pre Post Pre Post Pre Post Mean 36.05 41.8 38.45 39.67 Mean 14.6 16.4 15.3 16.6 SD 4.495 3.705 4.272 3.637 SD .966 2.75 1.494 1.577 MD 5.75 1.22 MD 1.8 1.3 t 8.4 2.542 t 1.765 3.545 p < 0.001 < 0.032 p < 0.001 < 0.005

Discussion: associated with DGO and supported body weight tread mill The purpose of the current study was to compare the effect training. We Utilized gait evaluation parameters, including, of an intensive, loco-motor treadmill training program stride length, cadence, velocity and the Bruininks- using robot-assisted gait therapy (Driven gait-orthosis Oseretsky Test Motor Proficiency Subtest 2 for balance. The DGO) and manual treadmill therapy on gross motor skills results at the end of the treatment period indicated related to ambulation, walking speed and balance in significant improvement in cadence, stride length, gait children with diplegic cerebral palsy (CP) under the age of 5 velocity and balance in the study group who received a years. bilateral robotic orthosis that is used in conjunction with a body-weight support system whereas in the control group Walking ability, which is extremely important for the only the balance has shown a significant improvement. quality of life and participation in social and economic life, Such significant differences reflect the great influence of can be adversely affected by neurological disorders5 . the bilateral robotic orthosis that is used along with body- Rehabilitation of patients with such disorders should weight support system training in treatment of diplegic CP. include gait training, due to evidence that the desired function or movement has to be developed in a task- The use of DGO in patients with CNS disorders has many specific training programme1 4 , 1 5 . Recently, gait benefits. These include: providing a safe environment to rehabilitation methods in patients with neurological practice walking17 , making repetitive training more impairments have relied on technological devices, which feasible, increasing safety of standing and ambulation drive the patient's gait in a body-weight support condition training, and decreasing the work reducing the number of and emphasize the beneficial role of repetitive practice11 . therapists18,19 . However, the limitations and controversial The rationale for these approaches originates from animal findings in published research suggest the need for further studies, which have shown that repetition of gait studies19, 20 . Unfortunately we could not find much of movements may enhance spinal and supraspinal published articles on the effect of DGO in CP children to locomotor circuits16 . have a comparison of the current study; meanwhile we could find many articles on the effect of body weight In this study we examined the changes in gait parameters

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 15 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science supported treadmill training (BWSTT) in different stated that BWSTT is beneficial as a treatment method neurological conditions. In our study it was found that both because the movement of the lower extremities into these treatment techniques are found to be effective but extension afforded by the treadmill assists in stimulating a DGO had a slightly better edge on the parameters tested in stepping response not otherwise able to be elicited. While CP children. upright and safe position of the patient not only functional for the patient, but it also allows the therapist to be more The study by Chrysagis N et al, found in their study on effect effective. of treadmill training on CP children that, children receiving treadmill training had higher mean posttest GMFM and Even though therapists are using BWSTT because of its walking speed scores compared with the control group clinical effectiveness, evidence supporting the clinical receiving conventional physiotherapy. Therefore, patients significance of the treatment method still rather limited. with CP exposed to treadmill training may improve their Some limitations do not allow for generalizations of the motor function and gait speed to a greater extent, without present findings without adequate caution. An additional an adverse effect on spasticity, compared with their secondary outcome variables like muscle strength and counterparts after conventional physiotherapy. This energy expenditure, were not assessed in the current study supports the theory of motor learning through task- and in addition, the effect of the training program on the specific repetitive movements. According to this approach, participants' psychologic parameters, like quality-of life, training should be customized around a treatment goal was not examined. demanding the participant's active motivation21 . Another Conclusion : study by Richards et al.(1997)22 who have stated that, From the results of the present study we can conclude that, pattern of walking seen in children with CP is very similar to the study group CP children who were receiving DGO were the leg muscle activity described in stepping newborns. showing slightly better improvement in all the gait They assumed that in children with cerebral palsy, the variables tested except the balance as compared with the locomotor pattern cannot mature because of impaired BWSTT group. supraspinal influence, and the impact of BWSTT is shown to have a greater effect on neuronal connections in spinal Acknowledgements : cord. The work was funded by the Deanship of Scientific Research (DSR), King Abdulaziz University, Jeddah. The Schindl et al,(2000)23, reported that stretching the hip authors therefore acknowledge with thanks the DSR's flexors in terminal stance stimulates the primary nerve technical and financial support. ending of the muscle spindles, thereby activating the muscles and initiating the leg to come forward. In addition, Conflict of Interest the increased tension placed on the triceps surae muscle Authors agree that there was no source of conflict of by loading the limb in mid-stance during BWSTT, has also interest. found to facilitate muscle activation. Hesse et al. (1999)11,

References: 1. Diane L. Damiano, Katharine E. Alter, Henry Chambers. New Clinical 4. Colombo G, Joerg M, Schreier R, Dietz V. Treadmill training of and Research Trends in Lower Extremity Management for Ambulatory paraplegic patients using a robotic orthosis. J Rehabil Res Dev. Children with Cerebral Palsy. Phys Med Rehabil Clin N Am. 2009; 20(3): 2000;37:693–700. 469–491. 5. Mariusz Druzbicki, Wojciech Rusek, Slawomir Snela, Joanna Dudek, 2. Bodkin A. W, Baxter R. S, Heriza C B. Treadmill training for an infant Magdalena Szczepanik, Ewelina Zak, Jacek Durmala, Anna born preterm with a grade III intraventricular hemorrhage. Physical Czernuszenko, Marcin Bonikowski, Grzegorz Sobota. Functional Therapy, 2003; 83: 1107-1118. effects of robotic -assisted locomotor treadmill therapy in children 3. Lünenburger L, Colombo G, Riener R, Dietz V. Biofeedback in gait with cerebral palsy. J Rehabil Med. 2013; 45: 358–363. training with the robotic orthosis Lokomat. Conf Proc IEEE Eng Med 6. Willoughby KL, Dodd KJ, Shields N, Foley S. Efficacy of partial body Biol Soc. 2004;7:4888–4891. weight–supported treadmill training compared with overground

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 16 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

walking practice for children with cerebral palsy: a randomized Medicine and Child Neurology. 1991; 33(7): 567-577. controlled trial. Arch Phys Med Rehabil. 2010; 91: 333-9. 16. Lepage C, Noreau L, Bernard P. Association between characteristics of 7. Mohamed Faisal CK, Priyabandani Neha Om Prakash, Ajith S. Efficacy locomotion and accomplishment of life habits in children with cerebral of Functional Neuromuscular Electrical Stimulation (FNMES) in the palsy. Physical Therapy.1998; 78(5): 458-469. improvement of hand functions in Acute Stroke Survivals. NUJHS. 17. Henning Schmidt, Cordula Werner, Rolf Bernhardt, Stefan Hesse and 2012; 2(4): 16-21. Jörg Krüger Gait rehabilitation machines based on programmable 8. Day J, Fox E. J, Lowe J, Swales H B, Behrman A L. Locomotor training footplates. J Neuroengineering Rehabil. 2007; 4: 2. with partial body weight support on a treadmill in a nonambulatory 18. Metaxiotis D, Accles W, Siebel A, Doederlein L. Hip deformities in child with spastic tetraplegic CP: A case report. J Pediatric Physical walking patients with cerebral palsy. Gait & Posture. 2000; 11: 86-91. Therapy. 2004; 16: 106-113. 19. Katherine J Sullivan, David A Brown, Tara Klassen, Sara Mulroy, Tingting 9. Dobkin B, Apple D, Barbeau H. Weight-supported treadmill vs over- Ge, Stanley P Azen, Carolee J Winstein; for the Physical Therapy Clinical ground training for walking after acute incomplete SCI. Neurology. Research Network (PTClinResNet). Effects of task-specific locomotor 2006; 66: 484–493. and strength training in adults who were ambulatory after stroke: 10. Dodd K J, Foley S. Partial body-weight-supported treadmill training can Results of the STEPS randomized clinical trial. Physical Therapy. 2007; improve walking in children with cerebral palsy: A clinical controlled 87: 1580-1600. trial. Developmental Medicine and Child Neurology. 2007; 49(2): 101- 20. Straus S, Richardson W, Glasziou P, Haynes B. Evidence based 105. medicine: How to practice and teach EBM (3rd ed.). 2005; 11. Hesse S, Uhlenbrock D. A mechanized gait trainer for restoration of Philadelphia: Elsevier Churchill Livingstone. gait. J Rehabil Res Dev. 2000; 37: 701–708. 21. Chrysagis N, Skordilis EK, Stavrou N, Grammatopoulou E, Koutsouki D. 12. Hornby TG, Zemon DH, Campbell D. Robotic-assisted, body-weight- The effect of treadmill training on gross motor function and walking supported treadmill training in individuals following motor speed in ambulatory adolescents with cerebral palsy: a randomized incomplete spinal cord injury. Phys Ther. 2005; 85: 52–66. controlled trial. Am J Phys Med Rehabil. 2012; 91: 747-760. 13. Husemann B, Muller F, Krewer C. Effects of locomotion training with 22. Richards C L, Malouin F, Dumas F, Marcoux S, Lepage C, Menier C. Early assistance of a robot-driven gait orthosis in hemiparetic patients after and intensive treadmill locomotor training for young children with stroke: A randomized controlled pilot study. Stroke. 2007; 38: cerebral palsy: A feasibility study. Pediatric Physical Therapy.1997; 349–354. 9(4): 158-165. 14. Kelso J A S. Anticipatory dynamic systems, intrinsic pattern dynamics 23. Schindl M R, Forstner C, Kern H, Hesse S. Treadmill training with partial and skill learning. Human Movement Sciences. 1991; 10: 93-111. body weight support in nonambulatory patients with CP. Archives of 15. Leonard C T, Hirschfeld H, Forssberg H. The development of Physical Medicine and Rehabilitation.2000; 81: 301-306. independent walking in children with cerebral palsy. Developmental

Keywords : Spastic Diplegic Cerebral Palsy, Driven Gait Orthosis, 17 Motor Function. - Mohamed Faisal Chevidikunnan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article A STUDY TO ASSESS THE LEVEL OF ATTITUDE TOWARDS EUTHANASIA AMONG HEALTH PERSONNEL Maria Therese A. 1 , Rukumani J. 2 , Pon Princess Mano3 , Ponrani4 & Nirmala5 1Professor, Medical Surgical Nursing, 2 Principal, College of Nursing Mother Theresa Post Graduate and Research Institute of Health Science,3 Tutor, PIMS College of Nursing, 4 Staff Nurse, Jawaharlal Institute of Postgraduate Medical Education and Research, 5 Staff Nurse, Rajiv Gandhi Maternal & Children Hospital, Puducherry. Correspondence: Maria Therese A. Professor, College of Nursing Mother Theresa Post Graduate and Research Institute of Health Sciences Indra Nager, Gorimedu, Puducherry. Mobile : +91 98941 41223 E-mail : [email protected] Abstract : Most people would probably want to live to a ripe old age, and then die painlessly in their sleep. Unfortunately, this is not the reality most people face. Some people will die after a long struggle with a painful disease. Euthanasia has become a complex global issue for the 21st century, with different cultures wrestling with variety of ethical, religious and legal factors involved in helping someone to die legally. The role of health personnel in euthanasia would ultimately cause more harm than good. Euthanasia is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks. Aim : it aims at contributing to the current literature in regard to euthanasia through shedding the light onto the attitude towards euthanasia among health personnel. Material and Methods : An exploratory descriptive design was used to conduct this study non probability ampling technique was employed, the sample consisted of 70 Health Personnel including Doctor & Nurses who are working in Government and Private health institutions at Puducherry. After obtaining informed consent data was collected using with self structured questionnaire for demographic variables of the samples and the Euthanasia attitude scale (EAS) developed by Holloway, Hay slip, Murdock et al 1995,was utilized to measure the attitude of a person has towards end of life decisions. Results : The study findings revealed that out of 70 health personnel 42 (60%) had Positive attitude and 28 (40%) had Negative attitude towards euthanasia. Conclusion : Health personnel had positive attitude towards euthanasia in certain circumstances for terminally ill clients with unbearable pain Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, health Professionals

Introduction : deteriorates to such a degree, that they wish they were The preservation of human life is the ultimate value, the dead. A person might argue that all available medical pillar of ethics and the foundation of all morality. This held technology ought to be brought to bear in the true in most cultures and societies throughout history. Life preservation of life, but the pain and financial burdens is sacred, valuable to be cherished and perished1 Most that family members, patients or society might have to people would probably want to live to a ripe old age, and endure could be so great that although the person might then die painlessly in their want to go on living ,it would be in the best interest of the sleep. Unfortunately, this patient family or the society that the individual should Access this article online 2 Quick Response Code is not the reality most choose to die. The known purposes of the medical people face. Some people profession are to help people survive, live longer in spite of will die after a long chronic illness and get rid of pain. Advancement in medical struggle with a painful care and the application of its technology have always disease. Others will find helped in attaining this goal. Unfortunately among all long that their body lived individuals, some die peacefully and some with

Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, 18 health Professionals - Maria Therese A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science painful, tortuous deaths. When life is without quality, when weakening of public and social morality. Some views state pain and discomfort rob life of its significance, some that doctors are willing to perform voluntary euthanasia if persons cry out for release through death- a good death it becomes legal in the country. It is thought that the through euthanasia (2,3) . majority of medical practitioners are in favor to change the law and allow euthanasia in certain circumstances.(7) The word euthanasia is linked to the Greek words for good (eu), and death (thanatos). Euthanasia is therefore According to British Social Attitude Survey in 1996, associated with the idea of wanting to die free from euthanasia was preferred for incurable conditions by 86% suffering, or to have a good death4 . Euthanasia refers to the of population, for dying patients by 80% of population, for practice of intentionally ending a life to relieve pain and patients in coma by 58% of population and for patients with suffering. The term euthanasia was first used in medical danger of death and not much pain by 57% of population(8). context by Francis Bacon in the 17th century to refer to an According to 2010 British Social Attitude Survey, 82% of the easy, painless, happy death during which it was physicians' general public believed that doctor should be allowed to responsibility to alleviate the physical sufferings of the end the life of a patient with a painful incurable disease at body5 . But Euthanasia is controversial, because it puts the the patient's request, which was supported by 71% of plight of suffering, dying individuals against religious religious people and 92% of non-religious people (9) Recent beliefs, legal tradition, and, in the case of physician assisted reports from Netherlands and Belgium provide that there death, medical ethics. The role of health personnel in is a growing number and percentage of people who are euthanasia would ultimately because more harm than dying by euthanasia. The reports from Netherlands stated good also it heightens the significance of its ethical that there were 2331 cases of euthanasia in 2008 up from prohibition rather. Euthanasia is fundamentally 2010 cases in 2007 and 1923 cases in 2006. This incompatible with the physician's role as healer, would be represented an increase of 10%each year. The Belgium difficult or impossible to control, and would pose serious study examined 6202 death certificates in Flanders region societal risks.(2,6) Instead of engaging in euthanasia, and found that 118 were euthanasia deaths. A study that physicians and nurses must aggressively respond to the was published in the New England Journal of medicine needs of patients at the end of life. Patients should not be indicated that 7.1% of all deaths in Netherlands in 2005 abandoned once it is determined that cure is impossible. were related to terminal sedation which is often done to Patients near the end of life must continue to receive cause the death of the person and not to relieve intractable emotional support, comfort care, adequate pain control, pain (7,10) . In 1962, a high court in Nagoya, Japan, declared respect for patient autonomy, and good communication. euthanasia legal under special circumstances and specified that it should be performed by a medical doctor. A 1990 Need For The Study: survey of members of the Japan Medical Society revealed The controversy over euthanasia has sparked many views that 87 % of its members would honor a patient's desire "to that it is the act of taking the life, for reasons of mercy of a die with dignity." However, any euthanasia performed person who is hopelessly ill, while other view it as morally without patient consent is against the law. outrageous. The attitude towards euthanasia is not a simple thing and there are many factors that influence it, In India, Passive euthanasia is legal since 7th March 2011. these include, culture, religious beliefs, age and gender. The supreme court of India legalized passive euthanasia by Although euthanasia is illegal in many countries, it is legal in means of the withdrawal of life support to patients in a some countries such as the Netherlands, Belgium and the permanent vegetative state. The decision was made as part US state of Oregon. Some studies stated that such debate of the verdict in a case involving Aruna Shanbaug, who has about legalizing euthanasia would cause a general been in a vegetative state for 37yrs at King Edward

Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, 19 health Professionals - Maria Therese A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Memorial Hospital. The high court rejected active of the doctors supported euthanasia for the relief of euthanasia by means of lethal injection. In the absence of a unbearable pain and suffering (14) law regulating euthanasia in India, the court stated that its Objectives: decision becomes the law of the land until the Indian 1. To assess the attitudes towards Euthanasia among Parliament enacts suitable law. Active euthanasia including health personnel. the administration of lethal compounds for the purpose of 2. To associate the attitudes with the selected ending life, is still illegal in India and in most countries.(11) demographical variables. Nurses take up a central position in care of terminally ill patients, where being dealt with euthanasia request is an An exploratory descriptive design was used to conduct this ever present possibility. Based on their professional study non probability ampling technique was employed, expertise and unique relationship with patient, nurses are the sample consisted of Health Personnel Doctor & Nurses participating as full members of the interdisciplinary expert who are working in Government and Private health team are in a key position to provide valuable care to institutions at Puducherry informed consent was obtained patients receiving euthanasia. (12) . from the samples.

Medical professional can make significant contribution to Tool and Techniques the quality of care by assisting and counseling patients and Self-administered questionnaire was used which consisted their families, in a professional manner, even in countries of Section A and Section B. Demographic data like Name, where euthanasia is not legal. Age, Sex, Religion, Educational qualification, Designation, Years of working experience, Place were included in Review of literature Section A. In Section B to measure the attitude of a person Gielen J, conducted a study on religion and nurses has towards end of life decisions the Euthanasia attitude attitudes to euthanasia and physical assisted suicide, they scale (EAS) was utilized which is developed by Holloway, searched pub med for articles published before August Hay slip, Murdock et al 1995. It contains 30 statements, it 2008 using combination of search terms, most Identified frames in the pattern of likert scale, ranging between 1-4 studies showed a clear relationship between two, with the statement of Strongly Agree, Agree, Disagree, difference in attitudes were found to be influenced by Strongly Disagree. Scoring key: The total highest score is religious or ideological affiliation , observance of religious 120.The score was interpreted in the following way.75-120 practices, religious doctrine and personal importance -Positive attitude towards euthanasia < 74 – Negative attributed to religion or world view, nevertheless, a attitude towards euthanasia coherent comparative interpretation of the results of the identified studies was difficult, we concluded that no Results and Findings study has so far exhaustively investigated the relationship The sample size was selected as 100, among only 70 were between religion or world view and attitudes toward responded. The structured Euthanasia Attitude Scale (EAS) euthanasia or physically assisted suicide and that further with 4-points likert scale was used to assess the attitude research is required .(13) towards euthanasia.

Sneha Kamath et.al (2011) conducted a cross sectional The responses were analyzed through descriptive study to assess the attitudes toward euthanasia among 213 statistics, (Frequency, Percentage, Mean, Median, doctors in a tertiary care hospital in South India. A self standard deviation and Inferential statistics “t” value and administered questionnaire was used, 69.3% respondents chi-square) by using PASW (18.0 Version) statistical supported the concept of euthanasia and 66.2% were package.(*) against to euthanasia. This study conclude that a majority

Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, 20 health Professionals - Maria Therese A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table (1) reveals the distribution of sample on concluded that there was no association between attitudes demographic variables Among 70 samples, the age group towards euthanasia and various attributes such as age, of 25yrs – 35yrs are 45 ( 64.2%) who were the highest of the gender, religion and designation respectively and the other age groups, 36yrs – 45yrs of 20 is 28.5%, 46yrs – euthanasia concept is strongly supported. 55yrs of 3 is 4.2% and >56yrs of 2 is 2.8%. Sex wise , the Tables females were the highest samples and holds 57% (40) Table -1 Distribution of demographic variable (N=70) whereas the males were 42.8 %( 30).Among the samples Demographic variables Frequency Percentage 52(74.2%) were Hindus, 3(4.2%) of Muslims, 14(20%) of Age 25 – 35 45 64.2% Christians and the other religion showed 1(1.4%). The 36 – 45 20 28.5% Hindu religion holds the highest percentage. According to 46 – 55 3 4.2% the 26(37.1%) were UG, 36(51.4%) were PG, 4(5.7%) were Above 56 2 2.8% Sex Doctorate and 4(5.7%) have did other courses. The PG Male 30 42.8% possessed the highest percentage among other graduates. Female 40 57.1% When bring out the occupation samples of 33 (47.1%) were Religion Hindu 52 74.2% physicians, 17(24.2%) were staff nurses, 12(17.1%) were Muslim 2 4.2% students and 8(11.4%) were faculties from health teaching Christian 14 20% profession. The physicians were the highest samples Others 1 1.4% among the group. Qualification Undergraduate 26 37.1% Table (2) denotes that among 70 samples 42(60%) have Postgraduate 36 51.4% Doctorate 4 5.7% positive attitudes towards euthanasia whereas 28(40%) Other specify 4 5.7% have the negative attitude. Designation Physician 33 47.1% Table (3) denotes that the comparing the mean score Staff nurse 17 24.2% between the male and female. Based on the PASW (18.0) Teaching profession 8 11.4% Students 12 17.1% software, The obtained Mean value was 83.07, with SD of 13.036 for males and for females the obtained Mean value (**)Table -2 Distributions Of Samples On Overall Level Of Attitude , Towards Euthanasia N=70 was74.63 with SD of 10.8167 which had been inferred that Score Attitude Frequency Percentage the t-value = 2.958 and the corresponding p-value < 0.004, 75 – 120 Positive attitude 42 60% Therefore it was concluded that there was significant < 75 Negative attitude 28 40% difference in the average attitude towards euthanasia (***)Table -3 comparison of attitude with gender N=70 between males and females. This inference shows Gender N Mean Std. t -test df Sig. (2-tailed) that the attitude towards euthanasia was differing Deviation according the males and females thoughts, in the study. Male 30 83.07 13.036 2.958 68 .004 Female 40 74.63 10.817 In associating the attitude with the related demographic variables (age, sex, religion, designation). The association Discussion : between attitudes towards euthanasia and different The study was to assess the attitude towards euthanasia attributes such age, gender, religion, educational among the health personnel. SnehaKamath et.al. (2012) qualification, designation, working experience and studied to assess the attitudes of doctors toward working place respectively had been seen using PASW euthanasia and possible factors responsible for these (18.0 Version) statistical package. It had been inferred that attitudes. They concluded that a majority of the doctors all the p-values were greater than 0.05. Hence we supported euthanasia for the relief of unbearable pain and

Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, 21 health Professionals - Maria Therese A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science suffering. The study findings revealed that out of 70 health on the gender wise 83.1% of Male supported strongly the personnel 42 (60%) had Positive attitude and 28 (40%) had euthanasia concept whereas the 74.6% of female leastly Negative attitude towards euthanasia. Mr.Naser supported the euthanasia concept. Based on the religion Agababaei.et.al., (2011) studied on Euthanasia Attitude 84.3% of Muslim and 89% of other religion strongly Scale (EAS) from 197 students in June 2011. They supported the euthanasia concept. Finally, based on the concluded that analyzing the attitude towards euthanasia designation wise the staff nurses and students strongly scale results in lower levels of opposition against supported the euthanasia concept and holder 81.2% and euthanasia. 80.5% respectively. Thus we conclude that most of the Health Personnel have got positive attitude towards The attitudes of Health Personnel towards euthanasia the euthanasia. When compared with the attitude with age p- highest and the lowest score level out of 120 denoted that value is 0.434, there was no association core between the the highest score was 110 /120, it showed the strong different age groups and the attitude towards euthanasia. positive attitude towards euthanasia and the lowest score The same findings had come out in religion and was 48/120, it revealed that the strong opposition towards designation, holded the p-value of 0.954, 0.280 euthanasia concept. From the EAS, the 30 items of respectively, these values were more than 0.05, so it was statements were categorized into 4 divisions that of the found that there was no association between attitudes concept of supporting euthanasia , the concept of towards euthanasia and various attributes such as age, opposing euthanasia, the individual decision on gender, religion and designation respectively and the euthanasia and the methods supporting / opposing euthanasia concept is strongly supported. euthanasia concept. SnehaKamath et.al. (2012) studied to assess the attitudes of doctors toward euthanasia and Recommendations: possible factors responsible for these attitudes. They • A comparative study can be conducted among the concluded that a majority of the doctors supported health personnel. euthanasia for the relief of unbearable pain and suffering. • Similar type of studies may be conducted in paramedical Based on the items of statements from the Euthanasia health personnel. Attitude Scale (EAS), score of 67.2%( average score of 32.3 • A study can be conducted to assess knowledge among out of 48) supports euthanasia whereas score of 63.2% ( the nursing students. average score of 40.5 out of 64) oppose the euthanasia Limitations: concept and 70% ( average score of 5.6 out of 8) supports • The sample size was selected as 100, but only 70 were the individual decision towards euthanasia. Based on the responded. methods from EAS, 66.2% (score of 5.3 out of 8) supports • Most of the health personnel were busy with their the euthanasia concept whereas 63% (score of 5 out of 8) schedule. oppose the euthanasia concept. When compare with the assumptions made at the beginning of the research only Conclusion : some health personnel have got the positive attitudes Health personnel had positive attitude towards euthanasia towards euthanasia for a terminally ill client with in certain circumstances for terminally ill clients with unbearable pain, but as per the survey 60% of health unbearable pain. So in India passive euthanasia may be personnel have positive attitude towards euthanasia, implemented according to the Institutional Policy, since it is where as 40% have negative attitude. The age group of 35- legalized from 7th March, at all health institutions at certain 45yrs (45) and >56 years (2) have positive attitudes towards circumstances. euthanasia and holds 80.2% and 82% respectively. Based

Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, 22 health Professionals - Maria Therese A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Vankin S. The importance of human life 2005. Available from: URL : Attitude Survey 1996. Available from: URL : http://www.euthanasia. http://www.globalpolitician.org acc/97-1dvd.html. 2. Chandara Russell, Christian Ethics, 1997; 2nd Edition: 140 -147. 9. Dignity in dying. http://www.en.wikipedia.org/wiki/dignity_in_dying. 3. Elthar SA, Abel AA, Shanla A, Awad MA. Attitude towards euthanasia in 10. Schandenberg A. Incidence of euthanasia and assisted suicide psychology students. Sudanese Journal of Public Health 2010; continue to increase in the Netherlands and Belgium 2009September. 5(3):139-43. Available from: URL: http://www.sjph.net.sd. Available from: URL: http://alexschandenberg.blogspot.com. 4. Du Gas BW. Introduction to patient care- A Comprehensive approach 11. Aparna R. India: Euthanasia debate re-kindled. Available from: URL: to Nursing. 4th ed. New Delhi: Elsevier publications; 2006.p 694-5. http://www.globalvoices.org 5. Euthanasia. Available from: URL: http://en.wikipedia.org/wiki/ 12. Dierckx CB, Bal DN, Dee BT, Gatsman C. Involvement of nurses in caring euthanasia. for patients requesting euthanasia in Flanders. Journal of Advanced 6. Das.Sohen, (2004) Christian Ethics and Indian Ethos, 5th Edition : 171 Nursing 2010 November;66(11):2410-20. Available from: URL: - 191 . http://www.ncbi.nlm.nih.gov/pubmed/20722798 7. Denier .Y,Involvement of Nurses in the euthanasia care process in 13. Gielen.J,at el, Religion and nurse attitude to euthanasia and Physical Flanders (Belgium), nursing Journals ,2009 ; 25(4) :264-74. Assisted SuicideNurses Ethics 2001 ;16(3) : 303-18. 8. Donnison D. Not just an issue of life and death-The British Social 14. Sneha Kamath et.al. attitude towards euthanasia among Doctors in a Teritoty Hospital, Indian J Palliat Care. 2011 Sep-Dec; 17(3): 197–201.

Keywords : Euthanasia, Involundary, Mercy Killing, Attitudes, 23 health Professionals - Maria Therese A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article PREVALENCE OF UNDER-NUTRITION AND ANEMIA AMONG UNDER FIVE RURAL CHILDREN OF SOUTH KARNATAKA, INDIA Nanjunda UGC-CSSEIP Centre, Mysore University, Mysore, India. Correspondence : Nanjunda UGC-CSSEIP Centre, Mysore University, Mysore, India. Mobile : +91 98809 64840 E-mail : [email protected] Abstract : Infant and under five mortality rates are reliable indicators of health status of the children of any country. Despite accelerated growth, the prevalence of hunger, poor health status, under nutrition and mortality in rural part of the country are still persisting in India. While under nutrition among children is pervasive; child mortality is rather high in rural parts of India. The current study conducted in two remote villages of Hassan and Kodagu districts of South Karnataka-India. Study conducted on ( Boys 160, Girls 140) preschool children, selected through stratified sampling design technique. Through this study stunting in 75.0 %, wasting in 81.7% and underweight in 87.6% of both Boys and Girls of pre-school children were found. In case of Anemia, 48% of Girls and 56% of Boys were severely affected; while 47 % of Girls and 41% of the Boys were modestly affected and 10% of the Boys and 28% Girls observed mildly affected. It is also found that clinical sign of Anemia among 62% of the studied children. Next, 21% children found Vitamin A deficiency and 22% children found vitamin B complex deficiency. The Study also found that only 67% children put on breastfeeding within Three hours after the birth in the studied village. It is also noted that income poverty, bad personal habits, changing health seeking behavior, cultural practices regarding delivery, child rearing and breastfeeding also plays a vital role in case of mortality problem where Government and NGO (Non- Gov. Organizations) should focus on these issues immediately. Keywords : Mortality, Nutrition, Health, Rural , Children

Introduction : complex of the entire way of life2 . There are a number of Under nutrition and childhood mortality became a serious forces percolated from the larger socioeconomic problem among the rural children in many south Asian environment and guided through the attribute of nations. It is found that social- ethnic background, health historical, social and political dimension to the growth seeking behavior and health culture dynamics plays a pattern of rural health culture in the given settings. A good significant role as few vital determinants of the health health required a balanced diet. Under Five children need status of rural community in a multicultural society like a good nutritional diet which is scanty in many rural India. Because of unique heath seeking beliefs and settings in the country and this causes mortality and behavior under nutrition and childhood mortality are more morbidity among the rural population3 . common in rural areas1 . WHO (World Health Organization) It is found that Nearly Thirty (30) lakh children in India die report (1985) has found that 57% of the death of under Five before the age of Five due to various health issues. This has children in developing countries accompanied by under- become a common phenomenon in rural parts of the nutrition thereby low country. Various child health indicators reports of the weight for their age. Access this article online country have shown considerable improvement and infant Quick Response Code Medical Anthropologists mortality has gone down from 78 to 57 deaths per 1000 live have revealed that the births and under-five mortality from 109 to 74 deaths per development of health 1000 live births1 . However, under-five mortality levels culture of the rural among rural children are still shockingly high (at 97 deaths community should be per 1000 live births). Rural's constitutes 60 to 62 percent of examine as a sub cultural the total population, but accounts for about 19 percent of

Keywords : Mortality, Nutrition, Health, Rural, Children - Nanjunda 24 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science all under-five deaths, and 23 percent of deaths in the 1-5 Major Objective : age group4 . This present study is to assess the extent and prevalence rate of Under-nutrition and Anemia among under Five rural In India, the flagship program for preclusion and control of children in the Two districts of south Karnataka, India. anemia stress on pregnant women and young children less than 5 years. On the other hand, the position of anemia in Materials and Methods : children is not well recognized, though information on This current study conducted in Two remote villages of underweight and stunting is available. Hence Anemia in Hassan and Kodagu districts of south Karnataka. The study children continues to be given a very little precedence. had 300 ( Boys 160, Girls 140) preschool children, selected Despite the marvelous development focusing preventive using stratified sampling design technique. Household and curative medicine, the child healthcare delivery survey carried out in Three villages covering 300 families services in several rural communities are still poor and under the jurisdiction of Four primary health centers (PHC). unscientific. It is found that poverty, illiteracy, Anthropometric measurements taken using standard malnutrition, scarcity of potable water , sanitary techniques. Infant meter was also used to measure below conditions, poor mother child health services, problems in 1 year old children. Date of birth was obtained from the covering national health and nutritional services, etc. have village directory for cross checking. The indices of been found most vital causative factors for the prevalence nutritional status have been mentioned in Standard of sever childhood mortality and morbidity amongst the Deviation (SD). Diet survey focusing cereals, pulses, milk rural communities in the country. Expert felt the health and milk products, vegetable etc have also been done. system of the country need further strengthening in order Hemoglobin collection and estimation also under the to achieve the goal of health for all in the country.5 guidance of a physician. Household socio-economic data collected through survey & analyzed using SPSS software. Further, experts opined that the poor health outcome of Nutritional deficiency and morbidities recorded under the the rural community and their children need to be read supervision of the dietician. Children classified after simple within in the context of rapid urbanization, poor health clinical test for Anemia and mean anthropometric infrastructure, costly treatment etc. However, in a measurements. multicultural society like India rural childhood mortality cannot be analyzed in a contextual vacuum. Instead, they Result : need to be looked in the light of larger socio economic Table -1 : Demographic Factors of the Studied Families 2 changes experienced by the rural community over the Variables No. (percentage) X P Age of the Parents 3.657 0.000 period of time due to the interventions of various external Just above 20 123(41%) 6 agencies . Till now various Governments have 20-30 132(44%) implemented numerous programmes to improve the 30-40 45(15%) nutritional status of the pre-school children through Educational level 2.764 0.000 Primary education 154(51.3%) various innovative schemes. Huge money has been spent High school 88(29.3%) on health sector so far. Still country experiences sever College 16(5.3%) under nutrition and rural child mortality issue. Health Illiterates 37(12.3%) Professional education 5(1.6%) experts opined that lack of good primary health care, Occupational Status 3.789 0.000 perceived and personal risks, lack of awareness have lead Daily labors 34(11.3%) in failing health improvement programmes in the rural Agriculture 167(55.6%) Skilled labor 63(21.0%) settings of the country7 . Unemployed 22(7.3%) Business 14(4.6%)

Keywords : Mortality, Nutrition, Health, Rural , Children - Nanjunda 25 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Variables No. (percentage) X2 P the Table 1 Boys were slightly taller and heavier than Girls Income level (in Rs.) 4.458 0.000 for their ages. Mean anthropometric distribution of 3000-5000 165(54.4%) 5000-10000 123(41.0%) studied children (according to weight against age, height Above 10000 12(3.2%) against age and weight against height) has revealed that Food Norms 3.901 0.00 33% (average) of children are between -2SD to – 3SD and Just vegetarian 106(35.3%) Purely non vegetarian 15(5.1%) 33.3% (average) of children are between -2SD to-1SD. Mixed 145(48.3%) (Mean anthropometric measurement were used to find Seasonal 34(11.2%) out SD and Median calculated based on SD) (Table 2). In case of nutritional status of pre-school children, stunting in Table -2 : Mean Anthropometric Measurement of Studied Free School Children 75.0 %, wasting in 81.7 and under weight 87.6 observed in both Boys and Girls (Tab-3). Further, in case of Anemia, 48% Age N Sex Height (in cm) Weight (kg) of Girls and 56% of the Boys were severely affected; while 0-1 60 M- 35 5.1 ± 1.38 5.9 ± 1.7 F- 25 5.3 ±1.61 5.2. ±1.5 47 % of Girls and 41% of the Boys were modestly affected 1-2 60 M – 30 7.5± 1.38 8.2 ± 2.0 (Tab-4). However 10% of the Boys and 28% Girls observed F – 30 7.1 ± 1.03 7.5.3± 1.0 mildly affected in this study. Further, it is also found that 2-3 60 M -38 8.5 ±1.13 10.5± 2.1 F- 22 8.1 ±0.71 11.3 ±2.8 clinical sign of Anemia among 62% of studied children. 3-4 60 M-32 11.5 ± 1.81 13.1± 2.3 Next, vitamin A deficiency was found in 21% children while F-28 10.3± 1.70 15 ±1.3 vitamin B complex deficiency found in 22% children. 4-5 60 M-37 12.5 ±1.60 17± 2.0 F-23 11.3 ±1.50 16±2.3 In depth study found that only 87% children were put on Mean ± : Standers Deviation M- Male child F- Female child breast feeding within 3 hours after the birth. Our study Table -3 : Distribution of Pre-School Children according to SD also found majority of the children did not receive pre-local (standard deviation) classification feeds. It is found that supplementary feeding started after Parameter -3 SD to -2 SD -2S D to -1SD Median Weight/ Age 106 (35.3%) 96(32.0%) 114(38.0%) 8 months in the majority of the studied children. The socio- Height/ Age 102 (34.0%) 103(34.3%) 108(36.0%) economic data reveals that the majority of them is living in Weight/Height 92 (30.6%) 101(33.3%) 78(26.0%) poverty and illiteracy state and belongs to low income Table - 4 :Type and Degree of Malnutrition group. Still they are depending on traditional healers to Sex Stunting Wasting Underweight solve their various health problems6 . Normally they will not n % n % n % visit PHCs for any type of health problems. Local PHCs lack Girls 107 (35.6) 137 (45.6) 141 (47.0) Boys 118 (39.3) 106 (35.3) 122 (40.6) infrastructure facilities. Doctors rarely visit the Hospitals. Total 225 (75.0 243 (81.0) 263 (87.6) Absence of the lady physicians also one of the reasons why n, number of children Figures in parentheses are percentage 6 rural women's don't like to visit PHCs . Availability of clean Table -5 : Occurrence of Anemia in Pre-school Children potable water is very rare. It is found that age old Leve Girls Boys traditional health seeking behavior towards certain n % Anemia n % Anemia Severe 77 (48.12) < 5.3g/dl 84 (56.75) < 6.3g/dl diseases severally hampering their health status. We learn Modesty 47 (29.3) < 7.3g/dl 41 (27.70) < 7.2g/dl that high Anemia of the children is causing due to poor Mild 28 (17.5) < 8.7g/dl 15 (10.13) <19.6g/dl socio-economic status4 .Morbidity rate (32.5%) is Normal range of Hemoglobin > 12g/dl ( gram/deciliter) Figures in parentheses are percentages considerably high in the studied children it is due to poor and unhygienic conditions. It is found that the prevalence Discussion : of respiratory tract infection, anemia, typhoid, and A Total of 300 rural pre-school children ( Boys 160, Girls deficiency of vitamin A &B are more common and it might 140) examined through this study. It is found that from be due to their food habits. Poor household ecology,

Keywords : Mortality, Nutrition, Health, Rural , Children - Nanjunda 26 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science personal habits, cultural practices regarding delivery, child vitamin A deficiency in 21% children and vitamin B complex rearing and breast feeding also plays a vital role9 . It is also deficiency in 22% children were also found. It is found that noted that the food style of the responded manly causes the occurrence of under nutrition and anemia may be due malnutrition problems. and It is established fact that even to low iron bioavailability or absorption rather than though Government, NGOs and other developmental inadequate intake. It is noted that availability of pure agencies are working for the health issues of the rural water, sanitation, traditional beliefs plays a vital role in people mortality rate is still high in the rural part of the shaping health behaviors of the rural folks. In partnership country. Strong awareness about this issue should be with the NGOs and civil society, Govt. should try to provides created among the rural folk and rural PHCs should be high-impact, cost-effective health and nutrition upgraded in a war foot manner. interventions to decrease the number of neonatal and child mortality from various infectious diseases for the Conclusion : rural community. Govt. should frame programmes to Malnutrition in any phase of childhood impacts schooling create awareness about importance of nutritious foods and the lifetime earnings capacity of the child. and breast feedings amongst rural folk6 . Media can also Malnutrition also causes economic burdon on the state. play a vital role in the success of. the various immunization This study has found that causes of mortality related to programmes. Geographically and cultural specific malnutrition and lack of timely access to an adequate programmes for the speedy development of the socio primary health care service. Study found that Boys were economic conditions of the rural community is most slightly taller and heavier than Girls for their ages. Girls are necessary for the hour not showing less physical development to their ages. In case of nutritional status girl children, are more suffering Acknowledgements : from stunting, wasting and underweight than boys. In case Author is grateful to Mrs. S. Jyothi lakshmi Dr. P . N. Venu of Anemia, Girls (48%) and Boys(56%) are more or less gopal (Dietician) and Dr. Srivasta (Physician) for their equally suffering. The more worrying fact is that signs of support Anemia have been found among 62% children. Further

References: 1. Martorell R. “The Nature of Child Malnutrition and its Long-Term 6. Alderman, H., H. Hoogeveen, and C. Rossi. 2005. Reducing Child Implications. Food and Nutrition Bulletin 1999: 288-292. Malnutrition in Tanzania—Combined Effects of Income Growth and 2. Kishor, Sunita. Gender differentials in child mortality: A review of the Program Interventions. Policy Research Working Paper 3567, World evidence. In Monica Das Gupta, Lincoln Chen, and T. N. Krishnan, eds. Bank, Washington, DC. Women's health in India: Risk and vulnerability. Bombay: Oxford 7. Bhatia B.D. A study of prenatal mortality rate from rural based medical University Press 1985;45: 34-39. college hospital. Indian Journal of Pediatrics 1984; 409: 165–171. 3. Alderman, H., J. Hoddinott, and B. Kinsey. 2003. Long-Term 8. Measham A. The performance of India and Indian states in reducing Consequences of Early Childhood Malnutrition." Food Consumption infant mortality and fertility, 1975–1990. Economic and Political and Nutrition Division Discussion Paper 168, International Food Policy Weekly, 1999; 22; 1359–1367. Research Institute, Washington, DC. 9. Smith L.C. and Haddad L.,.Overcoming Child Malnutrition in 4. Frongillo EA, de Onis M, Hanson KMP., 1997, Socioeconomic and Developing Countries: PastAchievements and Future Choices, Food, demographic factors are associated with worldwide patterns of Agriculture and the Environment discussion paper 30 , 2000, IFPRI, stunting and wasting. Journal of Nutrition 127:230: 203-209. Washington D.C. 5. Jain A.K, Visaria P. Infant mortality in India: an Overview. In: Jain AK, 10. Tilak J.B.G. Socioeconomic correlates of infant mortality in India. Visaria P, eds. Infant mortality in India: differentials and determinants. Washington, DC, The World Bank (Population, Health and Nutrition New Delhi, Sage Publications, 1988 Division, Population and Human Resources Department).,1991

Keywords : Mortality, Nutrition, Health, Rural , Children - Nanjunda 27 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article CROSS SECTIONAL STUDY OF ATTITUDE, PRACTICE AND KNOWLEDGE OF ORAL HYGIENE PRACTICES AND DENTAL TREATMENT IN HEALTH CARE PROFESSIONALS IN SOUTH CANARA DISTRICT.( KARNATAKA) Sharath K.S.1 , Manavi Prabhu2 , Biju Thomas3 & Shamila Shetty4 1Professor, 2 Post Graduate, 3 HOD & Professor, 4 Assistant Professor, Departments of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018, India. Correspondence : Manavi Prabhu Departments of Periodontics, A.B.Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore-575018, India E-mail ID : [email protected] Mobile : +91 944895396 Abstract : Objective: The purpose of the study is to estimate the knowledge, attitude and practise of the oral hygiene,and dental treatment, and its correlation with everyday oral hygiene practices among the health care professionals of south canara district ( Karnataka) Methods : A cross sectional survey was conducted on 200 health care professionals between Jan 20th to Feb 20th 2013.Two hundred health professionals were asked to answer a questionnaire containing 15 questions.Data once collected was analysed using SPSS software. Results: 56.3% health professionals visited the dentist once in six months. 26% health professionals felt that unavailability of time is the main factor influencing dental visits. Main cause of taking a dental appointment in 33% subjects was found to be dental caries. 54.6% obtained information on oral hygiene practices through mass media followed by 22.3 % who obtained it directly from the dentist.59.2% brushed their teeth twice daily.50% used medium bristle tooth brush.48.5 % had a brushing time of 3-5 min. 41.5% did not use any other oral hygiene aid .28.64% got scaling done in the last 3-6 months. 56% did not have an habit of using a tooth pick. 43.3% used combination of circular, vertical and horizontal method of brushing.45.5% felt that scaling caused loss of enamel. Conclusion: It appears that knowledge, attitude, and behaviour attitude, practice and knowledge of oral hygiene practices and dental treatment in health care professionals in South Canara district is gud.Though more information needs to be provided about other oral hygiene aids. Keywords : oral hygiene, tooth brushing, flossing, oral hygiene practices

Introduction: hygiene in maintenance of gingival health. It is a well known fact that bacterial plaque plays a critical It has been demonstrated that an effective supragingival role in the host response leading to the pathogenesis of oral hygiene even may affect the sub periodontitis.Poor oral hygiene and exogenous infection 1 change the normal flora into a pathogenic flora. It is a well gingival microbiota2 .Effective plaque control is the understood fact that bacterial plaque is involved in cornerstone of any attempt to prevent and control pathogenesis of periodontal diseases. It was demonstrated that plaque also periodontal 3 4 Access this article online plays an important role in dental caries , gingivitis and Quick Response Code disease.Studies done by periodontal diseases5 lang et al in the year 1973 The use of other oral hygiene aids may improve tooth and study done by Sri cleaning effectiveness provided that cleaning is sufficiently Lankan tea workers in the thorough and performed at appropriate intervals. Tooth year 1985, showed the brushing 6 and flossing7 are reported to be fundamental importance of oral

Keywords : oral hygiene, tooth brushing, flossing, oral hygiene practices 28 - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science to reduce the amount of bacterial plaque and its virulence Results : potential, so they are considered the pillar of self- The results are presented in Tab. 1-14 prevention strategy8 .Several studies have shown the Source of information on oral hygiene practices usefulness of regular dental flossing for removing inter- Table 1: From where do you obtain your information on oral dental plaque and preventing calculus formation9 . Both the hygiene practices? Source Percentage American Dental Association and the British Dental from the doctor/dentist 22.3 Association recommended the daily use of dental floss in from mass media 54.6 addition to brushing. from family and acquantances 4 from school /college 19.1 Axelsson and lindhe 10 and Hellstrom et al. (Hellstrom, Table 1 gathers the answers concerning the sources of information about the rules of oral hygiene. 54.6% obtained the Ramberg, Krok & Lindhe 1996) found in a longitudinal study information from mass media.22.3% obtainted it directly from that it was possible to minimize periodontal attachment the dentist. Family and acquaintances were the source for the remaining 4%. loss and bone resorption with a combination of improved oral hygiene and professional prophylaxis 6 to 8 times a Flossing Table 2 : Do you have any information regarding flossing? year. Irregular or not frequent users of dental services have Number percentage 11 less restored teeth and higher number of carious teeth. No 19.5 Yes 80.5 Hence good oral hygiene practices and routine dental visits Among all the subjects 61% had information regarding flossing show a positive result for the preservation of a natural and and 39% were ignorant about flossing. functional dentition. Scaling effect on enamel Table 3 : Do you feel scaling causes loss of enamel? The aim of the current study was to investigate knowledge, Option Number of subjects Yes 91 attitude and practices of oral hygiene and the attitude No 103 towards preventive dental visits among health care Don't know 6 professionals in south canara district, Karnataka. Table 3: showed whether the health care professional felt that scaling caused loss of enamel. It can be seen that 45.5% subjects Materials and methods: felt that scaling caused loss of tooth material. A cross sectional survey was conducted on 200 health care Dental visits professionals between Jan 20th to Feb 20th , 2013.Ethical Table 4 : Factors influencing dental visits Factor Percentage clearance was obtained and consent was taken from all the Fear 26 subjects. The health care professionals included Lack of financial means 10 professionals from the field of Physiotherapy, Nursing, Lack of availability of time 52 Lack of availability of dentist 32 Psychiatry and Medicine.200 health care professionals Table 4: presents the factors influencing dental visits. Most often were asked to answer a questionnaire containing 15 mentioned cause was unavailability of time in 52% subjects. Another cause was lack of availability of dentist as mentioned by questions.The questions were in relation to the knowledge 32% students of dentistry. Fear of dental visit was mentioned by , attitude and practice of oral hygiene and attitude towards 26% subjects. Additionally 10 % felt the lack of financial means preventive dental visits among health care professionals. was among the main causes which affected the frequency of making a dental appointment. The health care professionals were in the age group of 23 to Chief complaint 40 yrs.Which included working graduates and post Table 5: What is the main cause of making a dental appointment? graduate students.Once the forms were collected, Data Cause Percentage was entered in an MS Excel spreadsheet and analyzed Deposits and stains on the teeth 21.89 Dental caries 33.33 thrsough SPSS16.0 Dental pain 27.36 Orthodontic treatment and other causes 17.41

Keywords : oral hygiene, tooth brushing, flossing, oral hygiene practices 29 - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 5 lists most common causes that motivate to make a dental Brushing time appointment. Dental caries was mentioned by 33.33% as the Table 10: How long do you brush? main cause of making a dental appointment.27.36 felt that dental Brushing time Percentage pain was the main cause followed by 21.89 subjects who felt 1- 3 min 33.35 deposits and stains on the teeth was the main cause. 3- 5 min 48.5 More than 5 min 9.5 Table 6: when was the last time you got a professional scaling done? Less than 1 min 5.0 frequency Percentage Table 10: brushing time varied in different subjects with 48.5% brushing for 3-5 min, followed by 33.35% who brushed for 1-3 Never 26.63 min. brushing for more than 5 min was seen in 9.5% subjects. Less Last 3- 6 months 28.64 than 1 min brushing time was seen in 5% of the population. Last year 24.62 More than an year back 19.1 Other oral hygiene aid Table 6 : showed when last the health professionals got their teeth Table 11: Do you use any other oral hygiene aid? professionally cleaned. It can be seen that 28.64% got it cleaned in Type of other oral hygiene aid used Percentage the last 3-6 months.26.63% never got their teeth cleaned.24.62 Floss 15.5 got their teeth cleaned last year. The remaining 19.1% got it done Mouthwash 29.5 one year back Interdental brush 14.5 none 41.5 Table 7: How often do you visit a dentist? Table 11 discussed the usage of other oral hygiene aids in health Frequency percentage care professionals 41.5 % subjects did not use any other oral Every 3 months 8.7 hygiene aid.29.5% used mouthwash. Only 15.5 subjects used Every 6 months 56.3 floss. And 14.5% used interdental brush. once a year 8.2 less than once a year 14 Table 12: If you have information regarding flossing, what is the no definite frequency 26.8 frequency of your flossing? Tab. 7 presents the results concerning the frequency of dental Frequency Number of subjects visits. It revealed that 56.3% subjects made a dental visit every 6 Never 133 months.26.8% subjects did not have any definite frequency.14% Once a week 44 visited the dentist less than once in an year.8.2 % visited the Once a day 13 dentist once in an year and 8.7 % of them visited once in 3 months. More than once a day 10 Table 12: table ten represented the frequency of brushing among Brushing frequency the subjects.133 subjects did not have the habit of flossing.44 Table 8: What is your brushing frequency? subjects flossed once in a week.13 flossed once in a day.flossing Frequency Percentage more than once in a day was seen among 10 subjects. After every meal 22.3 Tooth pick uses age Twice daily 54.6 Table 13: Do you have the habit of using tooth pick? Once daily 4 Habit Percentage Less than once daily 19.1 after every meal 12% The remaining few questions were regarding oral hygiene whenever required 38% practices of the subjects. It was noticed that 54.6% subjects had a brushing frequency of twice dialy.4 % brushed once daily. no habit of using tooth pick 56% Brushing after every meal was done by 22.3 % subjects. Table 13: table 12 discussed the prevalence of using tooth pick.56% had no habit of using tooth pick.38% used tooth pick Tooth brush bristle only when required.12% used it after every meal Table 9: Which type of tooth brush bristle you use? Brushing method Type Number of subjects Table 14: What is the brushing method you use? Soft 101 Method frequency medium 74 Circular 19.4 Hard 7 Vertical 19.9 Don't know 18 Horizontal 10.9 Table 9 showed the type of bristle used by the subjects.50.5% of Combination of all of the above 43.3 the subjects used soft bristle.37% used medium bristle.3.5% used No particular method 5.6 hard bristle and 9 % were not sure about the type of bristle they Table 14 represented the brushing techniques used by the used. subjects, it was seen that 43.3% subjects used a combination of vertical, horizontal and circular brushing method.19.4% had a circular method of brushing. Vertical horizontal and

Keywords : oral hygiene, tooth brushing, flossing, oral hygiene practices 30 - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science circular brushing method.19.4% had a circular method of deposits and stains on the teeth was the main cause. This brushing. Vertical brushing technique was used by 19.9% showed that subjects were more concerned about dental subjects. Horizontal brushing method was used by 10.9%. problems which were related to pain and which effected Discussion : aesthetics. Hence subjects should be educated about other The present study investigated the knowledge, attitude dental problems which are usually ignored, for instance and practice towards oral hygiene practices and the bleeding gums, recession, mobility etc and thus they attitude towards preventive dental visits of a group of should be motivated to treat these problems too at the health care professionals. right time.

In the cross sectional study questions were asked to check The subjects were asked when last the health the knowledge about oral hygiene practices. When asked professionals got their teeth professionally cleaned. The from where the subjects obtained information on oral effects of periodontal maintenance care provided every 6 hygiene practices, it was observed that 54.6% obtained the months were compared over 4 years according to Lightner information from mass media.22.3% obtainted it directly et al.16 Results indicated that plaque and gingivitis scores from the dentist. Family and acquaintances was the source improved more in groups receiving more frequent for the remaining 4%. maintenance. Similar results was found by Listgarten et al.17 and by Rosen et al.18 ,they suggested that recall intervals can The subjects were asked whether they had any information be extended upto a year for the purpose of reducing regarding flossing. It was noticed in our study that among periodontal disease progression in individuals with a all the subjects 61% had information regarding flossing and history of limited susceptibility to the disease. It could be 39% were ignorant about flossing. seen in our study that 28.64% got it cleaned in the last 3-6 There is a common misnomer that scaling causes loss of months.26.63% never got their teeth cleaned.24.62% got enamel. Enamel is 97% mineralised. Scaling once in six their teeth cleaned last year. The remaining 19.1% got it months will not cause any harmful effect on enamel. The done one year back. general population should be educated about this fact that It's well known that, professional plaque removal and undergoing a professional scaling once in six months is very regular follow up combined with patient oral hygiene beneficial and should be encouraged. instructions could minimize the level of gingival The subjects answered questions related to their attitude inflammation and swelling12 . Lang et al.13 demonstrated towards oral hygiene practices and dental visits. The that students who thoroughly removed plaque at least subjects were asked about the main factors which every second day, did not develop clinical signs of gingival influenced the frequency of dental visits. Most often inflammation over a 6-week period. This included the use mentioned cause was unavailability of time in 52% of inter-proximal aids as well as the toothbrush. A subjects. Another cause was lack of availability of dentist as recommendation to brush the teeth twice daily should be mentioned by 32%. Fear of dental visit was mentioned by considered 14 , particularly in patients showing gingival 26% subjects. Additionally 10 % felt the lack of financial inflammation. The results in the present study indicate that means was among the main causes which affected the 54.6% subjects had a brushing frequency of twice dialy,4 % frequency of making a dental appointment. brushed once daily.22.4% had the practice of brushing after every meal. The subjects were asked what is the main cause of visiting a dentist. Dental caries was mentioned by 33.33% as the Opinions regarding the merits of hard and soft bristles are main cause of taking a dental appointment. Following based on studies that are not comparable, are often which 27.36% felt its dental pain. 21.89 subjects who felt inconclusive, and contradict one another.19 Softer bristles

Keywords : oral hygiene, tooth brushing, flossing, oral hygiene practices 31 - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science are more flexible, clean slightly below the gingival margin health care practices. Though more emphasis should be when used with a sulcular brushing technique and farther put on usage of other oral hygiene aids. They should be into proximal surfaces.20 Use of hard bristled tooth brushes educated about the advantages of using other oral hygiene is associated with more gingival recession, and frequent aids and should be encouraged to use the same. brushers who use hard bristles have more recession than It can be clearly seen that most of the subjects had main those who use soft bristles.21 In our study, we could see that chief complaint of caries and dental pain. These symptoms 50% health care professionals preferred to use medium are important and subjects tend to notice them as they are bristle tooth brush. Results showed that, 48.5 % subjects associated with pain and aesthetics. Deposits and stains on had a brushing time of 3-5 min followed by 33.5%, who had teeth, bleeding gums, recession, and mobility are mostly a brushing time of 1- 3 min. ignored, so the subjects should be educated about these Many studies proved that by interdental cleaning, symptoms. They should be told the consequence of not periodontal patients are able to improve clinical outcomes getting the right treatment at the right time. and reduce clinical signs of disease and inflammation 15 .In The misconception among subjects about loss of enamel our study 41.5 % subjects did not use any other oral during scaling should be corrected. Enamel is the most hygiene aid like mouth wash, floss and tooth pick. It was mineralized tissue in the body with 97% mineral content, so seen that 29.5% used mouthwash. 15.5% subjects used undergoing scaling once in 6 months would not be floss and 14.5% used interdental brush. Hence there is a detrimental to the enamel. Subjects should be encouraged clear need for motivation among the subjects to use other to undergo a scaling once in six months. oral hygiene aids. Hence, Professional plaque removal and regular follow up Conclusion: combined with patient oral hygiene instructions can From the above survey it can be seen that majority of the minimize the level of dental and periodontal diseases. health care professionals are quite aware about the various References: Vega KJ, Pina I, Krevsky B. Heart transplantation is associated with an 11. Davenport C, Elley K, Salas C, Taylor-Weetman. The clinical effectiveness increased risk for pancreatobiliary disease. Ann Intern Med 1996; 124: and cost-effectiveness of routine dental checks: A systematic review and 980-3. economic evaluation. Health Technol Assess 2003;7: iii-v, 1-127. 1. Offenbacher S. Periodontal diseases: Pathogenesis.Ann Periodontol 1996; 12. Raber-Durlacher JE, van Steenbergen TJ, Van der Velden U. Experimental 1: 821-878. gingivitis during pregnancy and post-partum: Clinical, endocrinological, 2. Dahlen G, Lindhe, J, Sato K, Hanamura H. & Okamoto H. The effect of and microbiological aspects. J ClinPeriodontol 1994;21: 549-558. supragingival plaque control on the subgingival microbiota in subjects with 13. Lang NP, Cumming BR, Loe H. Toothbrushing frequency as it relates to periodontal disease. JClin Periodontol 1992; 19: 802-809. plaque development and gingival health. J Periodontol1973; 44: 396-405. 3. Ainamo J. Relative roles of toothbrushing, sucrose consumption and 14. Echeverria JJ, Manlau,Tejerina JM.fundamentals of periodontal treatment. fluorides in the maintenance of oral health in children. Int Dent J 1980; 30: Arch Odonto Estomatol1987 3: 359-364. 54-66. 15. Christou V, Timmerman MF, Van der Velden U.Comparison of different 4. Ainamo J, Holmberg S. A retrospective longitudinal study of caries approaches of interdental oral hygiene: Interdental brushes versus dental prevalence during and 7 years after free dental care at school in finland. floss. J Periodontol 1998;69: 759-764. Community Dent Oral Epidemiol 1973 1: 30-36. 16. Lightner L M, O'Lear JT, Drake RB. Preventive periodontic treatment 5. Lang NP, Cumming BR, Loe, Toothbrushing frequency as it relates to procedures: Results over 46 months. J Periodontol 1971;42: 555-561. plaque development and gingival health. J Periodontol 1973; 44: 396-405. 17. Listgarten MA, Sullivan P, George C. Comparative longitudinal study of 2 6. Hansen F, Gjermo P. The plaque-removing effect of four toothbrushing methods of scheduling maintenance visits:4-year data. J Clin methods. Scand J Dent Res 1971; 79: 502-506. Periodontol1989; 16: 105-115. 7. Hill H.C, Levi, Glickman I. The effects of waxed and unwaxed dental floss on 18. Rosen B, Olavi G, Badersten. Effect of different frequencies of preventive interdental plaque accumulation and interdental gingival health. 1973; J maintenance treatment on periodontal conditions.5-year observations in Periodontol 44: 411-413. general dentistry patients. J ClinPeriodontol1999; 26: 225-233. 8. Schmid M O, Balmelli OP, Saxer UP. Plaque removing effect of a tooth 19. Hinijker jj, Forscher BK.The effect of tooth brush type on gingival health,j brush, dental floss, and a toothpick. J Clin Periodontol1976; 3: 157-165. periodontal 1954;25:40. 9. Bauroth, K, Charles CH, Mankodi SM. The efficacy of an essential oil 20. Bass CC.An effective method of personal oral ygiene.part II, j la state med antiseptic mouthrinse vs. Dental floss in controlling interproximal soc 106:100.1948se, j periodont gingivitis: A comparative study.2003; J Am Dent Assoc 134: 359-365. 21. khocht A,Simon G, Person P. gingival recession in relation tp history of hard 10. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries tooth brush use,j periodontal 1993;64:900. and periodontal disease in adults. Results after 6 years. J Clin Periodontol .1981; 8: 239-248.

Keywords : oral hygiene, tooth brushing, flossing, oral hygiene practices 32 - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article OCCURRENCE OF IRON DEFICIENCY ANEMIA BETWEEN OVER WEIGHT AND NORMAL WEIGHT ADOLESCENTS IN SELECTED SCHOOLS IN UDUPI DISTRICT Sujatha R.1 & Reshma 2 Professor & HOD 1 , Lecturer 2, Department of Pediatric Nursing, Nitte Usha Institute of Nursing Sciences, Nitte University, Paneer, Mangalore - 575 018, India. Correspondence : Sujatha R. Professor & HOD, Nitte Usha Institute of Nursing Sciences, Department of Pediatric Nursing, Nitte University, Mangalore- 575018, India Mobile : +91 98809 01687 E-mail : [email protected] Abstract: Background : Overweight has become one of the common health concerns. A few studies have noted a possible association between iron-deficiency anemia and overweight. As many as 3crore Indians are overweight, and obesity continues rise, says statistics revealed by the National Family Health Survey (NFHS 2010), Around 20% of school-going children are overweight. Materials and Methods: In this study survey research approach and comparative descriptive design was adopted. The sample size was 300 adolescents. 300 adolescents were selected by convenient sampling technique, out of which 225 were normal weight adolescents and remaining. Among 225 normal weight adolescents 50 adolescents were selected by simple random sampling technique (lottery method) and out of 75 overweight adolescents, 50 overweight adolescents were selected by convenient sampling technique. Initially BMI identified, Talliquis method was used for identifying the anemia. Peripheral smear test used for identifying the iron deficiency anaemia. Results : The data were analyzed by using descriptive and inferential statistics. The result shows that out of 300 adolescents75 (25%) of adolescents were overweight. Out of 100 children (50+50) 19(38%) were anemic in adolescents with overweight and seven (14%) were anemic in adolescents with normal weight. Out of the total 26 adolescents with anemia (19 -overweight and 7- normal weight) no occurrence of iron deficiency anemia was found. There is no significant difference in occurrence of anemia between overweight and normal weight adolescence. Interpretation and conclusion : The findings of the study indicates that majority of the overweight adolescents were anemic compare to normal-weight adolescents. There is no association between the occurrence of anemia and demographic variables like age, food habits, physical activity, menstrual problems etc. Keywords : Adolescents, anemia, overweight, normal weight, Iron deficiency anemia.

Introduction : examination survey reported that the prevalence of Overweight has become one of the common health overweight children doubled and prevalence overweight concerns. A few studies have noted a possible association adolescents tripled between 1980 and 2000. between iron-deficiency anemia and overweight. The As many as 3 crore Indians are overweight, and obesity prevalence of overweight has been increased because of continues rise, says statistics revealed by the National the lifestyle and Access this article online Family Health Survey (NFHS-2010), Around 20% of school- socioeconomic status, Quick Response Code going children are overweight. And in Bangalore obesity is advancement in reaching epidemic proportions, with around 25% of city entertainment and children between the age group of four to 12, suffering technology such as from obesity1. television, computer, and videogames. The National The prevalence of obesity has increased at an epidemic health and Nutrition rate, and obesity has become one of the most common

Keywords : Adolescents, anemia, overweight, normal weight, 33 Iron deficiency anemia. - Sujatha R. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science health concerns in the United States. A few small studies overweight and normal weight adolescents. have noted a possible association between iron deficiency • To estimate the occurrence of iron deficiency anemia and obesity. among overweight and normal weight adolescents. • To compare the occurrence of anemia between Obesity is associated with low-serum iron concentrations. overweight and normal-weight adolescents. The inverse relationship between iron status and adiposity • To find out the association between the occurrence of was first reported in 1962, when Wenzel et al, anemia and selected demographic variables. unexpectedly found a significantly lower mean serum iron • To find out the association between the occurrence of concentration in obese compared with non-obese iron deficiency anemia and selected demographic adolescents2-3 . variables. The incidence of overweight in adolescence rapidly rising Materials and methods throughout the world, and also they are prone to get iron A) Study Design deficiency anemia. In an article published in health news on Research Approach: October 5, 2004, reveals that adolescents with higher body In this study survey research approach was adopted. mass index are prone for iron deficiency anemia4 . Research Design: The incidence of overweight has increased at epidemic The research design adopted for the study was rate, over weight among adolescents has become one of comparative descriptive design. the most common health concerns. The general public b) Subjects often perceives that overweight individuals are healthy, The sample size was 300 adolescents. well-nourished and free from illness. A few studies have noted a possible association between iron deficiency c) Specific Methods anemia and overweight. 300 adolescents were selected by convenient sampling technique, out of which 225 were normal weight The prevalence of overweight has been increased because adolescents and remaining. Among 225 normal weight of the lifestyle, socioeconomic status, advancement in adolescents 50 adolescents were selected by simple entertainment and technology such as television, random sampling technique (lottery method) and out of 75 computer, and video games. Now a days overweight is overweight adolescents, 50 overweight adolescents were more common among adolescents. National health and selected by convenient sampling technique. Nutrition examination survey reported that the prevalence of overweight children doubled and prevalence d) Procedures overweight adolescents tripled between 1980 and 20005 . For identifying the BMI the following assessments were done. The etiology of the hypoferremia of obesity is uncertain. Among the proposed causes are deficient iron intake from v Measuring the height : an iron poor diet, and deficient iron stores owing to greater Adolescents were asked to remove their shoes and they iron requirements in obese adults because of their larger were made to stand with their back to the height rule blood volume6 . (against the wall). Standing in the Frankfurt, by using the inch tape measure the height. Objectives of the Study: • To estimate the occurrence of overweight among v Measuring the weight : adolescents. Zero error corrected on the weighing scale. Adolescents • To estimate the occurrence of anemia among were allowed to stand in the weighing machine without

Keywords : Adolescents, anemia, overweight, normal weight, 34 Iron deficiency anemia. - Sujatha R. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

shoe or any objects in hands. Then weight was Identification Of Anemia Among Adolescents measured and recorded. Number of Anemic Cases Detected Among Overweight and Normal Weight Adolescents v Determination of Body Mass Index : 19(38%) were anemic in adolescents with overweight and BMI is identified by using the following formula, seven (14%) were anemic in adolescents with normal BMI = weight (kg)/ height (m2 ) weight. For identifying the anaemia the following assessment was done. Identification of I D A Among Adolescents Number of iron deficiency Anemia Cases Detected among v Hemoglobin estimation : (Talliquis method) Overweight and Normal weight Adolescents By using a spirit swab, fingertip was cleansed and 26 anemic adolescents were found among Overweight and allowed the spirit to dry. By using a lancet, a prick in the Normal weight Adolescents were not having iron fingertip was made and a drop of blood was allowed into deficiency anemia found after the peripheral smear the Talliquis paper. Keep it for drying, check the color of investigation. the filter paper. From the Talliquis booklet it was There were no iron-deficiency anemia found in the compared and hemoglobin level was estimated. selected samples. For identifying the iron deficiency anaemia the following Comparison of the Occurrence of Anemia Between assessment was done . Overweight and Normal Weight Adolescents v Peripheral smear test : Occurrence of Anemia between Overweight and Normal Adolescents who have Hb less than 10mg/dl were Weight Adolescents selected for peripheral smear test. Blood was collected Since t calculated value 1.432is less than of table value in EDTA vaccutainer and sent to hematology lab for the {2.064} at 0.05 level of significance {p>0.05}, research peripheral smear checking to rule out the iron hypothesis is rejected. There is no significant difference in deficiency10 . occurrence of anemia between overweight and normal weight adolescence. Results : Section I Section III Description of demographic characteristics Association between Occurrence of Anemia and Selected Majority, 70 (70%) of the adolescents was girls and 30 Demographic Variables (30%) were boys. Most of the adolescents 42 (42%) study in The calculated chi- square values, which is less than the the 11th standard. 74 (74%) of adolescents were consuming table values (p>0.05) at 5% level of significance. mixed diet. 50 (50%) of adolescents were coming to school Hence the research hypothesis H4 is rejected indicating by private bus. 51 (51%) of students spending the leisure that there is no significant association between occurrence time by watching television. 58 (83%) of adolescence were of anemia and selected demographic variables, like age not taken iron supplementation and 69 (69%) didn't take (1.790%), gender (0.356), education (2.552), income of the de-worming tablets. family(0.431), food habit (3.163), family history of overweight (0.253), mode of transportation (1.210), Section II spending the leisure time (3.240). Estimation Of Over Weight Among Adolescents Percentage of Overweight Adolescents Discussion : Out of 300 adolescents75 (25% ) of adolescents were The findings of the study indicates that majority of the overweight. overweight adolescents were anemic compare to normal- weight adolescents.

Keywords : Adolescents, anemia, overweight, normal weight, 35 Iron deficiency anemia. - Sujatha R. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

DEMOGRAPHIC VARIABLES FREQUENCY PERCENTAGE (%) DEMOGRAPHIC VARIABLES FREQUENCY PERCENTAGE (%) 1.AGE 14 . REGULARITY OF MENSTRUATION 15years 19 19% Regular 57 81% 16years 38 38% Irregular 13 19% 17years 43 43% 15.PROBLEMS DURING MENSTRUATION 2.GENDER Yes 6 9% Male 30 30% No 64 91% Female 70 70% 16. INTAKE OF IRON SUPPLEMENTATION 3. EDUCATION Yes 12 17% 10th std 22 22% No 58 83% 11th std 42 42% 12th std 36 36% ESTIMATION OF OVER WEIGHT AMONG ADOLESCENTS 4. EDUCATIONAL STATUS OF MOTHER No formal education Percentage of Overweight Adolescents n=300 High School 3 3% No. of adolescents No. of overweight Percentage Graduates 56 56% adolescents 5. EDUCATIONAL STATUS OF FATHER 300 75 25.00% No Formal Education 4 4% High School 39 39% IDENTIFICATION OF ANEMIA AMONG ADOLESCENTS Graduate 57 57% 6. INCOME OF THE FAMILY Number of Anemic Cases Detected Among Overweight And Rs<3000 0 0% Normal Weight Adolescents Rs3001-5001 8 8% Overweight adolescents Normal weight adolescents Rs5001-7000 55 55% n=50 n=50 Rs>7001 37 37% No Percentage No Percentage 7. FOOD HABIT 19 38% 7 14% Vegetarian 4 4% Non-Vegetarian 22 22% IDENTIFICATION OF I D A AMONG ADOLESCENTS Mixed 74 74% 8 .HISTORY OF ILLNESS Number of iron deficiency Anemia Cases Detected Among Yes 35 35% Overweight and Normal weight Adolescents No 65 65% ADOLESCENTS ANEMIC CASES IRON DEFICIENCY 9 .FAMILY HISTORY OF OVERWEIGHT NO. % ANEMIA Yes 27 27% Overweight n=50 19 38% Nil No 73 73% Normal weight n=50 7 14% Nil 10. MODE OF TRANSPORTATION TO SCHOOL By Walking 7 7% COMPARISON OF THE OCCURRENCE OF ANEMIA Cycling 15 15% BETWEEN OVERWEIGHT AND NORMAL WEIGHT Private Bus 50 50% ADOLESCENTS School Vehicle 28 28% 11. SPENDING THE LEISURE TIME Occurrence Of Anemia Between Overweight And Normal Play 33 33% Weight Adolescents Exercise 2 2% GROUP N MEAN 't' value SD df LOS Watching Television 51 51% Normal weight 7 10.6286 1.432 .74992 24 .165 Reading Books 14 14% adolescents 12. IN TAKE OF DE-WORMING TABLETS Over weight 19 9.7105 1.61689 p>0.05 Yes 31 31% adolescents No 69 69% 't' (tab) 24=2.064 ONLY FOR GIRLS n=70 13. AGE OF MENARCHE Estimation of overweight among adolescents 13years 6 9% From the 300 samples 75 (25%) adolescents were 14years 49 70% >14years 15 21% identified to be overweight.

Keywords : Adolescents, anemia, overweight, normal weight, 36 Iron deficiency anemia. - Sujatha R. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Identification of anemia among adolescents:- deficiency was particularly common among adolescents Out of the 50 adolescents with overweight 19(38%) were (3.5%, 7.2%, and 9.1%, respectively) 8 . anemic and in 50 normal-weight adolescents 7(14%) were A similar study indicated that the prevalence of anemia was anemic. A supportive study was conducted among 317 52.88% in the school children of Kattankulathur. The results adolescents (10- 19 years) Government school girls in of the study showed that 52.88% were anemic, the Bhopal city. The adolescents were divided into three prevalence of anemia in girls (67.77%) was higher than in groups by random sampling method. Level of anemia was the boys (35.55%).The prevalence of anemia was very higher in early adolescents (10 – 13 years) age group (81%) much higher in girls when compared to boys during as compared to the middle (58.3%) and late adolescents between the age of 8 and 14 years. The anemia was graded (17 – 19 years) age group girls (48.7%). according to WHO standards. It showed that 30.4% of girls Identification of iron-deficiency anemia among were mildly anemic, 37.33% were moderately anemic and adolescents. there were no severely anemic children diagnosed9 . There was no iron-deficiency anemia found in the 19 (38%) It was observed that 77.7% of tribal children of Mysore adolescents with overweight and seven (14%) adolescents District, Karnataka were suffering from anemia and also with normal weight with anemia. So H1 hypothesis is indicates similar results that the prevalence of anemia was rejected. So there is no significant difference in the significantly higher in girls when compared to boys (girls occurrence of iron deficiency between overweight and 83.33% and boys 70.89%)10 . normal weight. The overall prevalence of anemia among school-going A supportive study was conducted in Israel to identify the adolescent girls of urban Kathmandu, Nepal was 54.4%11 . prevalence of iron deficiency anemia in overweight, obese and normal weight children. Data was collected from 321 Another study of 393 children reported the prevalence of adolescents. The study revealed that iron deficiency 66.4 % anemia amongst primary school children (6-11 anemia was noted among 38.8% of the obese adolescents, years) in the national capital territory of Delhi12. 12.1% overweight adolescents and 4.4% of the normal 7. Comparison of the occurrence of anemia between weight adolescents overweight and normal-weight adolescents. Another study conducted USA to identify Overweight According to independent 't' test there is no significant children and adolescents: a risk group for iron deficiency, difference in occurrence of anemia between overweight among 9698 adolescents. and normal-weight adolescents. So H2 hypothesis is rejected. The study revealed that out of 9698 children, 13.7% were at risk for overweight and 10.2% were overweight. Iron Association between the occurrence of anemia and deficiency was most prevalent among 12- to 16-year-old selected demographic variables subjects (4.7%), followed by 2- to 5-year-old subjects There is no association between the occurrence of anemia (2.3%) and then 6- to 11-year-old subjects (1.8%). and demographic variables like age, food habits, physical Overweight 2- to 5-year-old subjects (6.2%) and activity, menstrual problems etc. So H4 hypothesis is overweight 12- to 16-year-old subjects (9.1%) rejected. demonstrated the highest prevalence of iron deficiency. Conclusion : Overall, the prevalence of iron deficiency increased as BMI The findings of the study indicates that majority of the increased from normal weight to at risk for overweight to overweight adolescents were anemic compare to normal- overweight (2.1%, 5.3%, and 5.5%, respectively), and iron

Keywords : Adolescents, anemia, overweight, normal weight, 37 Iron deficiency anemia. - Sujatha R. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science weight adolescents. In our society majority of the parents Acknowledgement : believe that their young child's excess fat is normal, that it Our sincere thanks to Nitte University for funding this will disappear as the child grows, and that it isn't a real research project and supporting us in every step during health concern. This is not the case for most overweight the process. We also thank Mrs. Vandhana, Statistician, children, who are very likely to become overweight adults. NUINS, Mangalore, for the guidance provided related to Anemia is high among children heavier and more analysis of the study. overweight. Further examination into the causes of anemia and overweight is warranted.

Reference : 1. www.indushealthplus.com/karnataka-health-statistics/ - 41k 2. Wenzel BJ, Stults HB, Mayer J: Hypoferraemia in obese adolescents.Lancet 1962, 2:327- 28. PubMedAbstract 3. Seltzer CC, Mayer J: Serum iron and iron-binding capacity in adolescents: Comparison of obese and non-obese subjects.Am J Clin Nutr 1963, 13:354-61 PubMedAbstract 4. Beryl Mohanraj, Chellarani Vijayakumar; Indian Journal of Paediatrics, Volume II: Issue 1; 2004 Page:47-49. 5. Wong's, Essential of paediatric nursing, 8th edition, Elsevier publication, Missuri. 6. Seltzer CC, Mayer J: Serum iron and iron-binding capacity in adolescents: Comparison of obese and non-obese subjects. Am J Clin Nutr 1963, 13:354-361 PubMedAbstract 7. Nead. G. Karen, Hailerman. S. Jill; Journal of the American Academy of Pediatrics; Indian edition; volume 16,no: 1- 6, Jan- Dec 2004 8. Nead KG, Halterman JS, Kaczorowski JM, Auinger P, Weitzman M. Overweight children and adolescents: a risk group for iron deficiency. Pediatrics. 2004 Jul;114(1):104-8. PubMed - indexed for MEDLINE 9. B Sudhagandhi, Sivapatham Sundaresan, W Ebenezer William, A Prema Prevalence of anemia in the school children of Kattankulathur, Tamil Nadu, India, SRM Medical College Hospital and Research Centre, SRM University, Tamil Nadu, India. 10. Jai Prabhakar SC, Gangadhar MR. Prevalence of anemia in Jenukuruba Primitive Tribal Children of Mysore District, Karnataka. Anthropologist 2009;11:49-51. 11. Tiwari K. Seshadri S. The prevalence of anemia and morbidity profile among school going adolescent girls of urban Kathmandu, Nepal. J Nep Med Assoc 2000;39:319-25. 12. Sethi V, Goindi G, Kapil U. The Prevalence of anemia amongst primary school age children (6-11 years) in national capital territory of Delhi. Indian J Pediatr 2003;70:519-20. PUBMED

Keywords : Adolescents, anemia, overweight, normal weight, 38 Iron deficiency anemia. - Sujatha R. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE OF POST OPERATIVE SELF CARE FOR MOTHERS UNDERGOING ELECTIVE CAESAREAN SECTION IN SELECTED HOSPITALS, MANGALORE Elizabeth Rajan1 & Sabitha Nayak2 1Senior Lecturer, Lourdes College of Nursing, Cochin, Kerala 2Vice Principal, Nitte Usha Institute of Nursing Sciences, Nitte University, Mangalore - 575 018, India. Correspondence : Sabitha Nayak, Vice Principal, Nitte Usha Institute of Nursing Sciences, Nitte University, Paneer, Mangalore - 575 018, India. Mobile : +91 94488 42698 E-mail: [email protected] Abstract : The study was conducted on Effectiveness of self instructional module on knowledge of post operative self care for mothers undergoing elective caesarean section in selected hospitals, Mangalore. The research design was a one group pre test post test design which was a pre experimental research design. 40 mothers undergoing elective caesarean section by purposive sampling. The pretest knowledge questionnaire was administered to the mothers two days prior to caesarean section, followed by a self instructional module on post operative self care. Post test was conducted after 5 days using the same tool. The collected data were analyzed using descriptive and inferential statistics. The mean knowledge score was 14.98 whereas maximum possible score was 30. Among the 11 areas, the mean percentage knowledge score in the area of caesarean section and self care was 77.50% bladder and bowel care was 60% breast feeding was 58.40% diet was 52.50% pain management was 47.50% post operative complications and home care was 46% baby care was 44.33% early ambulation and exercise was 44% perineal hygiene was 41% wound care was 40.67% and deep breathing and coughing was 40.67%. The 't' value showed significant in the post test ('t' calculated value of pretest and post test knowledge scores = 18.000, p<0.001) which showed that self-instructional module was effective in improving the knowledge of mothers on post operative self care after caesarian section. There was significant association between the level of knowledge and demographic variables namely age parity, education, occupation, monthly income, exposure to health awareness and history of caesarean section. Keywords : Caesarean section; mothers; post operative self care; self instructional module.

Introduction : successfully done through the process of caesarean In philosophy, the woman symbolizes the mother's natural section.1 feminine characteristics in the universe. A birth of a child is Today, it is one of the most frequently performed surgeries generally viewed as a time of rejoicing, despite the physical in the world. Caesarean births are more common than pain and exhaustion experienced by many women during most surgeries due to many factors. One factor, of course, is childbirth. Usually pregnancy is a normal pathway. Some that nearly 50% of the world population are women, and go with struggle, yet Access this article online pregnancy is still a very common condition. However, more couldn't achieve normal Quick Response Code important is the fact that a caesarean section may be life delivery. Such types of saving for the baby, or mother (or both). Caesarean birth is mothers are considered also much safer today than it was a few decades ago. Thus for operative delivery. The 'caesarean' is not something that should scare, as the ultimate aim is to preserve ultimate goal is a healthy mother and healthy baby, the life and health of the regardless of the method of delivery.2 mother and fetus which is

Keywords : Caesarean section; mothers; post operative self care; 39 self instructional module. - Sabitha Nayak NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Statement of the Problem boundary that filters the type and rate of exchange with the “Effectiveness of self instructional module on knowledge environment. A system consists of both structural and of post operative self care for mothers undergoing elective functional components. A structure refers to the caesarean section in selected hospitals, Mangalore”. arrangement of the facts at a given time. Function is the process of continuous change in the system as a matter; Objectives of the Study energy and information are exchanged with the 1. To assess the level of knowledge on post operative self environment. The client is an open system capable of both care among mothers undergoing elective caesarean input and output related to the environmental influences, section. interacting with the environment by adjusting the 2. To identify the effectiveness of self instructional module environment to itself. The feedback information of in terms of gain in knowledge among mothers environment in response to the system's output is used by undergoing elective caesarean section. the system in adjustment, correlation and accommodation 3. To find the association between the pre test level of to the interaction with the environment. knowledge on post operative self care with selected demographic variables. Review of Literature An experimental study was conducted on 60 mothers to Background of the Study assess the effectiveness of structured teaching programme Internationally caesarean section rate is on the increase. on knowledge and practice of breast feeding to primi During the last decade there has been two to three fold rise postnatal mothers of Sir Ivan Stedeford hospital, Chennai. in the incidence. WHO recommends that the caesarean Results showed that the overall mean score of the section rate of 10 – 15% should not be exceeded. But the experimental group was 52.14 in the pretest and 77.38 in results of National Sentinel caesarean section audit shows the post test, where as for the control group the overall that caesarean section rates are high as above 24% in most mean score was 50.48 in the pretest and only 54.19 in the of the developed and developing countries. According to post test (p = <0.001). 5 the centre for disease control and prevention more than 7Lakh pregnancies per year go to first time caesarean A randomized controlled trial on 200 women on early section.3, 4 initiation of oral feeding after cesarean section was conducted by Obafemi Awolowo University Teaching Self care is an integral part of holistic living of one's life. Self Hospital, Nigeria. The results showed that early feeding care approach is a challenge in post operative period in the group had a shorter mean post-operative time interval to health care system. Post operative period after caesarean bowel sounds, passage of flatus and bowel movement (p < section is a time of transition during which the mother 0.001). Early feeding group had a shorter mean hospital must care for herself and for her newborn. Educating the stay and required less intravenous fluid (p < 0.001). The mother preoperatively on post operative self care will help study concludes that early feeding after caesarean section them to practice it as early as possible after the delivery; was well tolerated and safe and can be implemented there by improving the self care practices and preventing without an increase in adverse outcome. 6 complications. A quasi experimental study was conducted on 80 primi Conceptual Framework mothers on the effectiveness of planned teaching The framework of the study is based on general system programme regarding self perineal toileting after delivery theory model developed by Ludwig Von Bretalanffy in a selected hospital, AndhraPradesh. The results showed (1986).General system theory serves as a model for that the mean gain level of knowledge between pre and viewing people as interacting components within a post test in experimental group was 39.89 and that in

Keywords : Caesarean section; mothers; post operative self care; 40 self instructional module. - Sabitha Nayak NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science control group was 0.09.The calculated t value is Most of the mothers (35%) completed high school 23.6(P<0.001) shows that there is a significant increase in education. Majority of the mothers (75%) were the level of knowledge in the experimental group than the housewives. Majority of the mothers (80%) had monthly control group. The researcher concluded that planned income between Rs.3001 - Rs.10, 000. Most (52.5%) of teaching is effective in promoting the knowledge on self them had no exposure to any of the health awareness. perineal care after delivery. 7 Many of the mothers (52.5%) had history of previous caesarean section. Methodology : One group pre test post test design which is a pre The data showed that out of 40 mothers maximum number experimental research design was adopted. of mothers 24 (60%) had average knowledge. The mean knowledge score was 14.98 whereas maximum possible Sample score was 30. Among the eleven areas, the mean 40 mothers undergoing elective caesarean section at percentage knowledge score in the area of caesarean selected hospitals in Mangalore and who satisfied the section and self care was 77.50%, bladder and bowel care inclusion criteria were included as samples. was 60%, breast feeding was 58.40%, diet was 52.50%, pain Data Collection Process management was 47.50%, post operative complications Pre-test was administered to the mothers two days prior to and home care was 46%, baby care was 44.33%, early caesarean section on knowledge of post operative self care ambulation and exercises was 44%, perineal hygiene was after caesarean section using structured knowledge 41%, wound care was 40.67% and deep breathing and questionnaire. The researcher collected the demographic coughing was 40.67%. data along with this. It took approximately 30 minutes. There was significant difference found between the mean After pre test researcher distributed the self instructional pre test knowledge score and mean post test knowledge module on post operative self care to the mothers. After 5 score,('t' calculated value of pretest and post test days of intervention, the researcher administered the post knowledge scores=18.000, p <0.001) which showed that test to assess the level of knowledge of mothers using the self instructional module was effective in improving the same structured knowledge questionnaire. knowledge of mothers on post operative self care after Results : caesarean section. The collected data were analyzed by using descriptive and There was significant association between the level of inferential statistics. The findings revealed that highest knowledge and demographic variables namely age, parity, percentage (42.5%) of mothers were in the age group of 21 education, occupation, monthly income, exposure to -25 years. Majority of the mothers (45%) were Muslims. health awareness, and history of caesarean section. Many of the them (52.5%) were primigravida mothers.

References : 1. Orshman AS. Maternity Newborn and Women's Health Nursing.1st 5. Vijaya SS, Menon AV, Breast feeding teaching for better practice. The edition. Philadelphia: Lippincott Williams and Wilkins publishers; Nursing Journal of India 2002, Aug; LXXXXIII (8):173-75. 2008. 6. Orji EO, Olabode TO, Kuti O, Ogunniyi SO. A randomized controlled trial 2. Fraser DM, Cooper MA, Fletcher G. Myles Textbook of Midwives. 14th of early initiation of oral feeding after caesarean section J Matern Fetal edition. Philadelphia : Churchill Livingstone, 2003. Neonatal Med 2009 Jan; 22(1):65-71. 3. Lowdermilk LD, Perry ES. Maternity and Woman's Health Care 8th 7. Yasoda. Effectiveness of planned teaching programme on self perineal edition. Missouri: Mosby Publishers; 2004. toileting in postnatal mothers. Indian Journal of Nursing and 4. http://www.who.int/reproductive_health/index.htm(20-10-08) midwifery 2002 Mar; 70(1):34-5.

Keywords : Caesarean section; mothers; post operative self care; 41 self instructional module. - Sabitha Nayak NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article PERCEPTION REGARDING FEMALE FETICIDE AMONG FEMALES ATTENDING OUT PATIENT DEPARTMENTS OF SELECTED HOSPITAL OF LUDHIANA CITY Mamta Choudhary Assistant Professor, Institute of Nursing, Guru Teg Bahadur Sahib © Hospital, Ludhiana, Punjab, India. Correspondence : Mamta Choudhary INE, GTBS© H, Shastri Nagar, Model Town, Ludhiana, Punjab, India Mobile : +91 98032 27705 E-mail : [email protected] Abstract : Background : Although the Indian girl child's position is precarious throughout the country, she remains the most vulnerable in Punjab. Objectives : To assess the perception of females regarding female feticide. Study Design: Cross- sectional study. Materials and Methods: The study involved collection of information regarding perception of females about female feticide using multiple-choice questionnaire. Two hundred and fifty female patients attending medical and surgical OPD's of selected hospital were recruited in the study by using simple random sampling. Results: Majority of the females perceived that male child is more preferred in society. Moreover, majority of subjects have the view that female feticide has harmful impact on the society and should be stopped. The suggestion given by subjects to curb this evil practice included enforcement of strict laws, punishment to people and doctor involved and creating awareness regarding the issue. Keywords : Perception, female feticide, Declining Sex Ratio.

Introduction: differential contraception. Contraception used is based on Female feticide is an extreme manifest of violence against the number of surviving sons irrespective of family size. women. In India feticide, especially female feticide & sex Following conception, fetal sex is determined by prenatal selections are the worst conditions. It tends to be serious diagnostic techniques after which fit female fetus are decline in sex ratio in states of India. A sloka of Atharvaveda aborted. (Das Gupta)2 says “The birth of a girl, grant it elsewhere. Here, grant a The preference for a male child and discrimination against son.” Thousands of years later, this thing stands very true in the female child are causing the rapid disappearance of modern times as well, when, despite the so called female children in India. 35 million females were found to modernity, industrialization, literacy and equality, parents be missing according to the census of 2001, which was 32 still pray the same. (Nilanjana Mukherjee)1 million during 1991. 3 As per the census of 2011, the child Female feticide is a major social problem in India and has sex ratio of India has declined from 927 to 914 females per cultural connection with the dowry system that is ingrained 1000 males, which is the lowest since the country's in Indian culture, despite independence4 . The inhabitants of Punjab, who pioneered the fact that it has been the green revolution in the last century, are now heading Access this article online Quick Response Code prohibited by law since for a devastating economic and social fall out in the near 1961. In India, a strong future due to sharply declining (882 in 1991; 874 in 2001) preference for sons exists sex ratio. by abuse of medical In India, a women's status is associated not only with her technologies. Pregnancies reproductive capability but also on her success in are planned by restoring to delivering a male child, which enhances women's will to

Keywords : Perception, female feticide, Declining Sex Ratio. 42 - Mamta Choudhary

NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 3: Perceived reasons for less preference of female child Table 5: Females view points for opposing the practice of female n=180 feticide. n=229 Reasons for less preference Number of f (%) Females view points for opposing Number of to female child Subjects (f) the practice of female feticide. Subjects (f) f (%) Girls cannot take care of their Girls are more responsible towards parents in old age 17 09.4 parents and family. 38 16.6 They are consider as Girls deserve equal status in family 89 38.9 burden on family 35 19.5 Girls are important part of society 57 24.9 Due to dowry system 63 35.0 Every individual has right to live 31 13.5 Due to increase crime Girls take care of parents in old age 14 06.1 towards girls 61 33.9 Any other* 04 02.2 Maximum 82.4% (206) of the study subjects perceived that *Marriage expenses female feticide has harmful impact on society. Among * Due to social norms these 36.8% and 29.1% opinioned that social problems in Maximum 40.4% (101) of the study subjects had viewpoint society and marriage problems for males will arise due to that illiteracy is responsible for female feticide. Poverty female feticide respectively. (Table 6) However, 17.6% of (19.6%) and family pressure with rituals and customs the subjects perceived female feticide as beneficial to the (17.2%) were also perceived as contributory factors for this society. They support this belief with reasons, as female evil. However, least 11.4% each believed that feticide will decrease crime towards females (15.9%), determination of sex and desire of son are responsible for decrease population (38.6%), and increase power of female feticide. Maximum 91.6% (229) subjects responded females in the society (15.9%). (Table 7) that practice of female feticide is morally wrong, however 8.4% (21) responded that practice of female feticide is Table 6: Perceived harmful impact of female feticide on society. n=206 morally right. Females who were in favor of this practice Perceived harmful impact of Number of supported this reason that it is easy to rear up male child female feticide on society Subjects (f) f (%) than female child (33.3%), boys are important to run a Marriage problem for male will arise 60 29.1 family(28.6%) and multiple girl child can cause burden on It will effect mother psychological health 28 13.6 the family(23.8%). (Table 4) Females opposing this practice It will lead to social problem in society 76 36.9 Number of rape cases and other crime perceived that girls deserve equal status in family (38.9%), will develop 34 16.5 girls are important part of society (24.9%) and girls are Raise power status of male in family 08 03.9 more responsible towards parents and family (16.6%). (Table 5) Shashi Manhas and Jabina Banoo in their attempt Table 7: Perceived beneficial impact of female feticide on society. n=44 to study the perception and beliefs regarding female Perceived beneficial impact Number of feticide among Muslim community of Jammu found that of female feticide on society Subjects (f) f (%) majority of fathers (96%) and mothers (82%) believes that Crime towards female will decrease 07 15.9 female feticide is morally wrong. However, (18 %) mothers Population will decrease with female feticide 17 38.6 responded that it is morally right (4%) fathers responded Female feticide will decrease when number that there is no harm in this practice. of girls will decrease 10 22.7 It will be easy for government to Run Table 4: Females view points for supporting the practice of female a country 03 06.8 feticide. n=21 Value of woman will increase 07 15.9 Females view points for supporting Number of f (%) Majority 96% females responded that female feticide has the practice of female feticide. Subjects (f) Boys are important to run a family 6 28.6 an impacts on mothers as it arise psychological problems It is easy to rare up male child than among mothers (55.2%), develop feeling of guilt or crime female child 7 33.3 among mothers (36.4%), and can cause behavioral changes Multiple girl child can cause burden in mothers(4.4%). Majority 98% (245) subjects had an on the family 5 23.8 Due to social norms 3 14.3 opinion that female feticide can be stopped by taking various measures. (Table 9) Keywords : Perception, female feticide, Declining Sex Ratio. 44 - Mamta Choudhary NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 9: Perceived ways to stop female feticide Conclusion and Recommendations : n=245 The study reveals that majority females have awareness Perceived ways to stop female Number of f (%) about causes and harmful impact of female feticide, and by the subjects Subjects (f) By giving punishment to people oppose this evil practice. However, maximum females have and doctor 83 33.8 an opinion that Government should strictly enforce laws By enforcing strict law 100 40.8 against female feticide and punish people and doctors By providing financial aid to families with girls child 17 06.9 involved in this practice. In addition to this, efforts should By creating awareness regarding this issue 35 14.8 be taken to create awareness regarding this issue and to Giving equal status to men and women 10 04.0 ensure equal status among men and women. As females are important stakeholders in elimination of the practice of female feticide, it is recommended that this group should be equipped with ample amount of knowledge so that they can act as change mediators in the society. References: 1. Audio-Visual Review, (1991). Born female, Produced by UNICEF reference to kolahpur district. International Journal of scientific and Regional Office for South Central Asia. Govt. of India. Directed by research Publication, 2(12): 1-5 Nilanjana Mukherjee. Indian J Social Work, 52: 115-17. 10. Shaikh Nawal1, Viradiya Hiral2, Thakkar Dhwanee3, Bansal RK4, Shah 2. Das Gupta, M. (1987). Selective Discrimination against Female Dhara1, Shah Shashank1.(2011). Female feticide perceptions and children in Rural Punjab, India, Popul Dev Rev, 3:77–100. practice among women in Surat city. National Journal of community 3. Female foeticide in India. C2007. Available from medicine. 2(3): 171-4. http://www.unicef.org/india/media 3285.htm. [cited on 2012 Jun 26] 11. Siddharam S. Metri, Venktesh G.M., Thejeshwari H.L., (2011). 4. Census of India 2011. Population Census Abstracts. Registrar General Awareness regarding Gender preference and female feoticide among of India, New Delhi, Govt. of India. teachers. Journal of clinical and diagnostic research, 5(7): 1430-1433. 5. Baligar PV(1999). Mother and girl child.jaipur. Rawat Publication: 523- 12. A-H.El-Gilany and E. Shady. Determinants and causes of son 25. preferences among women delivering in Mansoura, Egypt. Eastern 6. Shashi Manhas and Jabina Banoo, (2013). A Study of Beliefs and Mediterranean Health Journal, 13(1): 199-128. Perceptions Related to Female Foeticide among Muslim Community in 13. Arnold F, Kishore S. Roy TK, (2002). Sex selective abortions in India. Jammu, Jammu and Kashmir, India. Stud Home Com Sci, 7(2): 125-130 Population development Review ; 28:759-85. (2013). 14. S. Sureender, G. Rama Rao & S. Niranjan, (1997). Attitude Towards 7. Dr. Kusum Jain, Dr. Anju Sachdeva, (2013). Attitude of urban society Female Foeticide: Does it Influence the survival Status of Female towards female foeticide. Advanced International Research Journal of Children?. IASSI Quaterly, 16(3): 106-114. Teacher Education, 1(1): 83-86. 15. Srivastav Shalini, Kariwal P, Kapilasrami MC (2011). A Community 8. Niharika Joshi, Ashu K Bajwa, (2012). Socio- economic based study on awareness and perception on gender discrimination intergenerational differences in attitude of rural women towards and sex preference among married women in a rural population of female foeticide. Stud Home Com Sci, 6(1): 57-59 district bareilly, Uttar Pradesh. National Journal of community 9. Aithal U.B, (2012). A statistical analysis of female foeticide with medicine, 2(2): 273-276.

Keywords : Perception, female feticide, Declining Sex Ratio. 45 - Mamta Choudhary NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article SURFACE TOPOGRAPHY OF DENTAL IMPLANTS Vinaya Bhat1 & S. Sriram Balaji2 1Professor, Department of Prosthodontics & Implantology, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575018, Karnataka., 2 Senior Lecturer, Department of Prosthodontics, Sri Ramakrishna Dental College & Hospital, Coimbatore - 641 006, India Correspondence : Vinaya Bhat Professor, Department of Prosthodontics & Implantology, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018, Karnataka, India. Mobile : +91 94819 21180 E-mail : [email protected] Abstract : Surface treatment of titanium implants has been a new frontier in clinical dentistry. Usually it is based on additive and subtractive techniques that modify the surface topography of implants. It alters the roughness/smoothness of the implant surface which becomes more favourable to achieve osseointegration. This modified surface exhibits varied biological responses when the implant is placed in the oral cavity. This article reviews the principles behind treating the surface of titanium, the numerous methods employed for treating the surface and the cellular response elicited. A complete electronic search and hand search has been conducted for the purpose. Keywords : Dental Implants, Surface treatment, topography, osseointegration.

Introduction : analyze the exact role of surface chemistry on Early osseointegration determines the clinical success of osseointegration. But due to poor standardization dental implant therapy1 . In order to achieve such early techniques and lack of comparative studies between osseointegration, delicate surgical technique during different surface treatment procedures, understanding implant placement, geometry and surface topography of this aspect of osseointegration is incomplete. This review the implant are very crucial factors2-5 . Immediately after focuses on the different surface treatment methods and a fixture placement titanium reacts with body tissues and comparative evaluation of the different techniques and the fluids. Two possible types of response observed would be cellular responses observed as a result of the treated formation of fibrous tissue capsule, which causes clinical surface. failure of implant therapy and the direct contact of bone to Surface Chemical Composition And Roughness implant, which is called as osseointegration1 . In the latter Chemical composition and roughness of the implant there is no intervening connective tissue layer and the surfaces have been known to play a crucial role in fixation is usually biological. The surface properties of development of osseointegration. The titanium implants titanium have been found to have an influence on the rate used presently have different surface compositions based and quality of biological fixation. Surface properties on the type of metal used. For dental applications, include composition, energy, topography, hydrophilicity Titanium is used in pure form (CpTi) or alloyed with and roughness. These are aluminium and Vanadium (Ti6Al4V). Based on the content Access this article online interrelated and of oxygen, carbon and iron, Cpti has graded as 1-4 and alloy Quick Response Code individually they has been placed as grade 516 . determine the clinical outcome of implant The reaction of water or body fluids on to the implant therapy. Numerous in vivo surface depends on the surface composition. A surface and in vitro tests6-15 have which will increase the hydrophilicity has found to be been performed to preferable. Numerous authors have attempted to

Keywords : Dental Implants, Surface treatment, 46 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science determine the ideal contact angle of the surface of the drawbacks are, difficulty in achieving nano level roughness implant which could make the surface hydrophilic. It is and quantifying the above mentioned protein adsorption suggested that shallow contact angle of 0 ? enhances and adhesion of osteoblasts. So far only fewer studies have hydrophilicity and contact angle of 140? results in been reported with nano surface modifications in a hydrophobicity17-22 . reproducible manner. The roughness formed in the nano meter level positively guides osteoblasts to attach Ti Surface morphology enhances osseointegration by surface implant. Further, it also helps in primary healing. directing protein adsorption kinetics. Osteoblasts tend to attach more readily and their differentiation occurs more Titanium Plasma Spraying (TPS) easily on a rough surface. This utilises a plasma torch through which titanium powders are injected at high temperatures. Then these A turned/ machined implant has a smooth surface titanium particles are sprayed on the surface of implants. A macroscopically and it has been in use for several decades film of 30um thick is formed on the implant surface due to after Prof PI Branemark invented implants. In machined condensation and fusing. Ideal thickness must be 40-50 um implants bone contacted only the tip of the thread and not 25 with levels of roughness reaching 7 um. Buser et al stated the root of the thread and also there is no connection that this configuration increased tensile strength at bone between peri implant bony surface and implant surface. 34 implant surface. Roccuzzo compared Sand Blasted Acid Since there is a delay in osseointegration and later loading Etched (SLA) and TPS implant surfaces and found no of the implants by the prosthesis, the need for hastening significant difference between those two. Taba Junior et the process is felt. Ever since, the implant surface has 35 al conducted a study in which TPS demonstrated inferior undergone tremendous metamorphosis in its roughness. bone- to- implant contact when compared to plasma The roughness of titanium implants has a direct effect on 25,36 sprayed hydroxyapatite coated implants. Few authors osseo integration and its bio mechanical fixation23, 24 . Three suggested the use of micro level surface roughness while levels of surface roughness have been identified. They are using TPS. The main drawbacks of this procedure are macro, micro and nano size topography. porosity of coating and residual stress development in the Macro level ranges from millimetres to tenth of microns. coated surface. Few cases of loosening of the coating and 35 High surface roughness increases early osseointegration delamination has also been reported . and stability. But increase in ionic leakage is a potential Sand Blasted Acid Etched (SLA) Treatment problem since it may lead to peri implantitis25-29 . In this method, surface is bombarded with aluminium Micro level ranges from 1 -10 micrometers. Maximum oxide (Al2O3) particles and later followed by acid etching. interlocking between bone and implant surface occurs at This treatment results in formation of titanium hydride this level according to Wennerberg et al24, 27 . According to layer, which increases the mechanical properties of the Hannson30 ideal surface should be covered with implant. Uniform micro pits of 1-2 um diameter were hemispherical pits 1.5um in depth and 4 um in diameter31 . formed which results in increased bone-to-implant- 37 Implants with surface roughness are mainly indicated contact . where poor quality of bone is present. Rough surface Grit Blasting : increases bone to implant contact enhancing superior In this procedure, hard ceramic particles are used to 32 clinical results . roughen the surface of dental implants. Alumina, titanium

Brett33 proposed that nano level roughness helps in protein Oxide (TiO2) and Calcium Phosphate particles have been adsorption and osteoblasts adhesion. The potential used for this purpose, because they are chemically stable and biocompatible. These particles are delivered through a

Keywords : Dental Implants, Surface treatment, 47 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science nozzle at high velocity using compressed air. The size of deposition directly on the implant surface. Several these particles determines the surface roughness authors51-54 reported increased bone to implant contact and achieved. reduced bone loss compared to TPS and machined surfaces. According to Novaes55 and Papalexiou56 Alumina is a commonly employed blasting material. homogenous micro porous surface with higher bone to However, main problem is that it gets embedded on the implant contact results from high temperature acid etching implant surface and cannot be removed by ultrasonic as compared to TPS surfaces. Surface wettability provides cleansing, acid passivation and sterilization. Since it is acid fibrin adhesion which guides osteoblasts migration over insoluble it is hard to remove thus leading to differential the implant surface. Buser et al17 showed improved bone to surface composition on titanium surface. Aparico et al38 implant contact of the hydrophilic surface. Qahash57 showed that this chemical heterogeneity decreases conducted an animal model study in which he concluded corrosion resistance of titanium in physiological surface dual acid etching accelerates osseo integration environment. both in newly formed and native bone irrespective of Titanium oxide particles of size 25um produce roughness of differing bone densities. Sand blasted acid etched implants 1-2 um. Ivanoff39 demonstrated higher bone ti implant can be restored successfully after a 6-12 week healing contact of Tio2 blasted implant surface when compared to period. According to Nelson et al.58 acid etched titanium machined surface. Researchers40-42 showed higher bone surfaces shows increased fibronectin absorption when implant contact, positive success rates and higher marginal compared to machined surfaces. bone levels of Tio2 blasted implants. Abron43 et al showed Fluoride treatment of titanium produces surface that torque force increased with increase in surface roughness favouring osseo integration. titanium forms roughness while positive bone apposition was observed. soluble titanium fluoride which produces osteoblast Roughening of implants increases the mechanical fixation differentiation59 . Ellingsen60,61 demonstrated greater and not biological fixation. resistance to push forces and increased torque for removal Calcium phosphates like hydroxyapatites and ß tricalcium when implants are fluoride treated. This increases bio phosphates have also been used because they are bio activity at the implant surface. compatible, osteoconductive and resorbable. Novaes et Yokoyama62 showed that acid etching causes hydrogen al44 and Piatelli et al45 seperately demonstrated higher embrittlment of titanium causing microcracks leading to bone- to- implant contact of these surfaces when decreased fatigue resistance. He also explained formation compared to machined surfaces. of a brittle hybrid phase causing decreased ductility which Acid Etching : causes fracture. Strong acids like Hcl, H So , HnO and Hf produces micro pits 2 4 3 Anodization : ranging from 0.5um to 2 um in diameter46,47 . Wong et al48 When strong acids are used at high density and potential of showed increased osseo integration as a result of acid current (200A/m2, 100V), it results in micro or nano etching. Micro rough surface is produced by immersing surfaces. Anodization is employed to thicken the surface titanium implants in concentrated solution of HCL and oxide layer upto 100nm63,64 . According to Sul65,66 H2SO4 heated above 100c . This is called as dual acid modifications in microstructure and crystallinity are etching. Cho and Park49 stated that the above processes produced as a result of anodization. Anodization depends increase osseointegration and help in long term success of on density of current, acid concentration and electrolyte implant therapy. Park and Davis50 demonstrated that dual composition. Sul and Rocci67-69 postulated increased acid etching increases osseo conduction and causes bone

Keywords : Dental Implants, Surface treatment, 48 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science biomechanical and histomorphometric values for to cut titanium to be visible in light microscope. When anodization when compared to machined surfaces. implants are alkali and heat treated it forms a foci over Jungner70 demonstrated higher clinical success of anodized which bone matrix is deposited. The apatite formed due to dental implants. Both Mechanical interlocking and this treatment is similar to inorganic component of bone. Biochemical bonding occurs due to anodization. The apatite is formed by amorphous sodium titanate that is Magnesium, sulphur, calcium and phosphorous was used preformed on the metal after treatment. This is a complex by Sul65,66 to modify surface oxide layer of titanium. process which occurs as a result of electrostatic interaction According to Sul65,66 , magnesium ions provide increased between surface of metal and fluids in the body. Ban removal torque values when compared to other ions. proved that alkaline treatment is a simple and effective procedure for surface modification of titanium and it also Ion Implantation71 increases adhesion to resin by formation of rutile particles. It is a procedure where in sodium, calcium and phosphorous ions are implanted onto the surface of Bio Mimetic Agents implants to modify their topography at a dose of 1 into 10 17 Bio ceramics, bioactive proteins, ions and polymers ions/cm-2 utilizing a beam energy of 25KeV and a vaccum of constitute biomimetic agents. According to shin a bio 10-6 Pa. A novel technique of double implantation was also mimetic agent is one that has been designed to elicit followed where Calcium ions were implanted followed by specified cellular responses, mediated by interactions with phosphorous ions. Care must be taken not to exceed the scaffold- tethered peptides from extra cellular matrix. temperature above 40c . This technique increased the According to glossary of implant dentistry bio mimetic corrosion resistance of titanium and also accelerated material is one which is able to replicate/ imitate a body osseointegration. The highest corrosion resistance was structure (anatomy) and/or function (physiology). The seen in Ca+ P implanted titanium. Implants were treated material must be easy to manufacture causing no allergic or initially with alkali to achieve heterogenous nucleation of immune response. Further it must have good Ca and P, since mechanical stability of this coating depends differentiating capacity being chemically stable and on rough surface of titanium. Presence of hydroxyl groups economical. Biomimetic layer on the implant surface is a is a major necessity for calcium and phosphorous valuable alternative to other surface treatment modalities. 74 deposition since it provides sites for adsorption of ions Munisamy et al developed a newer method to deposit from body fluids. cone like collagen mineral compositie layer, which increased osseointegration in vitro. Higher percent of Alkali and Heat Treatment success is noticed when the mineral formed is similar to the c Here, the implants are soaked in 10M NaOH at 60 for 8 one present in tissue itself. Recently biomimetic implants hours. Then it is washed with de ionised water and dried at are available commercially and prove to have faster c 40 for 24 hours. Further these were heated gradually from osseointegration. But further studies are required in this c c c 500 to 700 at rate of 5 / min and then allowed to cool at discipline to understand better the way of accelerated 72 room temperature. Krupa et al found out that increase in osseointegration and comparative studies with other temperature increases corrosion resistance. This also surface treatment modalities. increases bone bonding ability without causing roughening of the surface. According to Kim and Kokobo73 alkali and Biologically Active Drugs heat treatment form a bone like apatite that binds to bone Tgf, Igf and Pdgf are employed with dental implant therapy apatite chemically forming high bond strength. The above these days. Care must be taken to ensure gradual release of mentioned effect was demonstrated by applying the substance rather than a instant release. Bis fluorescent agent on the treated surface since it is difficult phosphonates are drugs that prevent resorption of bone

Keywords : Dental Implants, Surface treatment, 49 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science and they can be coated on implants used in bone deficiency blasted implant surface demonstrated higher bone-to- regions. According to Josse et al75 bis phosphonates implant- contact and good marginal bone levels. Grit increase bone density at the vicinity of the implant. Other blasted implants have 31% contact with bone and is much studies76-79 using these drugs also showed increase in bone higher when compared to porous (17%) and polished (15%) contact area and absence of negative effects. But the implants. But grit blasting produces differential surface optimal dose of these drugs to be coated onto the implant composition and chemical heterogenicity, which decreases surface is yet to be determined. corrosion resistance of titanium. Acid etching results in increased bone-to-implant-contact and reduced marginal Lasers80 bone loss when compared to TPS and machined surfaces. Lasers are used in dentistry for decades for cutting hard Irrespective of differing bone densities acid etching tissues. Co lasers were the first lasers to be used. Now 2 accelerates osseointegration and also demonstrated lasers occupy a prime position in every field of medicine increased fibronectin absorption. But this procedure including dentistry. Bacterial infiltration of peri implant causes micro cracks on titanium surface which decreases tissue reduces success rate of implant therapy. Hence, an the fatigue resistance. Anodization increases removal adequate maintenance of peri implant tissues is a must for torque values, because it causes both mechanical successful osseo integration. Other than plastic curettes interlocking and bio chemical bonding. Implantation of and bactericidal chemicals, lasers also are an adjunct for pri calcium, sodium and phosphorous ions increases corrosion implant sterilization. Lasers are mainly used while resistance and hastens osseointegration. SLA treatment exposure of cover screws (stage II surgery). The most has shown higher clinical success rates and forms uniform commonly used lasers are Co laser and NdYag laser. They 2 diameter pores. But acid etching decreases surface are used in surface treatment of implants. However, higher roughness after sand blasting. Alkaline treatment is a doses of Co laser (3.5- 5v) cause destruction of micro 2 simple procedure for surface modification. It forms an mechined groove. When focussed, Co2 lasers are employed apatite similar to inorganic component of bone. This no discolouration of titanium is seen. In contrast, NdYag increases bonding to bone without roughening of the laser treatment surface melting, porosity loss and other surface. Bio mimetic agents increase osseointegration but damages were observed. The damage observed was further studies are required in this discipline. Implantation proportional to the dose applied. NdYag lasers are also of biologically active drugs onto the implant surface is used for decontaminating the surface of failing and being practiced off late. But optimal dose of these drugs is diseased implants. Also laser treatment did not sterilize yet to be determined. Co2 lasers are reflected back so they plasma sprayed titanium and plasma sprayed are used in surface treatment. They are also used on 80 Hydroxyapatite (HA) coated titanium. Park et al diseased and failing implants. But studies showed that they contraindicates use of lasers as they cause peri implant soft cause peri implant soft tissue damage. Electron beam tissue damage while used near endosseous implants. Co2 radiation decreases surface roughness and causes lasers gets reflected from the implant surface, so they do polishing of the surface, so it cannot accelerate not cause temperature rise and more useful in surface osseointegration. None of the surface treatment implant treatment. procedures have been proved optimal. Every manufacturer has their own theory for the treatment procedure they Critical Evaluation of Different Surface Treatment follow. So the search for ideal surface treatment method is Procedures not complete. TPS increases tensile strength at the bone implant surface and surface is similar to SLA treated surface, but it causes Cellular Responses To The Surface Treatment Procedures porosity, delamination and loosening of the coating. Grit Cell attachment on the implant surface takes by direct and

Keywords : Dental Implants, Surface treatment, 50 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science indirect methods. Physico chemical links are responsible Higher calcium phosphate ratio is seen on fluoridated for direct attachment and proteins such as fibronectin and implant surface when compared to anodizes, alkali treated vibro nectin helps in indirect attachment. Fibronectin is the and heat treated implants and hydroxyapatite coated earliest protein produced by the tooth and bone forming implants. But the above studies have been done on cells. simulated body fluid which lacks many components contained in human plasma. Wang et al81 stated that carbonate apatite globules is necessary for adequate cell attachment. Ti OH groups Anodization of dental implant surface produces which is seen on the titanium surface is the major driving osteoblasts which has higher alkaline phosphatase activity. factor for the formation of calcium and phosphate Since anodization results in higher surface roughness it precipitates. Fibroblast growth and adhesion depends on causes increased Calcium and phosphorous deposition. the intrinsic chemical composition of the material rather Anodization followed by hydrothermal treatment than roughness of the surface. Osteoblasts attach more on demonstrated best bio activity. Also ALP production the blasted surface when compared to acid etched and TPS increases with increased B glycerophosphate production. surfaces. Also TPS and smooth surfaced implants showed But the validity of the above mentioned responses must be lesser levels of alkaline phoashatase activity. Major further evaluated. emphasis is placed on ALP because it is the earliest marker Future Trends for osteoblast differentiation. Micro rough surfaces ranging Researchers have developed a novel method of spraying from 7 -10um give the optimum environment for mesenchymal stem cells on the surface of titanium and osteoblast differentiation. Since sand blasting gives such making it to differentiate into osteoblasts or bone building optimum surface, osteoblasts adhere more readily over cells. these surfaces. A titanium foam is prepared by mixing titanium powder Recombinant human bone morphogenic protein 2 (rh with foaming agents. These foaming agents cause swelling BMP2) forms fine trabecular woven bone along the surface of polymer when heated. Later this polymer is removed of the implant. It also increases osteogenic activity without and titanium is condensed to provide strength to the any obvious compression of tissues. porous structure. This enhances bone growth into the A machined implant treated subsequently with acid and pores created and makes it less invasive. alkali demonstrated higher attachment and growth of When zinc and titanium are made in nano topography, it bone forming cells. Ban82 showed that acid etching reduces increases the surface area providing more space for bone bone marrow cell proliferation. forming cells to adhere. They also have shown to possess NaOH and heat treatment results in uniform formation of anti bacterial effect. the sodium titanate layer on the metal. This treatment When SLA treated surface is coated with Arg–Gly–Asp modality results in bone growth into the porous surface (RGD), peptide-modified polymer (PLL-g-PEG/PEG–RGD) created by it. This results in reducing immobilization time higher bone-to-implant contact is seen. These peptides act prior to loading. The stability obtained is long lasting since a on integrins which leads to increased bonding of bone like apatite layer is formed. But few studies have osteoblasts onto the implant surface. shown the bio activity obtained as a result of alkaline and heat treatment is limited and not satisfactory. Recombinant human Bone Morphogenic Protein (rhBMP- 2) when coated on the implant surface causes regeneration Amorphous surface is formed as a result of implantation of of the lost surface. ions, which is not advocated for apatite layer formation.

Keywords : Dental Implants, Surface treatment, 51 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Off late high energy sputter deposition, adhesive coatings, osseointegration. Modifying the surface topography is one bio pore structuring, titanium zirconium alloying and nano of the aspects in this regard. Surface of titanium has been pore structuring have been evolved by various subjected to various treatment procedures to improve its manufacturers. They are still in infancy and further long chemical composition and roughness which is favourable term clinical studies are required to validate their clinical for bone formation. Certain procedures are additive in application nature and certain procedures are subtractive in nature. This review article evaluated, critically, the different Conclusion : surface treatment procedures that are in vogue to modify From the earlier days when titanium was used for implants, the dental implants. The future of this concept has also it has undergone a sea of changes to improve been discussed.

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Keywords : Dental Implants, Surface treatment, 53 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

70. Jungner M, Lundqvist P, Lundgren S. Oxidized titanium implants (Nobel bone and influence of alendronate sodium on early bone Biocare TiUnite) compared with turned titanium implants (Nobel regeneration. J Periodontol. 1999;70:1228–1233 Biocare mark III) with respect to implant failure in a group of 77. Meraw SJ, Reeve CM, Wollan PC. Use of alendronate in peri-implant consecutive patients treated with early functional loading and two- defect regeneration. J Periodontol. 1999;70:151–158 stage protocol. Clin Oral Implants Res. 2005;16:308–312 78.Yoshinari M, Oda Y, Ueki H, Yokose S. Immobilization of 71. Krupa D, Baszkiewz j, Kozubowski JA, Mizera J, Barcz A, Sobczak JW, bisphosphonates on surface modified titanium. Biomaterials.2001; Bilinski A, Rajchel B. Corrosion resistance and bioactivity of titanium 22: 709–715 after surface treatment by three different methods: ion 79. Kajiwara H, Yamaza T, Yoshinari M, Goto T, Iyama S, Atsuta I. The implantation,alkaline treatment and anodic oxidation. Anal Bioanal bisphosphonate pamidronate on the surface of titanium stimulates Chem 2005;381:617-625. bone formation around tibial implants in rats. Biomaterials. 72. Krupa D, Baszkiewz j, Kozubowski JA, Mizera J, Barcz A, Sobczak JW, 2005;26:581–587 Bilinski A, Rajchel B.2001 Biomaterials 22:2139-2151. 80. Park CY, Kim Su Gwan, Kim MD, Eom TG, Yoon JH, Surface properties of 73. Kim H-M, Miyaji F, Kokubo T, Nakamura T(1996) J BiomedMatter Res endosseous dental implants after NDYag and CO2 laser treatment at 32:409-417. various energies. J Oral Maxillofac Surg 2005;63:1522-27. 74. Munisamy S, Vaidyathan TK, Vaidhyanathan TK. A bone like precoating 81. Lu X, Wang Y, Yang X, Zhang Q, Zhao Z, Weng LT, Leng Y. Spectroscopic strategy for implants: Collagen immobilization and its mineralization analysis of titanium surface functional groups under various surface on pure titanium implant surface. 2008. 34;2:67-75. modification and their behaviours in vivo and in vitro. J Biomed Matter 75. Josse S, Faucheux C, Soueidan A, Grimandi G, Massiot D, A1onso B. Res 84A:523-534,2008. Chemically modified calcium phosphates as novel materials for 82. Ban S. Effect of alkaline treatment of pure titanium and its alloys on the bisphosphonate delivery. Adv Mater. 2004;16:1423–1427 bonding strength of dental veneering resins. J Biomed Matter Res. 76. Meraw SJ, Reeve CM. Qualitative analysis of peripheral peri-implant 66A:138-145,2003.

Keywords : Dental Implants, Surface treatment, 54 topography, osseointegration. - Vinaya Bhat NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article COMPARATIVE EVALUATION OF ANTIMICROBIAL SUSCEPTIBILITY PATTERN AND VIRULENCE FACTORS AMONG ESBL AND NON- ESBL PRODUCING ESCHERICHIA COLI Shilpa Shenoy1 , Sumathi K.2 & A. Veena Shetty3 1Research Scholar, Nitte University Centre for Science Education & Research, 3 Associate Professor, Department of Microbiology, K. S. Hegde Medical Academy, Nitte University, Mangalore 575018, 2 Assistant Professor, Department of Mathematics, Manipal Institute of Technology Manipal University, Manipal – 576104, India. Correspondence : A. Veena Shetty Associate Professor, Department of Microbiology, K. S. Hegde Medical Academy, Nitte University, Mangalore 575018, India Mobile : +91 94485 45811 E-mail : [email protected] Abstract : Objectives: The present study was carried out to compare the antimicrobial susceptibility pattern and phenotypic characteristics in ESBL and non-ESBL producing clinically isolated E.coli. Material and Methods: A total of 100 non-duplicate consecutive isolates of E.coli were collected from various clinical specimens obtained from K.S. Hegde Charitable Hospital, Mangalore. All the isolates were studied for antimicrobial susceptibility pattern using modified Kirby-Bauer method. ESBL production was screened phenotypically by an initial screening test, which was followed by confirmatory Double disk synergy test. These isolates were screened for virulence factors such as Biofilm assay, hemolysin production and Congo red agar to detect the invasiveness of the isolates. Result : Out of the 100 E.coli isolates, 45(45%) isolates exhibited ESBL production. Among the ESBL producing isolates 62% were haemolytic, 77% exhibited Congo red uptake, and these two factors were statistically significant as compare non ESBL producing isolates, while 47%, 35% and 18% of the isolates exhibited high, moderate and low biofilm forming ability, respectively. The ESBL producing isolates were multi-drug resistant. There was statistical significance among the ESBL production and expression of virulence factors Conclusion : The present investigation revealed, a high prevalence of multiple virulence factors among the ESBL in addition to multi- drug resistance when compared with non - ESBL isolates. This indicates a dire need for effective ESBL surveillance and control in the hospitals and judicious use of antibiotics among the general public. Keywords : Extended Spectrum beta lactamases, E.coli, Biofilm, curli fimbriae, hemolysin

Introduction: to be poorly adapted to cause disease in healthy The advances in the field of antimicrobials have not been individuals, there exist a plethora of pathotypes that can sufficient to curb the persistently growing population of cause specific type of illness in normal hosts and those with multidrug resistant bacteria. These multidrug resistant compromised nonspecific defence mechanisms1 . Bacteria bacteria remain the major threat to public health are endowed with certain special characters which help worldwide. E.coli is one of the major forerunners in causing them in proliferation and to cause life threatening the nosocomial and infections in humans. Pathogenic strains differ from Access this article online community acquired commensal organisms in that they produce virulence Quick Response Code infections. It is a factors specific for each pathotype1 and the term virulence commensal in the human refers to a quantitative measure of the pathogenicity or the intestinal tract. While likelihood of a pathogen causing infection.2 However, most strains of E.coli virulence factors (VFs) apply to the elements (i.e. gene reside harmlessly in the products) that enable a microorganism to colonize a host human colon and appear niche where the organism proliferates and causes tissue

Keywords : Extended Spectrum beta lactamases, E.coli, 55 Biofilm, curli fimbriae, hemolysin - A. Veena Shetty

NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Rodriguez-Bano et al.7 among the ESBL and non ESBL producing isolates. Our study found a statistically significant increase of the Statistical analysis: The results of the study were analyzed hemolysin(62%), curli fimbriae(77%), presence of by Mann- Whitney U Test and the level of significance was multidrug resistance(80%) and multiple virulence set at P<0.05. factors(80%) among the ESBL producing isolates. Results: Whereas, there was no statistical significance on biofilm The 100 extraintestinal E.coli isolates were collected from forming ability of the isolates. various samples such as Urine(65%), Exudates(pus, pus Discussion : swab, wound aspirates)(26%), Body fluid(4%), and The ability of the organism to survive the hostile blood(5%). environments of the host, adhere colonise and cause Antimicrobial resistance was studied to the commonly disease is brought about by the hidden armamentarium of used antibiotics. The 100 E.coli isolates studied were found virulence factors endowed on the bacteria. Studies to be susceptible to the carbapenems tested. Among the conducted during the early 20th century found that the ESBL producing isolates high susceptibility rates were organisms required the presence of specific microbial found among the Nitrofurantoin, Piperacillin Tazobactum determinants which led to the view that there were and Co-trimaxazole. The commonly used antibiotics were intrinsic differences between pathogens and non- found to be resistant among both ESBL as well as non ESBL pathogens and the concept that disease associated groups. Among the 45 isolates in ESBL group 36 isolates microbes were endowed with certain characteristics that exhibited multidrug resistance. enabled them to cause disease. This enabled the investigators to differentiate between pathogenic and non The virulence factors such as hemolysins, curli fimbriae pathogenic bacteria3 . Our study was an approach to and biofilm formation ability were investigated. The understand the expression of virulence factors under the presence of the curl fimbriae(60%) was found to be the influence of antimicrobial resistance exhibited by the most common virulence factor among the isolates. The organism. virulence factors were studied comparing two groups

Table 1 : Antibiotic susceptibility pattern of ESBL Table 2: Comparison of virulence factors among ESBL and non ESBL producing producing and non ESBL producing E.coli isolates E.coli isolates Antibiotics Percentage of susceptibility Sl. Virulence Factors ESBL isolates Non ESBL isolates P value ESBL NON ESBL no 45(45%) 55(55%) Imipenem 100 100 1 Hemolysis 28(62%) 6(11%) .000 Piperacillin/ Highly significant tazobactam 65 74 2 Curli assay 35(77%) 25(46%) 0.001 Amikacin 56 64 Highly significant Chloramphenicol 36 70 3 Biofilm formation Co-trimoxazole 60 68 High 21(47%) 18(33%) Not Ciprofloxacin 45 69 Moderate 16(35%) 28(51%) significant Ertapenem 100 100 Low 8(18%) 9(16%) Nitrofurantoin 77 78 4 Multidrug resistance 36(80%) 18(32%) 0.000 Ceftazidime 0 84 Highly significant Ceftriaxone 32 85 5 Strains exhibiting 36(80%) 22(42%) 0.000 Cefotaxime 30 82 multiple virulence Highly Significant Gentamycin 52 74 factors

Keywords : Extended Spectrum beta lactamases, E.coli, 57 Biofilm, curli fimbriae, hemolysin - A. Veena Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Antibiotic susceptibility studies brought to light the higher on inert surfaces. 21,22 The curli-expressing cells form red, resistance among the commonly used antibiotics. Along while noncurli-expressing cells form colourless colonies on with third generation cephalosporins, amikacin and the indicator agar. Chloramphenicol exhibited higher resistance to the We found that expression of curli fimbriae was seen 77% in antibiotics tested. The greater prevalence of resistance to ESBL producing isolates as compared to 46% non - ESBL common antibiotics may be due to the excessive use and producing isolates. The difference was statistically misuse by the healthcare personnel. Similar trend has been significant in the ESBL group. The production of Curli reported by different group of investigators 5,8 . Our study fimbriae and the co existence of ESBL production has not indicated a high rate of ESBL production by E.coli which may been undertaken earlier to discuss in detail. Curli fimbriae be due to the selective pressure imposed by extensive use has been associated with virulence and pathogenicity of antimicrobials. The indiscriminate use and misuse of among several bacterial species including E.coli causing cephalosporins is responsible for the high rate of selection avian septicaemia 23 and UPEC strains 24 .But our study of ESBL producing microorganisms. These results are reveals the fact that the antimicrobial resistance confers consistent with previous studies from India.5,9,10 This trend additional resistance abilities to the organism. The biofilm can be only managed by constant and consistent screening production has been of major concern since its discovery and surveillance of the isolates. on medical catheters and implants. A structured Our study brought to light that the ESBL producing strains consortium consisting of bacterial DNA, polysaccharide expressed virulence factors significantly higher than the and protein is a biofilm. Bacterial biofilms have known to non ESBL isolates. We studied the adhesive property of the cause chronic illness in the medical setting resulting in organism by fimbrial adhesins such as curli fimbriae. These increased resistance to the antimicrobial agents and are one among the numerous adhesins possessed by the disinfectants used in the medical world 25 . We studied the organism. It is a known fact that the adhesins are the first biofilm formation of the isolates on microtitreplate line of virulence factors which help the organism to method as described by Rodrigez Bano et al. We also made colonise the host and establish itself.11 an effort to semiquantitate the biofilm formation by identifying the isolates forming High, moderate and low E. coli cells associated with a surface generally clump biofilm forming isolates. In our study we found that biofilm together to form microcolonies or biofilm in order to forming ability of ESBL and Non ESBL were not statistically maximize metabolic breakdown and stress management.12 significant but both were fairly positive to form biofilms. It The bacterial interaction with a surface is a two-stage is also noteworthy that Non ESBL forming organisms were process.13 Bacterial cells can easily be removed from the not far behind in forming biofilms. It has been noted that surface during the first phase. In the second phase catheters and other medical devices colonization and Bacterial association with the surface becomes biofilm formation occurs in many patients undergoing irreversible. The formation of biofilm is seen during this invasive treatment, from a very early stage.25 Hence the phase as the cells multiply and produce polysaccharide. detection of the biofilm on medical catheters and its proper E. coli produce a long, thin and wiry surface fibre known as treatment is necessary to minimize the colonization and curli and polysaccharide. 14,15,16 Curli plays an important role infection by the pathogens. in the adhesion of E. coli to its contact hosts.17 There is specific interaction with host matrix proteins such as Production of cytotoxic toxins is common phenomenon fibronectin, laminin and plasminogen to initiate adherence among the pathogenic bacteria.26 The more severe form of and colonization in the host.18,19.20 Prior research suggests E.coli infections are usually associated with hemolysin that curli may also play a role in the development of biofilm production by the organism. Hemolysins are known to have

Keywords : Extended Spectrum beta lactamases, E.coli, 58 Biofilm, curli fimbriae, hemolysin - A. Veena Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science numerous effects on host tissues including inflammation, pathogen in the host resulting in increased morbidity and tissue injury and impaired host defenses.27 Hemolysin mortality. Therefore appropriate empirical therapy and production among isolates during our investigation judicious use of the antibiotics is a necessary requisite to showed significantly higher presence among the ESBL prevent the resistance among the pathogens. In the isolates confirming that multi drug resistance contributes present study, ESBL producing E.coli isolates had strong to higher expression of virulence factors. A recent study positive correlation with multiple virulence factors. Hence, also found significant percentage of hemolysin production we feel that multidrug resistance will positively affect the among the multi drug resistant E.coli.8 expression of virulence factors. Therefore, the continuous screening of E.coli for the antimicrobial resistance is of The drug resistance is on an alarming rise. The resistance utmost importance. may provide a substantial advantage to the survival of the

References: 1. Donnenberg MS. Enterobacteriaceae. In: Mandell GL, Bennet JE, 15. Marshall KC, Stout, R, and Mitchell R, Mechanism of the initial events Dolin R. Principles and Practice of Infectious Diseases. 6th edition. in the sorption of marine bacteria to surfaces. J Gen Microbiol 1971 68, Churchill Livingstone. 2005: 2567-86. 337–348. 2. Raksha R, Srinivasa H, Mecaden RS. Occurrence and characterization 16. Olsen A, Jonsson A. and Normark S. Fibronectin binding mediated by a of uropathogenic E.coli in urinary tract infections. Indian J Med novel class of surface organelles on Escherichia coli. Nature 1989, 338, Microbiol 2003; 21: 102-7. 652–655. 3. Arturo Casadevall and Liise-anne Pirofski. Host-Pathogen Interactions: 17. Uhlich GA, Keen JE. and Elder R.O.Mutations in the csgD promoter The Attributes of Virulence. J. Infect. Dis 2001;184:337–44 associated with variations in curli expression in certain strains of 4. Clinical and Laboratory Standards Institute. Performance Standards Escherichia coli O157:H7. Appl Environ Microbio 2001, 67, for Antimicrobial Susceptibility Testing: Twenty Second Informational 2367–2370. Supplement M100-S22. Wayne, PA, USA: CLSI; 2012 18. Uhlich GA, Keen JE and Elder RO. Variations in the csgD promoter of 5. S.Sharma, G.K Bhat, S Shenoy .Virulence factors and Drug resistance in Escherichia coli O157:H7 associated with increased virulence in mice Escherischia coli isolate from Extra intestinal infections. Indian J Med and increased invasion of HEp-2 cells. Infection and Immunity 2002, Microbiol,2007,25(4):369-79. 70, 395–399. 6. Grozdanov L, Raasch C, Schulze J, Sonnenborn U, Gottschalk G,Hacker J 19. Gophna U, Oelschlaeger TA, Hacker J. and Ron EZ. Role of Fibronectin & Dobrindt U (2004) Analysis of the genome structure of the in curli-mediated internalization. FEMS Microbiology Letters 2002, nonpathogenic probiotic Escherichia coli strain Nissle 1917. J Bacteriol 212, 55–58. 186: 5432–5441. 20. Arnqvist, A, Olsen A, Pfeifer J, Russell DG and Normark S. The Crl 7. Rodriguez-Bano J, Marti S, Soto S, Fernandez-Cuenca F, Cisneros JM, protein activates cryptic genes for curli formation and fibronectin Pachon J, Pascual A., Martinez-Martinez L.,McQueary C., Actis L.A., binding in Escherichia coli HB101. Molecular Microbiology 1992, 6, Vila J. Biofilm formation in Acinetobacter baumannii: associated 2443–2452. features and clinical implications. Clin Microbiol Infect 2008 14: 276–8. 21. Olsen A, Arnqvist A, Hammar M. and Normark S. Environmental 8. Mittal S, Sharma M, Chaudhary U. Study of virulence factors of regulation of curli production in Escherichia coli. Infectious Agents uropathogenic Escherichia coli and its antibiotic susceptibility pattern. Diseases 1993, 2, 272–274. Indian J Pathol Microbiol 2014;57:61-4. 22. Sjobring U, Pohl G. and Olsen A. Plasminogen, absorbed by Escherichia 9. Bradford PA. Extended spectrum ß-lactamases in 21st century: coli expressing curli or by Salmonella enteritidis expressing thin Characterization, epidemiology and detection of this important aggregative fimbriae, can be activated by simultaneously captured resistance threat. Clin Microbiol Rev 2001;:933-51. tissue-type plasminogen activator (t-PA). Molecular Microbiology 10. Anathakrishan AN, Kanungo R, Kumar A, Badrinath S. Detection of 1994, 14, 443–452. extended spectrum ß-lactamase producers among surgical wound 23. Vidal O, Longin R, Prigent-Combaret C, Dorel C, Hooreman M. and infections and burn patients in JIPMER. Indian J Med Microbiol Lejeune P. Isolation of an Escherichia coli K-12 mutant strain able to 2000;18:160-5. form biofilms on inert surfaces: involvement of a new ompR allele that 11. Shetty AV, Kumar SH, Shekar M, Shetty AK, Karunasagar I, Karunasagar increases curli expression. J Bacteriol 1998, 180, 2442–2449. I. Prevalence of adhesive genes among uropathogenic Escherichia coli 24. Prigent-Combaret C, Prensier G, Le Thi T.T, Vidal O, LejeuneP. and Dorel strains isolated from patients with urinary tract infection in C. Developmental pathway for biofilm formation in curli-producing Mangalore. Indian J Med Microbiol 2014;32:175-8. Escherichia coli strains, role of flagella, curli and colanic acid. 12. Berkhoff HA, Vinal AC. Congo red medium to distinguish between Environmental Microbiology 2000, 2, 450–464. invasive and non-invasive Escherichia coli pathogenic for poultry. 25. Rodney M. Donlan Biofilms and Device-Associated Infections. Avian Dis 1985;30:117-21. Emerging Infectious Diseases 2001. 7, No. 2, March–April,277 13. Silveira WD, Benetti F, Lancellotti M, Ferreira A, Solferini VN, Brocchi 26. Hacker, J., and C. Hughes. Genetic analysis of bacterial hemolysin M. Biological and genetic characteristics of uropathogenic Escherichia production. Bull. Inst. 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Keywords : Extended Spectrum beta lactamases, E.coli, 59 Biofilm, curli fimbriae, hemolysin - A. Veena Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article A STUDY OF FOOTPRINTS OF TREE-CLIMBING COMMUNITIES OF SOUTH INDIA P. Shivarama Bhat1 & Arunachalam Kumar2 1Professor Department of Anatomy, Yenepoya Medical College, Yenepoya University, Mangalore - 575 018. 2Professor, Department of Anatomy, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Correspondence : Arunachalam Kumar Professor, Department of Anatomy K.S. Hegde Medical Academy, Nitte University Mangalore - 575 018, India. E-mail : [email protected] Abstract : The paper details the morphological adaptations of the foot shape and its arches to sustained professional tree climbing activity. Foot inversion, as required by climbers on a long term and regular basis reshapes the bony architecture of the foot and the medial longitudinal arch over a period of time. These changes can be observed and measured, noninvasively through study of footprints. This community study on the progressive adaptation of the arch to the rigors of climbing was recorded through footprints collected from the climbers with varied experience in the profession. The collation of observations show that the medial arch continues to shrink with sustained inversion, raising the dome of the instep. The progressive compensatory rise in arch height however, is arrested abruptly after a phase, with failure of the arch to accommodate further to more stress – leading to slipping and falls from heights. The article discusses the bio-mechanisms and kinetics of foot adaptation to the rigors of climbers and analysis the cause of accidental falls, even though most of the accidental fall victims have had a number of years of climbing experience. Keywords: medial longitudinal arch, foot, coconut palm, community, inversion

Introduction : units1 . The question raised here is, are these time honored The human foot, though designed to bear weight and evolutionary anatomical features of the foot absolute?2 facilitate bipedal locomotion also shows the combined Can prolonged and sustained strain induced by specific effects of heredity and acquired lifestyle. Adaptation in usages such as in tree climbing, influence the foot structure shape and modifications in soft tissue and osteological to revert to its simian prototype? Are these changes, if any, components of the foot to large extent are dictated by measurable ?3 kinetic stresses and strains it is subject to. Functional The footprint is a unique record of the weight bearing biomechanics play a visually verifiable and metrically status. The print impress itself is a metrically assessable quantifiable anatomical remodeling of foot structure. permanent database. Evaluation of the hemi-dome The role of foot arches in aiding the early of biped to adapt (hollowness) produced by the medial edge of the human to a terrestrial existenceis a landmark milestone in foot, essentially the measurements of the components of development of the hominid. The ligaments, joints, bones, the medial longitudinal arch4 should present us with data muscles and soft tissue which can be compared and analyzed. In this paper we Access this article online components of the foot, present our findings on the evaluation of both feet of a Quick Response Code contribute in their own hundred adult males from local communities that practice unique ways in making tree-climbing. The results are compared with those man, the only one among collated from measurements in lay population of males his mammalian cousins, to Material & Methods have mastered the art of Footprints of both feet were recorded on graph sheets, walking on hind limbs as

Keywords : medial longitudinal arch, foot, coconut palm, 60 community, inversion - Arunachalam Kumar NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science using ink pads as staining medium (Fig. 1 & 2) Adult males breadth and increase in arch height. from Thiyya, Idiga, Billava and Namdhari communities of Visual observations showed both feet in most climbers, three contiguous districts of the southwest coast of India especially those with a number of years of adherence to formed the nidus for this study. The horizontal length, profession, had 'in-situ' partial inversion of foot. The hallux breadth and surface area of the hollow semilunar space in itself was invariably separated wide from the fellow toes the prints were measured using Meyer's line as reference. (hallux valgus). Calcaneovarus and adduction deformation The height of the medial arch was measured as a of both feet were also seen. Callosities were found perpendicular drawn from the tuberosity of the navicular pressure spots on plantar surface and on the medial edge to the horizontal (Fig.3). The study was conducted across dermal changes could be not just due to the stresses communities spread across three contiguous south India transmitted by climbing, but also to the friction and states (Tamilnadu, Kerala and Karnataka) tribadic pressures brought about by rapid descent from the Tabulations and graphical records for visually identifiable tree tops. gross changes and adaptations were prepared. The control The results of statistical analysis of data using students group consisted of adult males drawn at random from unpaired 't' test reveals that the 'P' value is highly similar age range. Field observations of the plantation significant in the parameters of length, breadth and surface industry, of palmyrah (toddy), areca and coconut were area for both feet. The P value for arch height is significant made to note the techniques of tree climbing used by for left foot, and highly significant for the right (Table V & professionals. The results were subject to statistical VI). analysis and evaluation. None of the volunteers for this project was subject to any hospital-based investigation or Discussion invasive procedure. Visual observations on external The tree-climbing activity is traditionally carried out by features of feet in professionals were also made. isolated communities, the men-folk adept in the art of tree climbing. The communities engaged in this professional Results & Observations calling are the Idiga, Thiyya Namdhari and Billava. The trees The metrical values of both feet in tree climbers of varied ages and years of experience in occupation, along with the Table I: mean of age of normal and tree-climbers with mean of values of the control group are shown in Tables I to IV. The experience measurements show an average of 88.63 mms, 39.95 mms, Normal (age) Mean Std. Error of Mean 40.74 051 53.03 mms and 2538 sq mms for left side (length, breadth, Tree Climbers (age) 42.92 1.11 height and surface area). In controls the same parameters Experience(Tree climbers) 20.14 1.15 showed 70.14 mms, 27.34 mms, 49.7 mms and 1345 sq Table II : mean of age parameters of left & right foot in normal & mms for left and 72.2, 27.4, 49.81 and 1391.89 sq mms for tree-climbers (with Standard Error of Mean) right foot. Normal Left Right Mean Std. Error Mean Std. Error There is an obvious increase in all parameters, length, of Mean of Mean breadth, height and surface area in climbers compared to A. Length 70.14± 2.08 72.20 2.71 controls. It is also noted that the increase is directly B. Breadth 27.34 1.28 27.40 1.19 C. Height 49.70 1.19 49.81 1.26 proportional to the number of years of practice of the D. Surface Area 1345.06 98.26 1391.00 99.88 profession. However, oddly, the increase – trend gets Tree Climbers arrested with the climbers attaining about 3 decades A. Length 88.63 1.19 89.00 1.15 B. Breadth 39.95 1.00 39.02 0.74 experience in profession, in fact, there is an overall dip in all C. Height 53.03 0.69 53.29 0.64 dimensions thereafter. The decrease is seen in length, D. Surface Area 2538.82 84.28 2587.97 76.20

Keywords : medial longitudinal arch, foot, coconut palm, 61 community, inversion - Arunachalam Kumar NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table III : Mean of parameters according to duration of experience in tree climbing Experience (years) <10 years 10-20 years 20-30 years >30 years Side Parameters Mean Std.err Mean Std.err Mean Std.err Mean Std.err of Mean of Mean of Mean of Mean Left A. Length 85.11 2.49 87.18 1.90 92.96 2.20 91.36 2.95 side B. Breadth 35.07 1.67 39.76 1.36 44.28 2.37 42.43 2.63 C. Height 51.25 1.43 53.08 1.19 53.06 1.41 56.432 1.28 D. Surface Area 2232.11 162.85 2547.06 116.78 2802.6 189.79 2661.4 224.57

Right A. Length 87.14 2.28 88.74 1.68 93.63 2.35 92.50 3.56 side B. Breadth 35.82 1.28 38.85 1.20 42.21 1.33 4.036 2.36 C. Height 52.41 1.32 53.38 1.13 52.81 1.27 55.61 1.25 D. Surface Area 2304.11 140.12 2545.91 112.18 3016.42 158.97 2523.36 206.96

Table IV: percentage increase according to mean of experience in climbers compared with controls LEFT SIDE Experience <10 10-20 20-30 >30 Length (A) 21.34 24.29 32.53 30.25 Breadth (B) 28.27 45.43 61.96 55.19 Height (C) 3.12 6.8 6.7 13.54 Surf. area (D) 65.96 89.36 108.37 97.86 RIGHT SIDE Length (A) 20.69 22.91 29.68 28.12 Breadth (B) 30.73 41.79 54.05 47.29 Height (C) 5.22 7.19 6.04 11.66 Surf. area (D) 65.64 83.03 116.85 81.41

Table VI : comparison between normal to tree-climbers (Students unpaired 't' test) Side Parameters 'T' test for Equality of Means T P Inference Left A. Length -7.844 0.000 Very highly Significant B. Breadth -6.790 0.000 Very highly Significant Fig. 1: Footprints of normal adult male C. Height -2.434 0.016 Not significant D. Surface Area -7.750 0.000 Very highly Significant

Right A. Length -7.063 0.000 Very highly Significant B. Breadth -8.101 0.000 Very highly Significant C. Height -2.647 0.009 Highly Significant D. Surface Area -8.440 0.000 Very highly Significant are scaled through a series of upward hops along the vertical face of the trunk, the exercise calling for flexion, abduction extension and lateral rotation of hip, flexion extension at knee, plantar and dosiflexion at ankle, inversion at the subtalar articulations and flexion at metatarsophalangeal and interphalangeal joints of the foot. To assist leverage, a 'rattan' loop is worn around the waist, which in turn is wound around the tree trunk. A Fig.2: Footprints of tree-climber with 10-20 years experience similar loop worn across the ankles prevents the splaying of

Keywords : medial longitudinal arch, foot, coconut palm, 62 community, inversion - Arunachalam Kumar NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table V : Students unpaired 't' test for equality of means Normal 't' test for Equality of Inference Means t Sig.2 tailed Left A. Length -2.597 0.011 Significant B. Breadth -3.047 0.003 Significant C. Height -1.435 0.154 Not significant D. Surface Area -2.055 0.043 Significant

Right A. Length -2.234 0.028 Significant B. Breadth -2.740 0.007 Highly Significant C. Height -0.681 0.498 Not significant D. Surface Area -2.609 0.009 Highly Significant feet, keeping them approximated to the trunk surface at all times of ascent or descent5 . The climb induces tremendous gravitational strain on the tibiotalar and intertarsal joints. Each professional climber works around 4 hours a day and scales 25-30 trees. Fig: 3: Showing increase in length (A) and surface area (D) in The percentages of the people who had fallen from climbers compared to normals coconut trees and had faced injuries in the different augmentation in size and strength through intrinsic experience groups were with less than 10 year of physiological compensatory counteractions. The failure of experience 15%, in 11-20 years of experience, 26.6%, In 21- compensatory changes, with age and exposure (beyond 3 30 years of experience it was 44% and in those with 30 decades) leads to an arrest of these mechanisms, which years of experience the value was 41.3%. A total of 35.5 % now show a reduction in dimensions (and probably (78 cases out of 220 climbers) fell down from coconut trees strength too.) The continued increase in arch height is while doing their job8 . mainly due to permanency of osteological changes in the The results of this study show that with sustained and foot architecture. The probable development of pressure prolonged strain the foot undergoes permanent and induced epiphysis or bony spurs or buttresses in the tarsi quantifiable shape change The forced inversion, abuts on through usage make the morphological adaptations in 10, 11 the osteo-myo-fascial bow of the medial longitudinal arch these bones permanent . The medial arch in which over time, shows an increase in length, breadth, experienced tree climbers is raised, not so much through surface area and height.6 . These changes through quite fascial inputs, but remains so by the rigidity of the rapid in the first few years of climbing, level off in the deformed bony arch base. second decade of engagement, after which the dimensions It is also interesting to note that, accidental falls and once again show a spurt in all parameters. However, after fatalities that are recorded from time to time from groves, three decades of climbing, the percentage values of usually involve very experienced and old climbers. The increase drops for length, breadth and surface area, but percentages of the people who had fallen from coconut continues to rise for the height of arch.7 trees and had faced injuries in the different experience, in It is our inference that the foot dynamics and kinesiological those with 10 year of experience it was 15%, in those with exertions strain the factors maintaining the medial arch, 11-20 years of experience it was 26.6%, in those with 21-30 the stress being overcome through a generalized years of experience, it stood at 44% and in those with more

Keywords : medial longitudinal arch, foot, coconut palm, 63 community, inversion - Arunachalam Kumar NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science than group 30 years of experience it was 41.3%. A total of ligaments, is unable to sustain the stress and weight of the 35.5 % (78 cases out of 220 climbers) fell down from aged climbers 11 . coconut trees while doing their job. The mystery of why an It is hoped that anthropometric studies such as this one may experienced and highly skilled laborer should slip may now serve to build up retrievable records of the anatomical and be explained through our observations that, there is abrupt functional dynamics of the physical attributes of cessation in progressive arch adaptation and functional communities of 'dying' professions such as tree-climbing 12, 13 . efficiency after 30 years climbing. The bony arch alone, now divested of its resilience provided by arch-sustaining

References : 1. Cailliet R; Foot and ankle pain, 1992, Jaypee Brothers, Delhi, 2nd Ed 2. Devis TA; Attempt at mechanical climbing of palms with special reference to coconut palm Journal of Plantation Cops 1997; 5(1): 31- 35 3. Huang CK Kitaoka HB and Chao EY; Biomechanical evaluation of longitudinal arch stability, Foot Ankle 1993; 14(6): 353-357 4. Kaye RA Jahss MH; Tibialis posterior: a review of anatomy and biomechanics in relation to support of the medial longitudinal arch: Foot Ankle 1991;11(4):244-247 5. Nandakumar TB; Hard climb made easy, Indian Coconut Journal, 1985; 17-22 6. Saltzman CL, Nawoczenski DA Talbot KD; Measurement of medial longitudinal arch, Archives of Phy. Med. Rehab, 1995; 76(1):45-49 7. Takai S; Structured components of the arch of the foot analyzed by radiogramatic and multivariate statistical method. Acta anat. 1984; 119(3): 161-64 8. George BM, Muddanna SR, Arunachalam Kumar, 2013, Biomechanics of climbing coconut trees and its implications in ankle-foot morphology, Journal of Clinical & Diagnostic Research, Vol.7, No.5, 789-793 9. George BM, Arunachalam Kumar, Muddanna SR, 2013, Foot Deformations in Coconut Tree Climbers of South India; Nitte University Journal of Health Science, Vol.3 (1) 45 - 51 10. George BM, Muddanna SR, Arunachalam Kumar, Niveditha S, JS D'Souza , 2012, Health of coconut tree climbers of rural south India - Medical emergencies, body mass index and occupational marks- a quantitative and survey study; Journal of Diagnostic and Clinical Research Vol. 6 (1) pp 57- 60 11. Bhat PS & Arunachalam Kumar, The medial longitudinal arch in tree climbing communities, Scientific Medicine 1 (2) 2009 12. Bhat PS, The medial longitudinal arch in tree climbing communities, M.S.(Anatomy) Dissertation, Manipal University, 2001 George BM, Osteoarchitectural adaptations of foot in tree-climbing communities, Ph.D Thesis, Manipal University, 2009

Keywords : medial longitudinal arch, foot, coconut palm, 64 community, inversion - Arunachalam Kumar NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article SLEEP DURATION AND SLEEP HYGIENE PRACTICES IN ADOLESCENTS : AGE AND GENDER DIFFERENCES Bindu John Lecturer, Department of Nursing, College of Health Sciences, University of Bahrain, P.O. Box. 32038, Sakeer, Kingdom of Bahrain. Correspondence : Bindu John Lecturer, Department of Nursing, College of Health Sciences, University of Bahrain, P.O. Box. 32038, Sakeer, Kingdom of Bahrain. Mobile : 00973-39231037; 00973-17285224. Fax : 00973-17231876. E-mail: [email protected] Abstract : Aim: The study aims at assessing the sleep hygiene practices among Indian adolescents and to identify the age and gender influence on sleep duration and sleep hygiene practices. Methods: The data was drawn from a part of pilot study conducted among adolescents from sixth to 12th grade in India as a part of doctoral research. A stratified random sampling method was used. A total of 58 adolescents, 29 males and 29 females participated in the study. Data was collected using two questionnaires, one for the general demographic data with a part on sleep duration and the second for estimating the sleep hygiene practices. Results: The adolescents slept on an average of 7.68±.99 h during school days, and 8.70±1.63 h on weekends. Middle adolescents slept less than early adolescents. Gender showed no significance with sleep duration, since p-values were >.05 level of significance. The mean sleep hygiene index scores were 28.59 ±6.71. Even though the sleep hygiene scores of males were slightly better than females, it was not statistically significant. Conclusion: Adolescents in the study obtained less than recommended hours of sleep for their age on school days. Sleep hygiene practices were moderately poor among adolescents. Emphasizing good sleep hygiene practices, and integrating sleep promotion programs into daily routines should be considered to improve the sleep problems in adolescents. Keywords : Sleep, Gender, Sleep Hygiene, Adolescents, Sleep duration

Introduction : students report difficulty staying awake during school.5 In Adolescent period is a characteristic time with many another study in Japan, the high school students were changes in sleep-patterns, as shown in many studies. reported to be getting only 6.3 hours of nocturnal sleep as These alterations are attributed to puberty, biological and attributed to their life style.6 homeostatic changes in the circadian and sleep/wake Sleep is essential for optimizing physical, cognitive and systems, as well as environmental factors influencing life emotional functioning and for maintaining good quality of style of adolescents.1-3 Adolescents increasingly suffer from life. Sleep deprivation, or obtaining less than insufficient sleep and excessive daytime sleepiness. It is recommended hours of sleep is found to impair estimated that adolescents requires 9.2 hours of sleep adolescents' ability in learning and academic success as across all pubertal stages, and the sleep need is not well as it leads to problems in emotional regulation reduced during resulting in increased stress, changes in mood, decreased Access this article online adolescence.4 But studies motivation and behavioral and emotional problems.7,8 In a Quick Response Code show that approximately prospective study during 3 years done by Shochat,9 on 2000 45% and 85% of sixth to young adolescents in age group of 11-14 years, it was found 12th -grade students report that shorter sleep increase the risk of depressive symptoms sleeping less than the and low self-esteem both concurrently and over time. Poor recommended amount on perceived mental health and low life satisfaction with school nights, and 44% of insomnia is also reported due to lack of sleep.

Keywords : Sleep, Gender, Sleep Hygiene, Adolescents, Sleep 65 duration - Bindu John NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Studies on sleep patterns of adolescents based on gender Questionnaires were distributed to adolescents during and age shows inconsistent results. Many studies did not school hours and collected back on the same day. Two find gender differences. 10.11 Whereas in some studies, girls questionnaires were used: one consisted of questions reported to wake up early on weekdays but later on related to adolescents' basic information such as age, weekends. In another study, girls found to wake up earlier grade in school, gender, and a part related to sleep on weekdays, and with same sleep length as boys, found to duration, i.e., hours slept during a typical school day and accumulate higher sleep debt resulting in delayed wake up weekend and the second assessed the sleep hygiene times on weekends than boys.12 The variability in these behaviors using Sleep Hygiene Index developed by Mastin, results could be due to the differences in measurement of Bryson and Corwyn, 2006.16 This questionnaire consists of sleep time or in the age of participants in the study.13 13 items, on a five point Likert scale (Never =1, rarely = 2, sometimes= 3, frequently= 4, always= 5). Items scores Sleep hygiene is the practice of several behaviors that were summed providing a global assessment of sleep optimize and promote good sleep and daytime hygiene. The scores ranged from 13-65, higher scores functioning. Ensuring regular bedtimes and rise times, indicative of more maladaptive sleep status. The limiting napping during the day, having a relaxing sleep Cronbach's a of the scale is 0.66 with a good test- retest schedule, avoiding stimulants before bedtime and reliability (r=0.71). Permission was obtained for using the ensuring a favorable sleeping environment are parts of scale in the study. promoting good sleep hygiene behaviors.7 The quality of sleep in children is affected by the level of sleep hygiene Results : practices.14 Poor sleep quality along with insufficient sleep A total of 58 adolescents participated in the study. Equal is found to affect academic performance.15 The primary aim number of boys and girls, i.e., 29 each were included. of this study was to assess the sleep hygiene practices Adolescents were aged between 11-17 years (mean age among Indian adolescents and to identify the age and 14.02). When classified according to groups (adolescent gender influence on sleep duration and sleep hygiene classification by American Academy of Pediatrics) of early practices. and middle adolescents (Table 1), 31 of them were in early adolescent age group (11-14 years) and 27 of them were in Methods : middle adolescent age group (15-17 years). The present study data was drawn from a part of pilot study conducted among adolescents from sixth to 12th grade in Sleep Duration on weekdays and weekends among India as a part of doctoral research. Participants were adolescents studying in various schools in Mangalore, and were aged The adolescents slept on an average of 7.68±.99 h during between 11-17 years. Three schools which were randomly school days, and 8.70±1.63 h on weekends. This shows that selected participated in the study. A total of 58 students, 29 they are not obtaining the recommended hours of sleep for male adolescents and 29 female adolescents, selected their age group on week days, and was compensated by using a stratified random sampling method, were included sleeping extra hours on weekends (Table 2). Middle in the study. Gender was used as a criterion for adolescents were affected more than early adolescents. stratification. Institutional Ethical Committee approval was The sleep duration of early and middle adolescents during obtained to conduct the study. Once the schools' weekdays and weekends were compared using Mann- permission was received, parental consent for the Whitney test. A highly significant difference in the average adolescent's to take part in the study and child's assent to sleep of early adolescents and middle adolescents was voluntarily participate in the study was taken. The data was found, in favor of early adolescents since all the p-values collected during the months of July and August 2013. were less than .05 significance level.

Keywords : Sleep, Gender, Sleep Hygiene, Adolescents, Sleep 66 duration - Bindu John NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

A gender-wise comparison of sleep was carried out for (Table 3). school day and weekends for the hours of sleep. The results Sleep Hygiene Practices showed that there is no significant difference between males and females in average sleep on school days and The mean sleep hygiene index scores were 28.59 ±6.71 weekends, since the p-values are > .05 level of significance (28.71±6.44 in the experimental group and 28.42± 7.21 in the control group). A gender-wise distribution of sleep Table 1. Classification of adolescents hygiene scores showed that the mean sleep hygiene scores n % Age (in years) Early adolescents 31 53.4% for males were slightly better than females (26.93± 6.82 vs. Middle adolescents 27 46.6% 30.24± 6.28). However, it was not statistically significant, Total 58 100.0% since the p-value .079 was > .05 level of significance (Table4).

Table 2 : Average Sleep Duration and Age of Adolescents Age (in years) Mann Early adolescents Middle adolescents Total Whitney Mean SD Mean SD Mean SD P-value* How much sleep do you get on an average during a school day? (hours/day) 8.06 0.97 7.24 0.84 7.68 0.99 0.001 How much sleep do you get on an average during a week end? (hours/day) 9.35 1.65 7.94 1.25 8.70 1.63 0.001 Overall average sleep 8.71 1.07 7.59 0.87 8.19 1.12 < 0.001 *p<.05 level of significance

Table 3. : Average Sleep Duration & Gender Distribution of Adolescents Sex Mann Male Female Total Whitney Mean SD Mean SD Mean SD P-value* How much sleep do you get on an average during a school day? (hours/day) 7.48 1.01 7.88 0.95 7.68 0.99 0.177 How much sleep do you get on an average during a week end? (hours/day) 8.95 1.65 8.45 1.60 8.70 1.63 0.232 Average sleep 8.22 1.12 8.16 1.15 8.19 1.12 0.797 *p<.05 level of significance

Table 4. : Gender and Sleep Hygiene Scores of Adolescents Discussion : Sleep Hygiene Score Sleep loss in adolescents, either by societal changes due to Male Minimum 16 Maximum 39 lifestyle choice, or due to academic pressures are Mean 26.93 becoming increasingly common in our modern society. SD 6.82 Insufficient sleep can result in excessive daytime sleepiness Female Minimum 19 and therefore lead to problems which affects adolescent's Maximum 45 17 Mean 30.24 health and cognitive functioning. But in spite of SD 6.28 increasing prevalence and negative consequences, the Total Minimum 16 awareness and appreciation of sleep and health issues Maximum 45 Mean 28.59 among the general public and health professionals are SD 6.71 extremely limited.1 The present study investigated the Mann Whitney P-value* 0.079 sleep duration and sleep hygiene practices and assessed its *p<.05 level of significance gender-wise differences among Indian adolescents. Adolescents in this study obtained 48.6 min less than the

Keywords : Sleep, Gender, Sleep Hygiene, Adolescents, Sleep 67 duration - Bindu John NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science recommended 9 h of sleep, i.e., only 8.19 h of sleep. But The magnitude of the sleep problems among adolescents is during school days, they slept much less, i.e., 7.68 h. This an important concern in their development and emotional made them sleepy over the weekends, indicating a marked well-being. Delayed circadian timings occur with puberty,19 sleep debt. The results were similar to other studies,7 in and in combination with minimal parental influence and which adolescents slept for more hours to compensate for environmental factors results in development of improper their lost sleep. Girls slept slightly more than boys on sleep schedules and poor sleep habits. Emphasizing good school days (7.88 ± .95 vs.7.48± 1.01). It was similar to the sleep hygiene practices, and integrating sleep promotion study results obtained by Moore,13 were girls slept 22.14 programs into daily routines should be considered to min more than boys. However, gender was not statistically improve the sleep problems in adolescents. significant in the present study. Sleep duration and age Acknowledgements : showed similar results with the study by Mateo,12 where The author would like to thank Mr. Hassan Al Basri, Senior bedtimes were later with increasing age and sleep length Lecturer, Statistics department, College of Health Sciences, decreased with increasing age. The adolescents in the University of Bahrain for the statistical support given in this present study reported moderately poor sleep hygiene study. practices.

References : 1. Heikkila OS, Laippala P, Koivikko M. Subjective Daytime Sleepiness and 11. Randler C, Bilger S. Associations among Sleep, Chronotype, Parental its Predictors in Finnish Adolescents in an Interview Study. Acta Monitoring, and Pubertal Development among German Adolescents. J Paediat. 2001; 90: 552-557. Psychol. 2009; 143: 509-520. 2. Millman RP. Excessive Sleepiness in Adolescents and Young Adults: 12. Mateo MJC, Morales JFD, Barreno CE, Prieto PD and Randler C. Causes, Consequences, and Treatment Strategies. Pediatrics.2005; Morningness-Eveningness and Sleep Habits among Adolescents: Age 115:1174-1786. and Gender Differences. Psicothema. 2012; 24: 410-415. 3. Crowley SJ, Acebo C, Carskadon MA. Sleep, Circadian Rhythms, and 13. Moore Melisa, Kirchner HL, Drotar D, Johnson N, Rosen C, Redline S. Delayed Phase in Adolescence. Sleep Med. 2007; 8: 602-612. Correlates of Adolescent Sleep Time and Variability in Sleep Time: The 4. Wolfson AR, Carskadon MA. Sleep Schedules and Daytime Functioning Role of Individual and Health Related Characteristics. 2011; 12: 239- in Adolescents. Child Dev. 1998; 69: 875-887. 245. 5. Asarnow LD, McGlinchey E, Harvey AG. The Effects of Bedtime and 14. Ofovwe GE, Ofovwe CE. Sleep Hygiene in Nigerian Children. IFE Sleep Duration on Academic and Emotional Outcomes in a National PsychologIA. 2008; 16:113-119. Representative Sample of Adolescents. J Adolesc Health. 2013:1- 7. 15. Cain N, Gradisar M. Electronic Media Use and Sleep in School-aged 6. Honda M, Genba M, Kawakami J, Maher AN. A Sleep and Life-style Children and Adolescents: A Review. Sleep Med. 2010; 11:735-742. Survey of Japanese High School Boys: Factors Associated with 16. Mastin DF, Bryson J, Corwyn R. Assessment of Sleep Hygiene Using Frequent Exposure to Bright Nocturnal Light. Sleep Biol Rhythms. Sleep Hygiene Index. J Behav Med. 2006; 29: 223-227. 2008; 6: 110-119. 17. Li S, Arguelles L, Jiang F et al. Sleep, School Performance, and a School- 7. Noland H, Price JH, Dake J, Telljohann SK. Adolescents Sleep Behaviors Based Intervention among School-Aged Children: A Sleep Series Study and Perceptions of Sleep. J School Health. 2009; 79:224-230. in China. PLoS One. 2013; 8: e67928. 8. Gregory AM, Sadeh A. Sleep, Emotional and Behavioral Difficulties in 18. Calamaro CJ, Mason TBA, Ratcliffe SJ. Adolescents Living the 24/7 Children and Adolescents. Sleep Med Rev. 2012; 16:129-136. Lifestyle: Effects of Caffeine and Technology on Sleep Duration and 9. Shochat T, Zion MC, Tzischinsky O. Functional Consequences of Daytime Functioning, Pediatrics. 2009; 123:e1005. Inadequate Sleep in Adolescents; A Systematic Review. Sleep Med Rev. 19. Cassoff J, Knauper B, Michaelsen S, Gruber R. School-Based Sleep 2013; 1-13. Promotion Programs: Effectiveness, Feasibility and Insights for Future 10. Giannotti F, Cortesi F, Sebastiani T, Ottaviano S. Circadian Preference, Research. Sleep Med Rev. 2013; 17: 207-214 Sleep and Daytime Behavior in Adolescence. J Sleep Res. 2002; 11:191- 199.

Keywords : Sleep, Gender, Sleep Hygiene, Adolescents, Sleep 68 duration - Bindu John NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article PREVALENCE OF ORAL MUCOSAL LESIONS AND THEIR CO - RELATION TO HABITS IN PATIENTS VISITING A DENTAL SCHOOL OF SOUTH KARNATAKA : A CROSS SECTIONAL SURVEY- 2012 Mithra N. Hegde1 , Radhika Jain2 & Ashwitha Punja3 1Professor & HOD, 2 Post Graduate, 3 Professor, Department of Conservative Dentistry & Endodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018, India. Correspondence : Radhika Jain Post Graduate, Department of Conservative Dentistry & Endodontics, A.B. Shetty Memorial Institute of Dental Sciences Nitte University, Mangalore – 575 018, India Mobile : +91 88844 07451 E-mail : [email protected] Abstract : The aim of the present study was to determine the prevalence of oral mucosal lesions and their co-relation to deleterious habits of smoking, tobacco and alcohol consumption. 2000 patients visiting both rural and urban centres were screened for oral lesions and information regarding habits was obtained through a questionnaire. The results showed the prevalence of oral mucosal lesion to be 16.7% in the study population. The most frequent observation was the presence of Fordyce's spots(6.2%) followed by smoker's palate( 5.6%), leukoedema(3.15%) , leukoplakia(2.1%), oral sumucous fibrosis(2%), recurrent aphthous ulcers and lingual varices(1.6%), Lichen planus(1.2%) and oral candidiasis(1%). The habits were found to be associated with increased prevalence of oral mucosal lesions, especially in men. The study concluded the need for formulation of public health programmes discouraging these practises and public awareness of their ill-effects. Keywords : oral mucosal lesions, prevalence, habits

Introduction : become increasingly aware of the significance of oral Oral malignancies collectively form the sixth most common mucosal lesions and the documented inclination of type of cancer in the world.1 The Indian subcontinent has 'potentially malignant lesions' to lead to cancer. Tobacco long been regarded as the epicentre of oral cancer around and alcohol have long been recognised as risk factors in the the globe and is recognised as a major health problem. It development of oral malignancies.4,5,6 Thus this paper aims imposes a huge a burden in terms of diagnosis, survival and to evaluate the prevalence of oral mucosal lesions in South the use of already stretched out health care facilities in the Karnataka district and to correlate the findings with habits course of treatment.2,3 of consuming tobacco and alcohol in the population.

Epidemiological studies help in determining the incidence, Materials And Methods : prevalence and the severity of diseases. They also help in Two thousand patients were examined under the study. assessing the distribution, the risk factors and associated These patients included those who came seeking aetiology. This information is useful in the formulation of treatment for dental problems at the outpatient health care programmes department of A. B. Shetty Memorial Institute of Dental Access this article online at the primary level to Sciences and at the rural centres instituted by Nitte Quick Response Code spread awareness, help University at Bailoor, Mundkur and Nitte from 1st June to guide in early diagnosis 31st August 2012. These patients were divided into four and lead to prompt groups- less than 20 years of age, 20-40, 41-60 and more treatment. than 60 years. Clinical examination of the patients was done by two trained dental surgeons using artificial light, Dental professionals, in mouth mirror and gauze. Kappa test done to assess recent times, have

Keywords : oral mucosal lesions, prevalence, habits - Radhika Jain 69 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science interexaminer reliability was 80-85% resulting in high and found highest in the 20-40 age group (5.4%). agreement amongst the two examiners. Diagnosis was Males (16%) had a higher tendency to chew tobacco made on the basis of history, clinical examination and against women (3.15%) and this habit was observed most standard accepted guidelines.7 Information regarding in the older age group of 41-60 (18.6%). The study found habits of smoking, tobacco and alcohol consumption was that the participants were more likely to consume paan gathered through questionnaire based interviews. masala or gutkha than other forms such as betel nut betel Excluded from the study were those patients who had quid, etc. This habit of chewing tobacco was the most limited mouth opening, those patients who had recent prevalent one in females as compared to smoking and maxillofacial trauma, those who had intermaxillary fixation drinking alcohol. In males, the habit of smoking was the and unconscious patients. most prevalent than tobacco or alcohol consumption.

The data was analysed using Statistical Package for Social Prevalence of habits according to age and gender: Sciences (SPSS-16 version). Chi- square test was used to Age group smoking Chewing tobacco Alcohol drinking males females males females males Females determine the association between different variables. <20 26 0 11 0 0 0 20-40 205 7 37 0 18 0 Results : 41-60 32 0 71 22 63 5 Profile of the study population: >60 44 0 59 6 4 0 Out of the two thousand patients, 960 belonged to the rural strata while 1040 patients were from the urban Prevalence of lesions: population. Males formed 55.6% of the study population The oral soft tissue lesions were found to have a prevalence and 44.4% were females. 9.40% of the participants were of 16.7% in the study population. They formed 334 subjects of the study population. Normal mucosal variants were under 20 years of age group. Majority of the subjects seen in 256 people in the study. The most common mucosal belonged to the 20-40 age group, being 63%. The 41-60 age lesion observed was smoker's palate. It was diagnosed in group included 25% of the subjects and the least 112 cases, all of which were seen in men. percentage of study population was in the more than 60 years age group, which was 2.70%. Males outnumbered The prevalence of leukoplakia was 2.1% in our population. females in all the age groups under the study. It was found to be most commonly present in the 20-40 Age group (years) Males (n %) Females (n %) year age group. Males showed a higher prevalence (3.41%) <20 102 86 as compared to females (0.45%). Oral submucous fibrosis 20-40 712 546 was seen in 2% of the population with highest prevalence 41-60 248 252 >60 50 4 observed in 41-60 age group. It was more frequently found in men (2.96%) than women (0.78%). Prevalence of habits: The prevalence of habits such as smoking, tobacco chewing Lichen planus was found to be 1.2% in our study. Females and consumption of alcohol was 16%, 10% and 4.5% (2.25%) had a higher predilection for this disease than males (0.35%). This disease was mostly seen in the 20-40 respectively. The habit of smoking was most prevalent in age group. The prevalence of candidiasis was observed to the 20-40 age group (16.85%) with a higher prevalence in be 1% in our study population. It was seen more in men men (28.23%) than women (0.78%). Majority of the (1.3%) than women(0.56%) and most frequently in the 41- participants smoked cigarettes (77.57%) and 235 of the 60 age group. Recurrent aphthae were present in 1.6% of total 321 people who smoked belonged to the urban the population. Mostly seen in the 20-40 age group, it had a population (73.2%). The habit of alcohol consumption was higher preponderance in males (1.97%) than females seen more in men (7.64%) as compared to women (0.56%) (1.7%).

Keywords : oral mucosal lesions, prevalence, habits - Radhika Jain 70 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

A total of 256 normal mucosal variants were recorded in The prevalence of oral submucous fibrosis found to be 2% 2000 patients. Fordyce's spots in 71 males (6.38%) and 53 in our population was less as compared to that observed by females (5.96%). Lingual varices were seen in 26 (2.33%) Sharma et al (3.39%) in the rural areas of Jaipur.13 This could males with the highest incidence in the 60–69 years age be due to the high number of participants in that study group and in 6 females (0.67%) with highest incidence in consuming areca nut and gutkha. The relation of the group aged 60–64 years. Leukoedema was reported in consuming these substances with the increased 54 male (4.85%) patients with peak incidence in those aged prevalence of OSMF is reinforced by our study (odds ratio= 40–44 years, and 9 female (1.01%) patients with the most 93.66, ?2 = 277.84, p<0.001). The signs seen were in those who are 35–39 and 60–64 years. generalised blanching, presence of fibrotic bands in the oral mucosa and the patients' complained of burning Prevalence of lesions: sensation. Oral submucous fibrosis was mostly seen in the Mucosal findings Males (n %) Females (n %) Leukoplakia 38(3.41) 4(0.45) 41-60 age groups which could be attributed to the habit of Oral submucous fibrosis 33(2.96) 7(0.78) chewing paan and gutkha prevailing in this age group. Lichen planus 20(2.25) 4(0.35) Oral candidiasis 15(1.3) 5(0.56) Lichen planus has an overall prevalence of 1.5% amongst Recurrent aphthous ulcers 22(1.97) 10(1.1) Indians which was comparable to that found in our study. Fordyce's spots 71(6.38) 53(5.96) Lingual varices 26 (2.33) 6 (0.67) This was in accordance with the prevalence reported by Luekoedema 54(4.85) 9(1.01) Axell & Rundquist.14 This study found no significant Smoker's palate 112(5.6%) correlation between tobacco consumption and Lichen 2 Discussion: planus (odds ratio= 1.7, ? = 1.07) although the prevalence Cross sectional studies are the tools used to determine the was higher in subjects with habits. The consumption of prevalence of diseases in a population and to identify the tobacco has the potential to alter the course of disease and groups which are at high risk. should not be overlooked. The buccal mucosa was the most common site to be afflicted by Lichen planus in our study The prevalence of leukoplakia was 2.1% in our study which with reticular type being the most common variant 8 is more than that reported by Matthew et al in Manipal. present. These findings were also consistent with those of Bhatnagar et al(2.38) in Uttar Pradesh, India(2013)9 and The prevalence of oral Candidiasis in our population is 10 lower in our population as compared to that in South Brazil Espinoza in Chile(2003) . However, a very high prevalence 15 11 documented by Carrard V et al(14%). Also these lesions was reported by Oakley et al (13%) in the habitual areca were found to be significantly associated with female nut chewer high-school students of Micronesia and by 12 gender as opposed to that observed in the current study. Zhang et al(9.18%) in China . As with other studies, our study also shows an association between smoking habits The most common type recorded in our study was the 2 and leukoplakia. The results were statistically significant (χ psuedomembranous candidasis. The higher prevalence of = 42.02, p<0.001). Also, oral leukoplakia was found to be candidiasis in older age group in our study reaffirms more prevalent in men than women. This could be due to extremes of age as a risk factor for oral candidiasis due to the very high number of male smokers as compared to decreased immunity and the use of complete dentures. females. Leukoplakia was most commonly found on the The habit of smoking was more prevalent in young adults buccal mucosa followed by the labial mucosa and the and there was no significant association found between commissural area. It was also seen in the retromolar region smoking and candidiasis. and alveolar ridge. The presence of recurrent aphthae being 1.6% in our

Keywords : oral mucosal lesions, prevalence, habits - Radhika Jain 71 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science population is drastically less than found in a study in size of the study sample is another shortcoming along with Jordanian adults where it was concluded to be a common the fact that detailed data on the predictors of oral lesions problem.16 However, these results were comparable to such as nutritional status could not be assessed. those of Chattopadhyay found in the American population Conclusion : and García-Pola Vallejo MJ in the Spanish population. 17,18 The study observes the increased risk of oral submucous The most common site in our observations was the lip fibrosis with consumption of tobacco such as gutkha and followed by the buccal mucosa. The lesions were found paan masala. Also, the habit of smoking has been more in males who were non-smokers. reaffirmed as a risk factor for oral leukoplakia. The information was gathered from questionnaire surveys Interventional public health programmes discouraging the which could lead to bias on the subject's part. The limited use of tobacco should be formulated. References: 1. Parkin DM, Bray F, Ferlay J, Pisani P: Global cancer statistics, 2002. required for patients reporting to a dental school in North India: In CA:Cancer Journal for Clinicians 2005;55(2):74-108. accordance with WHO guidelines. J Family Community Med 2. Petersen PE. The World Oral Health Report 2003: continuous 2013;20(1):41-8. improvement of oral health in the 21st century – the approach of the 10. Espinoza I, Rojas R, Aranda W, Gamonal J. Prevalence of oral mucosal WHO Global Oral Health Programme. Community Dent Oral Epidemiol lesions in elderly people in Santiago, Chile. JOralPathol Med 2003;31:3–23. 2003;32(10):571-5. 3. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 11. Oakley. Areca nut chewing habit among high school children in the 2008 v2.0, Cancer incidence and mortality worldwide: IARC commonwealth nation of Micronesia. Bulletin of the world health CancerBase No. 10 [Internet]. Lyon, France: International Agency for organisation 2005,83(9). Research on Cancer; 2010. 12. Zhang L, Cheung Jr KJ, Lam WL.Increased genetic damage in oral 4. Jaber MA, Porter SR, Gilthorpe. Risk factors for oral epithelial dysplasia leukoplakia from high risk sites: potential impact on staging and the role of smoking and alcohol. Oral Oncology 1999;35:151-6. clinical management. Cancer 2001;91(11):2148-55. 5. Moreno-Lopez LA, Esparza-Gomez GC, Gonzalez-Navarro A. Risk of 13. Sharma. prevalence of oral submucous fibrosis in patients visiting oral cancer associated with tobacco smoking, alcohol consumption dental college in rural area of jaipur, Rajasthan. JIAOMR 2012;24(1):1- and oral hygiene: a case- control study in Madrid, Spain. Oral Oncol 14 2000;36:170-4. 14.Axéll T, Rundquist L. Orallichenplanus--ademographicstudy. 6. Yen AM, Chen SC, Chen TH. Dose-response relationships of oral habit Community Dent Oral Epidemiol 1987;15(1):52-6. associated with the risk of oral pre-malignant lesions among men who 15. Carrard V, Haas A, Rados P, Filho M, Oppermann R, Albandar J. chew betel quid. Oral Oncology 2007;43:634-8. Prevalence and risk indicators of oral mucosal lesions in an urban 7. Axell T, Pindborg JJ, Smith CJ, van der Waal I. Oral white lesions with population from South Brazil. Oral Dis 2011;17(2):171-9. special reference to precancerous and tobacco-related lesions: 16. Safadi RA. Prevalence of recurrent aphthous ulceration in Jordanian conclusions of an international symposium held in Uppsala, Sweden, dental patients. Community DentOralEpidemiol 2002;30(4):277-85. May 18-21 1994. J Oral Pathol Med 1996;25:49-54. 17. Chattopadhyay A, Chatterjee S. Risk indicators for recurrent aphthous 8. Mathew AL, Pai KM, Sholapurkar AA, Vengal M. Theprevalenceoforal ulcers among adults in the US. Community Dent Oral Epidemiol mucosallesionsinpatientsvisitingadentalschoolinSouthernIndia. 2007;35(2):152-9. Indian J Dent Res 2008;19(2):99-103. 18. García-Pola Vallejo MJ, Martínez Díaz-Canel AI, García Martín JM. Risk 9. Bhatnagar P, Rai S, Bhatnagar G, Kaur M, Goel S, Prabhat M. Prevalence factors for oral soft tissue lesions in an adult Spanish population. study of oral mucosal lesions, mucosal variants, and treatment Community DentOralEpidemiol 2007;35(2):152-9.

Keywords : oral mucosal lesions, prevalence, habits - Radhika Jain 72 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article THE AWARENESS IN BIOMEDICAL WASTE MANAGEMENT OF NURSING STAFF AT A TERTIARY CARE HOSPITAL OF MANGALORE, SOUTH INDIA Rashmi Kundapur1 , Tanmay Bhat2 , Sanjeev Badiger3 & Rajesh Ballal4 1Associate Professor, 3 Professor Department of Community Medicine 2Assistant Professor Department of Medicine, 4 Professor, Department of Surgery K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Correspondence : Rashmi Associate Professor, Department of Community Medicine, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Mobile : +91 98804 96567 E-mail : [email protected] Abstract : Introduction : In country like India, where there is big and complex health care system, mixed economy, private and Government hospitals working together; while providing services generate waste. It is estimated that the quantity of waste generated from hospitals in our country ranges between 0.5 and 2.0 kg/bed/day and annually about 0.33 million tons of waste are generated in India Aim and objectives : To study the awareness of nursing staff about the biomedical waste segregation in a tertiary care center Material and methods : A cross-sectional study was conducted among the nurses of Justice K.S.Hegde Hospital, Derlakatte. Total of 123 nurses who were present at the time were the study subjects. The pre-tested semi-structured questionnaire which was validated by face validation method was distributed. Results : The total of 96.66% of nurses knew the segregation of biomedical waste was the need of the hour. 90% of them felt they have adequate knowledge about segregation. 96% knew the color coding of sharps and human anatomical waste. But 99% knew the colour coding of blood, blood products and microbiological waste. 67% knew the colour coding of pharmacological waste and double glove disposal. Only 89.3% were confident that they followed the correct methods of segregation. Keywords : Biomedical waste, Hospital waste, nursing staff

Introduction : In country like India, where there is big and complex health The Bio-Medical Waste means any solid, fluid or liquid care system, mixed economy, private and Government waste including the containers and any intermediate hospitals working together; while providing services product, which is generated during the diagnosis generate waste. It is estimated that the quantity of waste treatment or immunization of human beings or animal. It generated from hospitals in our country ranges between includes human tissues, body fluids, excreta, unused 0.5 and 2.0 kg/bed/day and annually about 0.33 million drugs, swabs, disposable syringes and sticky bandages tons of waste are generated in India2 etc.1 The doctors, nurses, technicians, sweepers, hospital Segregation means “separation of different types of wastes visitors, patients, rag pickers and their relatives are by sorting or the systematic separation of Bio-Medical exposed routinely to Bio- Waste into designated categories.”2 Hospital waste is not Access this article online Medical Waste and are at Quick Response Code managed properly it proves to be harmful to the more risk from the many environment. It not only poses a threat to the employees fatal infections due to working in the hospital, but also to the people surrounding indiscriminate that area. Infectious waste can cause diseases like Hepatitis management.1 potential A &B, AIDS, Typhoid, Boils, etc. If a syringe, previously used generators of Bio-Medical by an AIDS patient, is reused, it can affect the person using Waste.2

Keywords : Biomedical waste, Hospital waste, nursing staff - Rashmi 73 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science it. So, the hospital staff should dispose of the syringes subjects. 3 of the questionnaires were not able to be properly, by cutting the needles of the syringes with the collected, so in the end we had 120 subjects as participants. help of a cutter, so that the needle cannot be reused. The pre-tested semi-structured questionnaire which was When waste containing plastics are burnt, Dioxin is validated by face validation method was distributed. The produced, which can cause Cancer, birth defects, anonymity of the participants was maintained and decreased psychomotor ability, hearing defects, cognitive informed verbal consent was taken from the subjects. Also defects and behavioural alternations in infants. the subjects are given choices of filling the form or leaving it blank. The data was entered n excel and analyzed. The Y. Saraf, M. Shinde, S.C. Tiwari Study showed that all questions contained respondents had good knowledge about segregation of waste material generated in hospital. Although level of Results : knowledge was more among doctors & nurses as The total of 96.66% of nurses knew the segregation of compared to the ward boys & Sweepers. 3 Akter N, Hussain biomedical waste was the need of the hour. 90% of them Z, Trankler J, Parkpian P. It was been quite evident that a felt they have adequate knowledge about segregation. satisfactory hospital waste management system in 18% felt that the knowledge imparted in their course was government hospitals and several private clinics was not adequate enough for their day to day segregation. 20% severely lacking. Many doctors and nurses were not fully of them felt that the ward boys are not competent enough aware about segregation of waste material generated in to segregate biomedical waste. When tested for their hospital.4 Rasheed S, Iqbal S, Baig LA, Mufti K. Segregation actual knowledge 96% knew the color coding of sharps and and use of colour codes revealed gaps, which needed human anatomical waste. But 99% knew the colour coding correction. About 70% of the healthcare facilities used a of blood, blood products and microbiological waste. But needle cutter/destroyer for sharps management.5 With only 67% knew the colour coding of pharmacological such mixed results we tried to see the awareness about waste. Similarly when segregation of double gloves which hospital waste segregation among nurses, in a tertiary care were used in the procedures was asked only 66.6% hospital . answered the correct way. But 80% had a correct knowledge of hazardous illness due to improper waste Material and methods : management.10% of them did not know how to manage A cross-sectional study was conducted among the nurses the infected Lenin in the hospital. Only 89.3% were of Justice K.S. Hegde Hospital, Derlakatte. Total of 123 confident that they followed the correct methods of nurses who were present at the time were the study segregation.

Table depicting the awareness of the nursing staff Factors Percentage positive Percentage negative Felt need of segregation among nursing staff 9.66% 3.33% Self reporting of adequacy in knowledge 90% 7% (no) and 3% (don't know) Self reporting of adequacy in training during their college 82% 18% Nurses perception about ward boys knowledge 80% felt they have 20% felt their knowledge adequate knowledge is not adequate Knowledge of segregation of sharps and needles 96% 4% Knowledge of human anatomical waste segregation 96% 4% Segregation of microbiological and blood products 99% 1% Knowledge in double glove procedure to segregate the waste 66% 33% Disinfection of infected lennin 90% 10% Observation of correct procedure followed by the nurses 89.3% 10.7%

Keywords : Biomedical waste, Hospital waste, nursing staff - Rashmi 74 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Discussion : on their knowledge of biomedical waste management It is very interesting to know that 90% of the nursing staff which is similar to earlier studies(5,6,7,8) . Also the commonest knew about colour coding in biomedical waste which is problem of infected lenin handling was not known by 10% much higher as compared to earlier studies in north that is 12 nurses, which is really big issue needs an Indiawhich the awareness was much less from 87%.(6) But immediate training. The biomedical waste is a hazardous 97% of them felt that the knowledge is felt need of the material to health which needs more emphasis. We need hour. We have seen in all earlier studies (6, 7, and 8) that the to follow the continued education for nursing and staff, by sharps color coding and right disposal was a problem in 15- addressing this issue repeatedly in their meetings and in 20%. But this problem is only 4% which is significantly their curicullum. It is also found 97% feel they need such higher knowledge. 99% knew about blood and blood education and 18% were not happy with the amount of products which is very good but it was similar in earlier knowledge imparted to them in their courses and feel they study that this segregation was priority and was higher need more focus on this matter while they work in than 90%. Pharmacological waste and its disposal was hospitals. always a problem and the knowledge remained poor as in Conclusion : earlier studies (6,7) and also in our study that right disposal is Though the knowledge of nursing staff is increased in unknown by 23% of the nurses in our study hospital too. recent years there is a large knowledge gap in certain issues The disposal of double gloves was unknown by 24% which which needs to be addressed. is a huge gap emphasizing on improvement of their knowledge in biomedical waste management. Though 99% Acknowledgements : were aware how the disposal of blood and blood products All nursing staff of Justice charitable hospital it is more interesting to know that only 89% were confident

References : 1. Mukesh Yadav, Hospital waste - a major problem; Indian journal of Community Medicine;Vol. 8 No. 4, October - December 2001,277 2. The Bio Medical Waste (Management and Handling) Rules,1998. 3. Y. Saraf, M. Shinde, S.C. Tiwari Study of Awareness Status about Hospital Waste management among Personnel and Quantification Indian Journal of Community Medicine Vol. 31, No. 2 (2006-04 - 2006- 06) 4. Akter N, Hussain Z, Trankler J, Parkpian P. Hospital waste management and it's probable health effect: a lesson learned from Bangladesh;Indian J Environ Health. 2002 Apr;44(2):124-37 5. Rasheed S, Iqbal S, Baig LA, Mufti K. Hospital waste management in the teaching hospitals of Karachi;J Pak Med Assoc. 2005 May;55(5):192-5. 6. Jugal Kishore, Ravindra Agarwal, Charu Kohli, Pramod Kumar Sharma, NVKamat, SC Tyagi. Status of Biomedical Waste Management in Nursing Homes of Delhi; India Journal of Clinical and Diagnostic Research. 2014 Mar, Vol-8(3): 56-58 7. N. B. Pandit, H. K. Mehta, G. P. Kartha, S. K. Choudhary. Management of Bio-medical Waste: Awareness and Practices in a District of Gujarat; Indian Journal of Public Health, Vol.XXXXIX No.4 October-December, 2005 8. Rajiv Kumar1, Anil Kumar Gupta1, Arun Kumar Aggarwal and Ashok Kumar. A descriptive study on evaluation of bio-medical waste management in a tertiary care public hospital of North India; Journal of Environmental Health Science & Engineering 2014, 12:69

Keywords : Biomedical waste, Hospital waste, nursing staff - Rashmi 75 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article EVALUATION OF ANTIMICROBIAL AND CYTOTOXIC ACTIVITY OF ELECTRON BEAM IRRADIATED ENDODONTIC SEALER

1 2 2 3 4 5 A Geethashri , KJ Palaksha , B Mohana Kumar , KR Sridhar ,Ganesh Sanjeev , A Veena Shetty 1Senior Research Fellow, Nitte University Centre for Science Education & Research, 2 Associate Professor, Nitte University Centre for Stem Cell Research & Regenerative Medicine, 5 Associate Professor, Department of Microbiology, K.S. Hegde Medical Academy, Nitte University, 3 Professor & HOD, Department of Biosciences, 4 Senior Physicist, Mangalore University, Mangalore, India. Correspondence : Veena A Shetty Associate Professor, Department of Microbiology, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Email: [email protected] Abstract : Background : The persistent pathogenic microorganisms in root canal system even after chemo-mechanical preparations cause endodontic infection and failure of the treatment. Thus the filling material, in addition to its good sealing ability, should offer long term antimicrobial effect and be non-toxic to cells and dentin. Zinc Oxide Eugenol (ZOE) is the most commonly used root canal sealer in endodontics. Electron beam (e-beam) is an ionizing radiation and known to cause physiochemical and biological changes. The aim of this study was to evaluate the effect of e-beam irradiation on bioactive properties of ZOE. Methodology : The homogenous mixture of ZOE was prepared as per manufacturer's instructions and discs of 6 mm were prepared by loading the paste into sterile moulds. After complete drying discs were aseptically removed and subjected to e-beam irradiation at doses of 250 Gy, 500 Gy, 750 Gy and 1000 Gy at Microtron Centre, Mangalore University. Antimicrobial and antibiofilm properties of both control(non-irradiated) and irradiated sealer against Enterococcus faecalis, Staphylococcus aureus, Streptococcus mutans and Candida albicans were determined by well diffusion method and antibiofilm by O'Toole method, respectively. The cytotoxicity was determined by using MTT assay on human gingival fibroblasts. Results : The antimicrobial effect of ZOE was observed only against S. aureus and C. albicans. The ZOE sealer irradiated at 1000 Gy showed a significantly (P< 0.001) increased antimicrobial effect against S. aureus and C. albicans compared to control ZOE. However, the substantially increased antibiofilm activity against C. albicans was noticed in the ZOE irradiated at 250 Gy. There was no significant (P>0.05) difference in cytotoxicity between control and irradiated ZOE. Conclusion : The e-beam irradiated endodontic sealer ZOE at 1000 Gy and 250 Gy significantly enhanced the antimicrobial and antibiofilm activity respectively without changing its biocompatibility. Keywords : Electron beam irradiation, Endodontic sealers, Zinc Oxide Eugenol, Oral pathogens, Antimicrobial activity, Cytotoxicity.

Introduction: Several materials have been recommended as root sealers The outcome of endodontic treatment depends on the however, none of them has so far been proved to be an complete elimination of microorganisms present in the ideal sealer 3 . Despite differences of opinions on the root canal by instrumentation, irrigation and the use of spectrum of antimicrobial activity, Zinc Oxide Eugenol effective sealant 1 . An ideal root canal sealer should prevent (ZOE) is one of the most commonly used endodontic bacterial recolonisation sealers in root canal treatment 4-6 . Access this article online and recontamination of E-beam radiation is a form of ionizing energy has been Quick Response Code the canal system introduced as a means of sterilizing single-use, disposable completely and be non health care products. Ionizing radiation induces structural antigenic, non- changes in the native pharmaceutical compound resulting tumerogenic and non- in altered physico-chemical, microbiological and toxic 2 . toxicological properties 7 . It has also been reported to be an

Keywords : Electron beam irradiation, Endodontic sealers, Zinc Oxide 76 Eugenol, Oral pathogens, Antimicrobial, Cytotoxicity. - Veena A Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science effective tool to decompose the organic substances and mm. reduce the toxicity 8 . The biofilm inhibition ability of sealer was determined on Enterococcus faecalis, Staphylococcus aureus, the endodontic pathogens grown in 96 well plates as Streptococcus mutans and Candida albicans are among the described by O'Toole 12 . The control and irradiated sealers few endodontic pathogens causing the failure of the root were immersed in 1 ml of Mueller Hinton Broth (MHB) and canal treatment and reinfections 9, 10 . In this study, Sabouraud Dextrose Broth (SDB) for 24 hrs at room antimicrobial and cytotoxic activity of the most commonly temperature. The 20 µl of the elute was inoculated into the used sealer ZOE was evaluated before and after exposing to each wells and incubated for 15 min at room temperature. e-beam irradiation against persistent microbes and human Then the contents were discarded, followed by gentle wash gingival fibroblasts, respectively. in phosphate buffered saline (PBS, pH 7), the biofilms were stained with 0.1% crystal violet stain for 15 min. Excess Materials and Methods: stain was removed by washing the biofilm in double The commercially available ZOE (Septodent, Mumbai) was distilled water for three times. Following the destaining purchased from the market. The emulsion of zinc oxide and with 30% acetic acid, the quantification of viable cells was eugenol prepared as per manufacturers' instructions. The performed by taking the optical density reading at 560nm discs of ZOE (6×4 mm) after complete drying, were using Lisa chem plate reader. aseptically removed from the mould and divided into control and experimental (irradiated) groups. The The cytotoxicity of sealers to human gingival fibroblasts experimental group discs were irradiated by e-beam at 250 was evaluated by MTT 3-(4,5-dimethythiazol-2-yl)-2,5- Gy, 500 Gy, 750 Gy and 1000 Gy at a dose rate of 500 Gy/min diphenyl tetrazolium bromide assay 13 . Briefly, 20 µl of using the Microtron facility available at Department of eluted fraction of sealers, which were pre-incubated in 1 ml Physics, Mangalore University. Dulbecco's Modified Eagle Medium (DMEM) for 24 hrs at room temperature was inoculated to well containing 1×104 The antimicrobial activity of control and irradiated sealers cells in 96-well microtiter plate and incubated for 15 min at was evaluated by well diffusion and biofilm inhibition 37° C in 5% CO . Then the wells were washed once with PBS. assays. The microorganisms E. faecalis (ATCC 29212), S. 2 The cytotoxicity of sealers was evaluated by incubating the aureus (ATCC 25923), S. mutans (MTCC 890) and C. albicans cells with 100 µl of MTT dye (0.05 mg/ml) in PBS for 4 hrs at (ATCC 90028) were obtained from the stock cultures of 37° C in 5% CO incubator. The intensity of the colour was Nitte University Centre for Science Education and 2 measured by adding dimethyl sulphoxide (DMSO) at 545 Research. The bacteria and fungus were subcultured in nm using Lisa chem plate reader. Mueller Hinton Agar (MHA) and Sabouraud Dextrose Agar (SDA), respectively. All the assays were performed in triplicates. The results obtained were analyzed by one way ANOVA. The level of The well diffusion assay was carried out according to the 11 significance was considered at 5%. slightly modified method of Filho MT et al . Briefly, the optical densities of seven hrs old bacterial and fungal Results and Discussion: cultures were adjusted to 0.5 McFarland standard and The antimicrobial activity of ZOE was observed only against swabbed uniformly on the 20 ml of solidified MHA and SDA S. aureus and C. albicans. However, the ZOE sealer medium. Then, control and irradiated sealers were placed irradiated at 1000 Gy showed a significantly (P< 0.001) aseptically to the wells of 6×4 mm prepared by using sterile increased antimicrobial activity against S. aureus (Figure 1 cork and borer. Followed by overnight incubation of culture and 7) and C. albicans (Figure 2 and 8) compared to control 0 plates at 37 C, the zones of inhibition were recorded in ZOE.

Keywords : Electron beam irradiation, Endodontic sealers, Zinc Oxide 77 Eugenol, Oral pathogens, Antimicrobial, Cytotoxicity. - Veena A Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Figure 1 : Zone of inhibition by control and irradiated ZOE against Figure 2 : Zone of inhibition by control and irradiated ZOE against S. aureus C. albicans

Figure 3 : E. faecalis biofilm suppression by ZOE and irradiated Figure 4: S. aureus biofilm suppression by ZOE and irradiated ZOE. ZOE.

Figure 5 : C. albicans biofilm suppression by ZOE and irradiated Figure 6: Cytotoxicity of ZOE and irradiated ZOE ZOE.

Figure 7: The antimicrobial activity of ZOE at 1000 Gy against S. Figure 8 : The antimicrobial activity of ZOE at 1000 Gy against C. aureus albicans

Keywords : Electron beam irradiation, Endodontic sealers, Zinc Oxide 78 Eugenol, Oral pathogens, Antimicrobial, Cytotoxicity. - Veena A Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

The antibiofilm activity of sealer was observed against E. dodecyl sulfate was seen after e-beam irradiation at 3 and 6 faecalis, S. aureus and C. albicans. In addition, the kGy 8 . So in this study, efforts have been made to evaluate irradiated sealers showed an increased inhibition of E. the effect of e-beam on antimicrobial and cytotoxic activity faecalis (Figure 3), S. aureus (Figure 4) and C. albicans on locally available ZOE-based sealer. (Figure 5) biofilm. The ZOE irradiated at 250 Gy showed the In this study the antimicrobial activity of ZOE-based sealant substantially increased (P<0.01) suppression effect on the was observed only against S. aureus and C. albicans. On formation of biofilm by C. albicans. In cytotoxicity assay, the both the microbes, a significantly increased antimicrobial percentage viability of cells was observed as 92.82%, activity of irradiated ZOE- based sealer was seen at 1000 Gy 83.52% and 87.12% when treated with control, 250 Gy and of e-beam irradiation. Biofilm of S. aureus, E. faecalis and C. 1000 Gy irradiated ZOEs, respectively, and demonstrated albicans was significantly suppressed by ZOE. There was no that the cytotoxic effect of irradiated ZOEs was insignificant significant difference in suppression of E. faecalis and S. (P>0.05) compared to control (Figure 6). aureus biofilm by irradiated ZOE, but C. albicans biofilm Zinc oxide eugenol based sealers are most commonly was significantly suppressed by ZOE irradiated at 250 Gy. employed sealants in endodontics14 . Eugenol is a potent The biocompatibility of ZOE was not altered as there was antimicrobial agent, therefore the antimicrobial activity of no significant (P>0.05) difference between ZOE and ZOE- based sealants attributed to the free eugenol irradiated ZOE at 250 Gy. released from set material15 . Supporting these Conclusions: observations, previous studies also reported that the Based on the present study e-beam irradiation might be a cytotoxic effect of ZOE-based sealants due to their free tool in enhancing the antibacterial and antifungal activity eugenol component 16 . of the sealers. It has been reported that the irradiation of pharmaceutical Acknowledgement: compounds did not affect the biological properties like Authors gratefully acknowledge the financial support given antimicrobial activity 7, 17 . In addition, it is used as a tool to by the Department of Atomic Energy, Board of Research in degrade the detergents and reduce the adverse effects. Nuclear Sciences (BRNS), Government of India. The significantly decreased acute toxicity of sodium

References: 1. Sandqvist G. Ecology of the root canal flora. J Endod 1992;18:427-430. beam irradiation. Radiation Phys. Chem. 2004:71;409-411. 2. D'Souza L Henston, Sharma N, Chander S, Singh S, D'Souza R. Root 9. Narayanan LL, Vaiahnavi C. Endodontic Microbiology. J Conserv Dent canal sealers and its role in successful endodontics- A review. Annals of 2010;13(2):233-239. Dental Research 2012;2(2):68-78. 10. Peciuliene V, Reynaud AH, Balciuniene I, Haapasalo M. Isolation of 3. Zarrabi MH, Javidi M, Naderinasab M, Gharechahi M. comparative yeasts and enteric bacteria in root-filled teeth with chronic and apical evaluation of antimicrobial activity of three cements: new endodontic periodontitis. Int Endod J 2001;34(6):429-34. cement (NEC), mineral trioxide aggregate (MTA) and portland. Journal 11. Filho MT, Tonomaru JMG, Barros DB, Watanabe E, Ito IY. In vitro of Oral Science 2009;51(3):437-442. antimicrobial activity of endodontic sealers, MTA-based cements and 4. Gomes BPFA, Pedroso JA, Jacinto RC, Visnns ME, Ferraz CCR, Zaia AA,. Portland cement. J Oral Sci. 2007;49:41-45. In vitro Evaluation of the Antimicrobial Activity of Five Root Canal 12. O'Toole G.A. Microtiter Dish Biofilm Formation Assay. J Vis Exp. 2011; Sealers. Braz Dent J 2004;15(1):30-35. 30(47):1-2. 5. Queiroz AM, Nelson-Filho P, Silva LAB, Assed S, Silva RAB, ITO IY. 13. Sergeant JM, Taylor CG. Appraisal of the MTT assay as a rapid test of Antimicrobial Activity of Root Canal Filling Materials for Primary Teeth: chemosensitivity in acute myeloid leukaemia. Br. J.Cancer 1989; Zinc oxide and eugenol Cement, Calen Paste Thickened with Zinc 60:206-210. Oxide, Sealapex and EndoREZ. Braz Dent J 2009;20(4):290-296. 14. Kaiwar A, Nadig G, Hegde J, Lekha S. Assessment of antimicroibial 6. Pizzo G, Giammanco GM, Cumbo E, Nicolosi G, Gallina G. In vitro sealers on Enterococcu faecalis: An in vitro study. World Journal of antimicrobial activity of endodontic sealers. Jornal of Dentistry Dentistry 2012;13(1):26-31. 2006;34:35-40. 15. Hume WR. The pharmacological and toxicological properties of zinc 7. Beteshobabrud R, Nabardi F. The stability studies of penicillin and oxide- eugenol. Journal of American Dental Association ampicillin following ?-irradiation in the solid state. Iranian Journal of 1986;113:789-91. Pharmaceutical Research 2009;8(3):153-157. 16. Lindqvist L, Otteskog O. Eugenol- liberation from the dental materials 8. Romanelli MF, Moraes MCF, Villavicencio ALCH, Borrely SI. Evaluation and effect on human diploid fibroblast cells. Scandinavian Journal of of toxicity reduction of sodium dodecyl sulfate submitted to electron Dental Research 1981;89:552-556.

Keywords : Electron beam irradiation, Endodontic sealers, Zinc Oxide 79 Eugenol, Oral pathogens, Antimicrobial, Cytotoxicity. - Veena A Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

17. Singh B, Parwate DV, Shukla SK. Radiosterelization of Fluroquinolones and Cephalosporines: Assessment of radiation Damage on Antibiotics by changes in optical property and colorimetric parameters AAPS PharmSciTech 2009;10(1):34-43.

Keywords : Electron beam irradiation, Endodontic sealers, Zinc Oxide 80 Eugenol, Oral pathogens, Antimicrobial, Cytotoxicity. - Veena A Shetty NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article KNOWLEDGE AND PREVALENCE OF DIABETES AND HYPERTENSION AMONG ADULTS IN SELECTED VILLAGES OF UDUPI DISTRICT - KARNATAKA Suja Karkada1 , Navaneetha2 & Ansuya3 1Assistant Professor, RAKCON, UAE, , 2 Associate Professor, 3 Assistant Professor, Department of community Health Nursing, Manipal College of Nursing, Manipal University, Manipal – 576 014, Karnataka, India Correspondence : Ansuya Assistant Professor, Department of Community Health Nursing, Manipal College of Nursing, Manipal University, Manipal - 576 014, Karnataka, India. E-mail : [email protected] Abstract : Objectives : to assess the prevalence and knowledge of diabetes and hypertension among adults and to find the association between knowledge level and variables. Methods : Descriptive survey was conducted among adults in the selected villages of Udupi district during July 2009- July 2010. The study subjects were interviewed to collect the details with a questionnaire. Total 385 adults were selected by non- probability convenient sampling technique. Data were entered in SPSS11.5 version and analysed using descriptive and inferential statistics. Results : Out of 385 adults, 27.8% of adults were females and 72.2% had their education up to primary level. Majority (82.2%) of the adults were having unskilled occupation and 96% of them had exposure to mass media. Majority (50.4%) of them had average knowledge on diabetes mellitus and prevalence was found to be only 5%. Majority (50.6%) of the sample had average level of knowledge about hypertension and the prevalence of hypertension was 19.5%. Result shows that there is no significant association between knowledge and selected variables. Key words: Hypertension, Diabetes, Prevalence, Knowledge

Introduction : global capital of diabetes and WHO has revised the Diabetes mellitus is the single most important metabolic predicted number of diabetics in India to be nearly 80 disease recognized worldwide as one of the leading cause million by 20301 . of death and disability. The problem has reached pandemic Hypertension poses a significant risk for the development proportions. Type 2 diabetes is the commonest form of of heart disease and chronic kidney disease. Worldwide, diabetes constituting almost 90% of diabetic population. the major causes for chronic kidney disease are diabetes Prevalence of diabetes in the adults worldwide was mellitus and hypertension. A recent estimate suggests that estimated to be 4.0% in 1995 and expected to be 5.4% by approximately one billion adults have hypertension (333 the year 2025. Its incidence is higher in developing million in economically developed and 639 million in countries than developed countries. It has been estimated economically developing countries); with the highest that presently 19.4 million individuals are affected by prevalence being noted in Eastern Europe and the Latin diabetes and these numbers Access this article online 2 American/Caribbean region. The global response to this Quick Response Code are expected to increase to challenge is prevention, early detection, and treatment. 57.2 million by the year Hypertension is a massive public health problem in India, 2025 (one-sixth of the world incurring tremendous physical, emotional and financial total). World Health loss. Due to limited resource allocation in the health sector, Organization (WHO) has the available facilities seem to be scarcely available. A already declared India as the previous study conducted among the middle aged

Keywords : Hypertension, Diabetes, Prevalence, Knowledge - Ansuya 81 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science population of Kerala in 2003 showed 54.5% prevalence of Fifteen Multiple Choice Questions (MCQ) were developed hypertension3 to assess the knowledge on diabetes mellitus and 15 MCQ for hypertension; each with maximum score of 15 and Methods & Materials : minimum score of zero. Knowledge scores were arbitrarily A community based cross sectional descriptive survey classified as low (0-5), average (6-10) and good (11-15) study was carried out during the year 2009-2010 in level. Each individual was screened for diabetes mellitus by Athrady, Marne & Hirebettu villages of Udupi District. A performing Benedict's test and for hypertension by non- probability convenient sampling was used to select monitoring the blood pressure using calibrated 385 samples and collect data from them by using sphygmomanometer. structured and validated knowledge questionnaire on diabetes mellitus & hypertension. The adults were The reliability of the tool was determined by test-retest between the age group of 40-60 years, residing in the method. The reliability co-efficient was r=0.70. villages, willing to participate and present at home during Administrative permission was obtained to collect the data the time data collection. An adult who could not read from the concerned authorities. A written consent was Kannada (local language) was excluded from the study. also obtained from the eligible participants for this study and data were collected between July 2009 and July 2010. Demographic Proforma consisted of age, education, Data were analyzed using descriptive and inferential occupation, food habits and exposure to mass media. statistics.

Tables 1: Frequency & Percentage of distribution of samples Prevalence of Diabetes characteristics. N= 385 5% Variables Frequency Percent Gender male 107 27.8 female 278 72.2 95% illiterate 74 19.2 primary 203 52.7 Education high school 75 19.5 Diabetes Non-diabetes PUC 16 4.2 graduation 15 3.9 Fig 2 : Prevalence of diabetes PG 2 .5 unskilled 318 82.6 Percentage of Knowledge Level Occupation skilled 53 13.8 12.5% profession 14 3.6 36.9% Exposure to not exposed 4 1.0 50.6% mass media exposed 381 98.7 vegetarian 82 21.3

Diet non-vegetarian 61 15.8 Poor Knowledge Average Knowledge good Knowledge mixed 242 62.9 Figure 3 : Knowledge level regarding Hypertension

Percentage Prevalence of Hypertension 7% 19.5% Poor 43% Average 80.5% 50% Good

hypertensive Non-hypetensive Fig 1: Knowledge score on Diabetes Mellitus Figure 4 - Prevalence of Hypertension

Keywords : Hypertension, Diabetes, Prevalence, Knowledge - Ansuya 82 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 2 : Chi-Square test computed between knowledge score of were statistically not significant. According to the age, the adults and selected variables prevalence of diabetes was more in the age groups 30-39 Variables PoorAverage Good Chi. Sq df P-value Gender male 50 50 7 2.25 2 0.31 (9.62%) and 40-49 years (18.24%). This shows that the female 111 144 23 changing trends in disease occurrence are affecting the Education illiterate 39 32 3 7.7 4 0.10 people of productive age group and making them primary 85 101 17 socioeconomically inefficient4 . high school &above 37 61 10 The overall prevalence of hypertension in the study subject Occupation unskilled 138 156 24 1.86 2 0.45 skilled 23 38 6 was 19.5% (75 of 385). A similar study was conducted in Trivandrum, Kerala and the result showed that the Results : prevalence of hypertension is high(47%) but the awareness Out of 385 samples 27.8% of adults were females and 4 among the people is low which is contrary to the present 72.2% had their education up to Primary school level. study findings where the prevalence is 19.5% only and Majority (82.2%) of the adults were having unskilled 5 awareness is average . occupation, 62% were consuming mixed diet and 96% of them had exposure to mass media (Table1). Majority Another study was conducted in Aurangabad, Maharashtra (50.4%) of them had average knowledge on diabetes from June 2005 to December 2006 among 1297 persons 6 mellitus and hypertension (50.6%) (Fig. 1&3). The and it showed that the prevalence was 7.24% . prevalence of hypertension was 19.5% and diabetes was Conclusion : 5% (fig 2&4). Result shows that there was no significant The worldwide prevalence of diabetes mellitus and association between knowledge on diabetes mellitus and hypertension has risen dramatically in the developing selected variables (Table 2). countries over the past two decades. Regular screening of Discussion : adults is essential for early detection and care. There are Diabetes mellitus and cardiovascular diseases lead the list limited studies on awareness of diabetes and hypertension of all non-communicable diseases. A study done by Jali MV in rural communities. India is going to face a big challenge found that prevalence of diabetes was more among males posed by these diseases and its complications. (10.38%) compared with females (7.90%) but the findings

References : 1. World Health Organization, Regional Office for South East Asia. Health Situation in South East Asia Region (1998-2000), Regional office for SEAR New Delhi, 2002. Available from: http://www.searo.who.int /LinkFiles/Health_Situation_book.pdf. [cited in 2002]. 2. Kearney PM1 , Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. In press 3. Zachariah MG, Thankappan KR, Alex SC, Sarma PS, Vasan RS. Prevalence, correlates, awareness, treatment, and control of hypertension in a middle aged urban population in Kerala. Indian Heart J 2003; 55:245-51. 4. Jali MV, Kambar S. Prevalence of diabetes amongst the family members of known diabetics. International journal of diabetes in developing countries:26(2) 81-85, 2006 5. Vimala A1 , Ranji SA, Jyosna MT, Chandran V, Mathews SR, Pappachan JM. - The prevalence, risk factors and awareness of hypertension in an urban population of Kerala (South India). 2009 ; 20(4): 685-89 6. Todkar SS, Gujarathi VV, Tapare VS. Period prevalence and socio- demographic factors of hypertension in rural Maharashtra: A cross- sectional study. 2009; 34(3):184-87

Keywords : Hypertension, Diabetes, Prevalence, Knowledge - Ansuya 83 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE ON BREAST CANCER AND UTILIZATION OF MAMMOGRAM AMONG WOMEN IN SELECTED VILLAGES OF UDUPI DISTRICT, KARNATAKA Arkierupaia Shadap1 , Maria Pais2 & Anusuya Prabhu3 1Lecturer, Sikkim Manipal College of Nursing, Sikkim Manipal University, Sikkim - 737 102, 2, 3 Assistant Professors, Manipal College of Nursing, Manipal University, Manipal, Karnataka - 576 104. Correspondence : Arkierupaia Shadap Lecturer, Sikkim Manipal College of Nursing, Sikkim Manipal University, Gangtok, Sikkim - 737 102. Mobile : +91 81162 13637 E-mail : [email protected] Abstract : Breast cancer was considered to be one amongst the most commonly cancer disease in the world. Now it is considered to be the second cancer disease among women in India, with most of the affected population is in the urban areas. Breast cancer is seen mostly after the age of 40 years. According to the Cancer fact 2012, breast cancer is now seen to be among women aged from 35 years above. Materials and methods : The study was a descriptive survey study to assess the knowledge on breast cancer, awareness and utilization of mammogram among 320 married and unmarried women who were willing to participate in the study. After the consent, a questionnaire prepared by the investigator was given to them. Results: Majority 46.6% had low knowledge for breast cancer. There was an association between knowledge and age, marital status, education and source of information about breast cancer and it was found to be significant (p<0.05). Mammogram is underutilized among participants, from the total number of population i.e; n = 320, only 19.1% (61) were aware of mammogram. Out of 19.1% (61) who were aware of mammogram, did not utilise it. Conclusion: The study concluded that women have low knowledge on breast cancer and very less population was aware of mammogram which is one of the screening tests for breast cancer. Their low knowledge on breast cancer and unaware of the screening test is the main reason for not utilising mammogram even those who are aware of it. So, nurses as health care members play an important role in providing information and educating the community people. Key words: Knowledge, breast cancer, utilization, mammogram.

Introduction : fluctuate, with levels of oestrogen dramatically decreasing Breast development occurs in distinct stages throughout a and this leads to many symptoms. The connective tissue of woman's life from birth to puberty, during menstruation the breast becomes dehydrated and inelastic, and the period, child bearing age and till woman reaches breast tissue shrinks, loses shape and leads to the menopause. Once ovulation and menstruation begin, the "sagging" of the breasts. As age advanced these are the maturing of the breasts begins and continues to grow. changes in woman's breast which are normal, but some Women may also experience changes in breast texture and woman may have changes like lump which are tender and feeling particularly lumpy. As age increases by 35 years, non-tender, abnormal discharge from the breast, there is a gradual shrinking ulceration, redness; these are all the early pathological Access this article online of the mammary glands. changes which may cause malignancy. Quick Response Code By the time a woman Globally more than one million women are estimated to be reaches her late 40s and diagnosed with breast cancer every year, and more than early 50s, menopause 410,000 will die from breast cancer. Cancer facts revealed begins and the levels of that the age-standardised incidence rate for breast cancer oestrogen and in India is 22.9 per 100,000, one-third that of Western progesterone begin to

Keywords : Knowledge, breast cancer, utilization, mammogram. 84 - Arkierupaia Shadap NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science countries and the mortality rates are disproportionately breast cancer, awareness and utilization of mammogram higher. Breast cancer accounts for 22.2% of all new cancer among women in the selected villages of Udupi” was diagnoses and 17.2% of all cancer deaths among women in undertaken. India. Breast cancer in urban areas of India is three times The purpose of undertaken the study was to provide higher than in rural parts of the country. information through health education and leaflet on breast According to India statistics, the number of new breast cancer based on their knowledge on breast cancer, cancer cases is about 115,000 per year and this is expected awareness and utilization of mammogram. This provides to rise to 250,000 new cases per year by 2015. If discovered the evidence base regarding the importance of health early breast cancer can usually be cured; however, early information for preventing morbidity and mortality among detection through screening is the only way to reduce the target populations. mortality. The most common screening for the early Materials and Methods: detection is breast self-examination and mammogram. It The research design selected for the study was a has been shown that it reduced the breast cancer mortality descriptive survey approach. A non-probability purposive by 30% in women aged 50 and older. A descriptive study sampling technique was used to select the sample for the done at Saudi, found that 56% women were unaware of study. The sample consists of three hundred and twenty these changes and some of them are reluctant to go for women residing at Arthrady and Hirrebettu villages, Udupi check-up due to many reasons such as; lack of knowledge, District, Karnataka. Three tools were developed and send shyness, fears and delay in the treatment leads to for pretesting after content validity and test-re-test complications and death. Breast cancer has overtaken reliability. After the ethical clearance, administrative cervical cancer to become the leading site of cancer in permission and consent from participants, data was Delhi, Bangalore, Mumbai, Chennai, Bhopal, Ahmedabad, collected using the following tools during 15th Jan. 2013 to Kolkota with the relative population ranging from 21.7% - 22th Feb.2013. 28.7%. Incidence of breast cancer in Bangalore increased from 14.5% in 1990 to 23.5% in 2005. Cases of breast 1. Tool 1: Demographic proforma cancer among younger age group have increased by 15 – 2. Tool 2: Knowledge questionnaire on breast cancer 20%. It indicates each year, 1,82000 women are diagnosed with breast cancer and 43,300 die. It has been observed 3. Tool 3: Utilization of mammogram that breast cancer has been increasing in its onset in the Karnataka with 25% of the cancer is breast cancer. Findings of the study: The study findings revealed that 42.1% of the women were Promotion of health and prevention of disease is a very within the age group of 35- 44 years. About 85.9% are important responsibility of nurses towards the community married women and 92.5% belonged to the Hindu religion. people. There is no doubt that nurses are effective health Majority 45.3% had primary education, occupation of care workers in disseminating the knowledge on breast these women 59.4% were housewife and 59.4% of their cancer, its screening tests and motivate the utilization of monthly family income falls within Rs.3001- 5000. Out of health care services. Also facts gathered from literatures 320 women, 87.5% have heard about breast cancer and revealed that there is less study related to breast cancer 42.8% obtained the source of information from the health and utilization of mammogram among the community personnel. (Table 1) people of Udupi. So, in an attempt to elicit the knowledge and utilization of mammogram as a screening tool for early detection, “a descriptive study to assess the knowledge on

Keywords : Knowledge, breast cancer, utilization, mammogram. 85 - Arkierupaia Shadap

NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science done, as none of the sample has undergone mammogram care services. As a nurse administrator we can organize utilization. awareness programme and proper education for the community women regarding breast cancer and how to Implications: The study revealed that women were having identify the risk factors for the early detection and low knowledge on breast cancer and very less population prevention of morbidity and mortality rate. Data will were aware of mammogram which is one of the screening provide the new concept to conduct further research in the test for breast cancer. Their low knowledge on breast field of nursing practice. This will further improve the cancer and unaware of the screening test is the reason for community women's health and motivate them to adopt not utilising mammogram even those who are aware of healthier lifestyle. mammogram. There was a significant association of knowledge on breast cancer to age, marital, education and Conclusion: source of information about breast cancer. These findings To conclude, we can make more recommendations. In- have the wider implications for nursing practice, depth health education messages through mass media, education, administrator and research. newspapers should be tailored to fulfill knowledge gap among all population. Intensive educational campaigns to A nurse educator may be oriented through the findings of tackle the observed educational deficits should be planned the present study and able to provide adequate education in order to raise awareness towards breast cancer its risk and assist the people in developing their self-care factors with emphasis on role of prevention and guidelines potential. Nurses are the important and responsible for screening through self -breast examination, clinical providers who play an important role in imparting breast examination and mammography. We as nurse must knowledge and help the community people in the early continue to remind and update the community women detection of the breast cancer. The present nursing about breast cancer disease and women's cancer screening curriculum is community oriented where emphasis is given practices must be reinforced. to preventive aspects rather than curative. The practice nurse can encourage and motivate the target population Acknowledgement : for health seeking behaviour. Innovative teaching can be We would like to thank all the participants and friends for used for imparting the knowledge to the public which in their contribution and support during the study. turn will improve their utilization of the available health

References: 1. Tarek Amin, Mulhim Al, Abdullah Meqihwi. Breast cancer knowledge, risk factors and screening among adult Saudi women in a primary health care setting. Asian Pacific Journal of Cancer Prevention.2009; 10 :133-138 2. Karayurt O, Ozmen D, Çetinkaya A. Awareness of breast cancer risk factors and practice of breast self-examination among high school students in Turkey. BMC Public Health 2008; 8: 359- 62. 3. TS. Tang, LJ. Solomon, McCracken. Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older. Preventive Medicine. 2000 Nov; 31(5): 575 - 83 4. American Cancer Society. Cancer Facts and Figures 2005. http://www.cancer.org 5. http:// www. The hindu.com/todays- paper/ tp-national/ tp- Karnataka/article 3701640.ece. 6. http://www.hopkinsmedicine.org/healthlibrary/conditions/adult/br east_health/normal_breast_development_and_changes_85,P0015/ 7. Ahuja. S, Chakrabarti. N. To Determine The Level Of Knowledge Regarding Breast Cancer And To Increase Awareness About Breast Cancer Screening Practices Among A Group Of Women In A Tertiary Care Hospital In Mumbai, India. The Internet Journal of Public Health. 2010. 1(1). DOI: 10.5580/1b7c

Keywords : Knowledge, breast cancer, utilization, mammogram. 87 - Arkierupaia Shadap NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article EVALUATION OF SALIVARY ENZYMES IN POST MENOPAUSAL WOMEN WITH AND WITHOUT PERIODONTITIS Santhosh Shenoy B.1 , Prajnya Shenoy2 , Avaneendra Talwar3 , Biju Thomas4 , Sharath K.S.5 & Shamila Shetty K.6 1,3Readers, 2 Student (BDS), 4 Professor & HOD, Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore – 575 018, 5 Professor & HOD, Department of Periodontics, Srinivas Institute of Dental Sciences, Mukka, 6 Reader, Department of Periodontics, A.J. Institute of Dental Sciences, Mangalore. Correspondence : Santhosh Shenoy B. Reader, Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018. Email: [email protected] Abstract: Aim : To compare the levels of Lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) in post-menopausal women with and without periodontitis Methodology : A cross-sectional pilot study was conducted. A total of 50 postmenopausal women were recruited and categorized into two groups based on their periodontal status. Their salivary samples were collected and subjected to Lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) estimation in the laboratory Results : The activity of LDH and ALP were significantly higher in the post-menopausal women with periodontitis than those without periodontitis. Conclusion : The present study demonstrated post-menopausal women may have exaggerated inflammatory response to dental plaque. Keywords : Lactate dehydrogenase (LDH), Alkaline phosphatase (ALP),post-menopause, periodontitis, saliva

Introduction: metalloproteinases, nitrous oxide, and several cytokines Periodontitis is an infectious disease of microbial origin, implicated in bone resorption, especially in response to the progression of which is, however, mediated through bacterial infection. Thus, it has been proposed that host related factors. These host factors, may be, further alteration in the levels of sex hormones may exacerbate modulated by various systemic factors, the female sex periodontal tissue breakdown by altering host response5,6 . hormones, being one of them1,2 . The effects of circulating Lactate dehydrogenase (LDH) and alkaline phosphatase estradiol (E2) on the periodontal tissues homeostasis have (ALP) are intracellular cytoplasmic enzymes that previously previously been well documented3 . been used as markers for early diagnosis of periodontal Menopause is permanent cessation of menstrual cycle disease. The extracellular presence of LDH is thought to be after 12 consecutive months of amenorrhea and is also related to cell necrosis and tissue breakdown while alkaline characterized with decreasing levels of estradiol (E2) as the phosphatase is indicative of bone turnover and an increase principal circulating in its levels indicates bone resorption7-9 . estrogen4 . Estrogen Access this article online In recent years, saliva has been recognised as a bio-fluid Quick Response Code deficiency enhances the that can be used to evaluate for markers of various disease rate of breakdown of the processes due its ease of availability and non-invasive connective tissue means of collection. The composition of this oral fluid is components of the gingiva influenced by constituents derived not only from the major by stimulating synthesis of and minor salivary glands, but also from gingival crevicular m a t r i x fluid (GCF), serum, bacteria, desquamated epithelial cells

Keywords : Lactate dehydrogenase (LDH), Alkaline phosphatase (ALP), 88 post-menopause, periodontitis, saliva - Santhosh Shenoy B. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science etc9 . stored at -200 C, later these samples were brought to room temperature and then subjected for estimation of LDH and The purpose of the present study was to investigate ALP levels. salivary levels of lactate dehydrogenase and alkaline phosphatase in postmenopausal women with and without Enzyme estimation: periodontitis. LDH and ALP activity were measured at 370 C in laboratory by using Aspen Laboratory kit and Star 21+ semi auto Methodology : analyzer. Pyruvate and 4-nitrophenylphosphate were used Ethical clearance was obtained from the institution Ethics as substrate to determine LDH and ALP levels. committee. This cross-sectional study was conducted in the department of Periodontics, A. B. Shetty Memorial Statistical analysis: Institute of Dental Sciences, Mangalore and Department of The obtained values were tabulated and analyzed by using Obstetrics and Gynecology, K. S. Hegde Hospital, Nitte Independent Student't' test. Correlation among groups University, Deralakatte, Mangalore. The total of 72 interpreted using Pearson correlation coefficient and the postmenopausal women were screened while 50 patients p<0.05 was considered to be significant. among them were selected for the study based on Results: following selection criteria. Table 1 Independent Student's 't' value obtained between Inclusion criteria: a) Individuals age between 45-55 years b) mean values of LDH and ALP levels between two groups Naturally attained menopause c) 20-28 natural teeth to was found to be very significant[p<0.01] .Table 2 present Correlation coefficient at 0.05 level [2 tailed test] between LDH and loss of attachment [LOA] was significant and also Exclusion criteria: a) Patient on any medications b) Patient there was significant differences found between gingival with any other systemic diseases. index and pocket depth. A detailed medical and dental history was recorded. An Discussion: informed written consent was obtained from selected Estrogen deficiency is reported to increase a woman's risk patients who were categorized into two groups, Group-A for developing various acute and chronic diseases. The postmenopausal women with healthy periodontium and possible association between menopause and periodontal Group-B postmenopausal women with periodontitis based disease progression has been discussed in many studies. on periodontal health status. However, the results have been inconclusive, with some Periodontal examination: studies suggesting that menopause related systemic The periodontal status was assessed by measuring conditions may induce increased alveolar bone resorption severity of gingival inflammation by using Löe and Silness and periodontal attachment loss, while others have Gingival index , and periodontal pocket was measured at suggested no such relationship. The present study sought mesio-facial, mid facial, disto-facial, disto-lingual,mid to evaluate the influence of the post-menopausal state on lingual and mesio-lingual areas in millimeters using the periodontal tissue by evaluated the salivary levels of Michigan 'O' probe with William's graduation. LDH and ALP in post-menopausal women with and without periodontal disease. The loss of attachment (LOA) was calculated based on the position of marginal gingiva to cement-enamel junction. Most of previous literature that focused on LDH as a diagnosis marker for periodontal disease has been carried Collection of saliva: out in samples of gingival crevicular fluid (GCF). Studies Unstimulated saliva was collected in a sterile container and that have evaluated periodontal disease activity and LDH

Keywords : Lactate dehydrogenase (LDH), Alkaline phosphatase (ALP), 89 post-menopause, periodontitis, saliva - Santhosh Shenoy B. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 1 : Mean and standard deviation of age, LDH and ALP for The existing literature about the levels of activity of LDH in both the study groups. saliva is scarce. These studies have demonstrated Group A N=25 Group B N=25 Remarks Mean Std Mean Std significantly higher levels of salivary LDH activity in Deviation Deviation individuals with periodontal disease than those obtained in Age 52.64 8.103 50.48 7.7 Not patients with a healthy periodontium. De La Pen˜ a et al10 . significant Previous evidence suggests that the main source of LDH in ALP level 32.04 5.35 46.79 7.93 Highly (IU/L) significant* whole saliva is the oral epithelium and not the salivary LDH level 229.24 81.21 278.34 89.5 Highly glands. (IU/L) significant* *p value <0.01 Alkaline Phosphatase (ALP) found in whole saliva originate

Table 2: Correlation of LDH and ALP levels in saliva with gingival from salivary secretions, the GCF and disposed bacterial index, loss of attachment and pocket depth for group B patients. cells from dental biofilms and mucosal surfaces. Earlier Gingival Loss of Pocket studies have demonstrated a significant positive index Attachment depth correlation between salivary ALP and periodontal disease LDH Level Pearson Correlation 0.457* 0.593* 0.348 severity and inflammation. ALP Level Pearson Correlation 0.105 0.277 0.228 In postmenopausal women , studies have shown that *P value<0.01 plasma ALP and LDH activities were significantly elevated Graph 1 : LDH levels in Group A and Group B when compared to that of the pre-menopausal women 300 and this was thought be due to hormonal influence11,12 . 250 In the present study, salivary levels of LDH and ALP showed 200 significant increase in postmenopausal women with 150 GROUP A periodontitis as compared with postmenopausal women 100 GROUP B without periodontitis. There was also a significant 50 correlation between LDH and ALP with clinical parameters. 0 LDH levels Though the levels of LDH and ALP showed a significant Graph 2 : ALP levels in Group A and Group B difference between the two groups it was within normal

50 values suggesting that the systemic status of the patient 45 may have a limited role in the etiopathogenensis of 40 periodontal disease. 35 30 As a predictive indicator for future periodontal breakdown, 25 GROUP A 20 GROUP B both LDH and ALP has not been supported by research 15 findings and therefore may best serve as a marker in 10 5 periodontal inflammatory state and thus, facilitate 0 treatment planning and monitoring. Kinney et al 20079 . ALP levels Within the limits of the present study, our present data, levels has shown a weak correlation between the two. It suggests that menopausal state may only have a limited has been proposed that LDH is only indicative of the influence on the severity of periodontal disease, but may inflammatory process occurring in the periodontal tissues have influenced an exaggerated inflammatory response to 9 Kinney et al . 13 plaque .

Keywords : Lactate dehydrogenase (LDH), Alkaline phosphatase (ALP), 90 post-menopause, periodontitis, saliva - Santhosh Shenoy B. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

References : 1. Van Dyke,T.A., Lester,M.A., Shapira,L. The role of the host response in 8. Kaufman E, Lamster IB. Analysis of saliva for periodontal diagnosis- A periodontal disease progression; Implications for future treatment review. J ClinPeriodontol 2000; 27: 453-465. strategies.Journal of Periodontology 1993; Aug Supp: 792-806. 9. Kinney JS, Ramseier CA, and Giannobile WV. Oral Fluid-Based 2. Yildirim TT, Kaya FA. The Effects of Menopause on Periodontal Biomarkers of Alveolar Bone Loss in Periodontitis. Ann N Y Acad Sci. Tissue.Int Dent Res 2011;3:81-86. 2007 March ; 1098: 230–251. 3. Zittermann,A., Schwarz,I., Scheld, K. et al. Physiologic fluctuations of 10. De La Peña VA, Diz Dios P, Tojo Sierra R. Relationship between lactate serum estradiol levels influence biochemical markers of bone dehydrogenase activity in saliva and oral health status.Arch Oral Biol. resorption in young women. The Journal of Clinical Endocrinology & 2007 ;52(10):911-5. Metabolism 2000; 85: 95- 101. protected? Hum Reprod 11.OzlemDaltaban, Sayagun, BelginBal, KokasalBalos, and 2004;19:2175-79. MuhittinSerdar. Gingival crevicular fluid, alkaline phosphatase levels 5. Mariotti, J.A. Estrogen and extra-cellular matrix influence human in postmenopausal women: Effect of phase I periodontal treatment. J gingival fibroblast proliferation and production. Journal of periodontal 2006; 77: 67-72. Periodontology 2005; 76:1391-1397. 12. Ramesh A, BhandaryR ,Thomas B, D' souza S & Kumari S. Alkaline 6. Johnson,R.B.,Gilbert,J.A.,Cooper,R.C., et al. Effect of estrogen phosphatase – a diagnostic marker of periodontitis in postmenopausal deficiency on skeletal and alveolar bone density in sheep. Journal of women – A biochemical study. NUJHS 2013; 3 (4): 3 71-7 Periodontology 2002; 73:383-391. 13. Reinhardt RA, Payne JB, Maze CA, Patil KD, GallagherSJ, Mattson 7. Kugahara T, Shosenji Y, Ohasik. Screening for periodontitis in pregnant JS.Influence of Estrogen and Osteopenia/Osteoporosis on Clinical women with salivary enzymes. J ObstetGynaecol Res 2008;34(1): 40- Periodontitis in Postmenopausal Women. J Periodontol 1999;70 (8): 46. 823-828.

Keywords : Lactate dehydrogenase (LDH), Alkaline phosphatase (ALP), 91 post-menopause, periodontitis, saliva - Santhosh Shenoy B. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Original Article BASIC LIFE SUPPORT- A STITCH IN TIME Muralee Mohan1, Rajendra Prasad2 , S.M. Sharma3 , Deepthi Shetty4 & Kalpa Pandya5 1Professor, 2 Dean, Principal, 3 HOD, 4 Assistant Professor, 5 Post Graduate, Department of Oral & Maxillofacial Surgery, A.B. Shetty Memorial Institute Dental Science, Nitte University, Mangalore - 575 018, India. Correspondence : Kalpa Pandya Post Graduate, Department of Oral & Maxillofacial Surgery, A.B. Shetty Memorial Institute Dental Science, Nitte University, Mangalore - 575 018, India. Mobile: +91 96321 65530 E-mail : [email protected] Abstract : Basic Life Support is the identification of emergency medical conditions such as stroke, cardiac arrest, foreign body obstruction; cardiopulmonary resuscitation (CPR) and defibrillation. The main aim of CPR is to increase the blood supply to the brain and the heart. Any delay in providing CPR reduces the chances of survival for the victim. Thus timely CPR is also mandatory. Training in Basic life Support skills is a must for medical and paramedical professionals and students. Moreover, it is essential to train even the layman in these skills as bystanders are the first and the best rescuers if trained adequately. American Heart Association (AHA) guidelines are one of the most widely accepted ones in terms of measures for basic life support. These guidelines are updated every five years. The last update was in 2010. Through, this article an attempt has been made to throw light on the 2005 protocol and 2010 updates as recommended by AHA. Keywords: cardiac arrest, cardiopulmonary resuscitation, rescue breaths, chest compressions

Introduction : The American Heart Association (AHA) recommends a four Basic Life Support is a sequence of medical care which is link Chain of Survival for resuscitation of a victim who has provided as a life saving measure in cases of medical collapsed. [2] emergencies such as sudden cardiac arrest, drowning, It includes (Figure 1): choking and trauma. Activating the emergency medical services Sudden cardiac death [SCD] is thought to be a cause of one Delivering Cardiopulmonary Resuscitation (CPR) fourth of the human deaths. Of the various causes of Shock delivery with a defibrillator sudden cardiac death, ventricular fibrillation is found to be Post resuscitation care by healthcare organisations the most common. [1] Check for response: The main aims of Basic Life Support include: The first step in the event of a collapse is to try to elicit a Dealing with the unconscious victim response from the adult. The rescuer may forcefully tap the Preventing further injury patient and ask him if he is alright. If the patient responds, the rescuer must immediately call the nearest emergency Improving the chances of survival till definitive medical medical help available. Ensuring this, he must return back help arrives to the victim and continue to monitor him. Considering the aims Call Emergency Medical Help: above, it becomes Access this article online If the patient does not respond, the rescuer should Quick Response Code essential for even a immediately leave to call for emergency medical help. Care layman to learn basic life should to be taken to avoid panic and inform the support skills as emergency medical service of the exact venue of the bystanders are the best occurrence. Following this the rescuer must return rescuers if trained immediately and start with CPR. efficiently.

Keywords : cardiac arrest, cardiopulmonary resuscitation, 92 rescue breaths, chest compressions - Kalpa Pandya NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

If two rescuers are available, one must start immediately tidal volume. The various modalities of delivering rescue with CPR while the other takes care of calling for breaths include, emergency help. At no rate, should it be assumed that 1. Mouth-to-Mouth Rescue Breathing patient recovery will not require emergency help and the 2. Mouth to barrier device manoeuvres by the rescuers will be enough. Emergency 3. Mouth to nose help has to be called for without giving it a second thought 4. Bag mask ventilation or discussion. In case if the lone rescuer can conclude that Check for pulse the collapse is due to asphyxia of any cause, he must It is often difficult to detect pulse in a collapsed victim even provide CPR (cycles) and then proceed onto contacting the if it is present. In such cases the rescuer must not spend emergency help. more than 10 seconds to detect pulse. After 10 seconds, Opening the Airway failure of detection of pulse warrants start of CPR without The manoeuvre indicated for this is a head tilt and a chin wasting further time [2]. Carotid pulse is to be palpated. It is lift. However if any spine injury is suspected, a jaw thrust located by placing the fingers just between the trachea and should be used instead of a head tilt. In the case, where jaw the muscles at the side of the neck. thrust is not possible, one must not hesitate to use a head Chest compressions tilt - chin lift procedure even in case of a suspected spine It is essential to deliver effective chest compressions. Chest injury. [2]. This is important to consider as 2% individuals compressions are delivered in the region of the middle of having blunt trauma have a chance of suffering an the sternum between the nipple line. Compressions are underlying spine injury. (3) delivered at the rate of 100 per minute with a compression Check for breathing depth of 1.5 to 2 inches. [2] Chest should be allowed to One must Look-Listen-Feel for breathing. On failure to completely recoil after each compression. Any determine if any breathing is present, the rescuer must give interruptions during the chest compressions should be 2 rescue breaths. [2]. We should not mistake occasional reduced. gasps as effective breaths. A few occasional gasps should As per the AHA guidelines, with the victim in supine be considered as no breathing and such a situation position, the rescuer kneels besides the victim's chest. The demands rescue breaths. heels of the two palms are placed one over another with Rescue Breaths palms overlapped and parallel. The heel of the palm placed As reported by Deakin et al only compressions have limited lower, is placed in the middle of the sternum on the nipple ability to maintain adequate gas exchange in cases of line. advanced stages of cardiac arrest. [1] A compression to ventilation ratio of 30:2 is recommended. As per the AHA guidelines, a rescue breath must extend In cases of cardiac arrest with an obstructed airway over a period of 1 second. The adequacy of the rescue pulmonary ventilation assumes a great importance. breath is gauged on the basis of its ability to produce a Ventilation improves arterial oxygenation whereas in case noticeable rise of the chest. Very forceful breaths should be of compressions only, a near desaturation of arterial avoided as they can cause gastric inflation. It can cause oxygen concentration is seen. [5] aspiration, regurgitation, and restriction of lung movement Defibrillator and reduced respiratory compliance. [4]. Hence the need As mentioned earlier ventricular fibrillation is most to extend one rescue breath, for a period of 1 second. The commonly found in the cases of sudden cardiac arrest. aim to notice a chest rise is to deliver air nearly equal to the Defibrillation thus highly improves the chances of survival.

Keywords : cardiac arrest, cardiopulmonary resuscitation, 93 rescue breaths, chest compressions - Kalpa Pandya NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

An Automated External Defibrillator (AED) is commonly required. used for this purpose. These are devices which can identify 6. Shock is delivered after every 5 cycles or two minutes if the victim requires shock. It can then deliver the required of CPR. shock. CPR should be performed consistently until the AED 2010 updates in Basic Life Support as recommended by arrives. Also if more than one rescuer is present, one AHA: should continue with CPR while the other attaches the AED 1. A-B-C to C-A-B pads. The 2010 Guidelines for Cardiopulmonary resuscitation The four universal steps for operating an AED as given by (CPR) and emergency cardiovascular care (ECC) [6] show AHA are: a change in the sequence from Airway-Breathing- 1. The AED is switched on. Circulation to Circulation-Airway-Breathing (Figure 3). It 2. AED pads attached to the bare chest of the victim. was often seen that the chest compressions were given 3. Analyse the rhythm after “clearing” the victim. To much later than actually recommended. This was due to “clear” the victim is to make sure that no one is the prolonged time sometimes required to open the touching the victim including the rescuer. airway or retrieve the ventilation device. When chest 4. If the shock is required, command to clear the victim compressions are delivered first, the breaths should be is given again by the AED. given with a minimal delay. 5. Resume CPR after shock delivery or if shock is not

Activating emergency Shock delivery with a Delivering CPR Post resuscitation care medical services defibrillator

Figure 1

Universal Algorithm Figure 2 demonstrates the algorithm for BLS as given in 2005 guidelines provided by AHA.

Unresponsive individual or showing no movement

Breathing Call Emergency helpline number or Send second rescuer to do this Airway Open the Airway Check if the individual is breathing Circulation If not breathing, give two rescue breaths Figure 3

Still no response, check pulse 2. CPR of High Quality To deliver CPR of high quality, 2010 AHA guidelines [6] If pulse not felt, give Chest compressions and breaths in the ratio of 30:2 recommend: • A change of compression rate from approximately is the ryhthm shockable? 100/min to at least 100/min. If yes, give 1 shock followed If No, resume CPR by 5 cycles of CPR • Compression depth recommended for adults is 5 cm or 2 inches. It is 4cm or 1.5 inches in infants and 5cm or 2 Figure 2 inches in children. This is approximately equal to one

Keywords : cardiac arrest, cardiopulmonary resuscitation, 94 rescue breaths, chest compressions - Kalpa Pandya NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

third the antero-posterior diameter in infants and Conclusion : children. The protocol for basic life support as given by AHA is being updated every five years on the basis of evidence based A very important recommendation includes a team studies. Training and updating the knowledge in basic life approach rather than a single rescuer. This will allow the support is mandatory for medical and paramedical group of rescuers to perform different actions professionals and students. Moreover, it is the duty of simultaneously making the process highly efficient. these personnel to enlighten the layman about the 2. Eliminating look-listen-feel importance of learning skills of basic life support. A prompt Rescuers often wasted time in checking if the victim is action can prevent the medical condition to progress breathing. This often delayed the delivery of CPR. Also further and thus save a life. Indeed, a stitch in time saves while looking for breathing, occasional gasps were often nine. mistaken as breathing causing a failure of delivering CPR when the patient actually requires it.

References : 1. Abhilash SP1 , Namboodiri N2 Sudden cardiac death - Historical perspectives.Indian Heart J. 2014 January - February;66S1:S4-S9. doi: 10.1016/j.ihj.2014.01.002. Epub 2014 Feb 11, 2. Part 4: Adult Basic Life Support Circulation. 2005;112:IV-19-IV-34; originally published online November 28, 2005 3. Hackl W, Hausberger K, Sailer R, Ulmer H, Gassner R. Prevalence of cervical spine injuries in patients with facial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:370 –376. 4. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 3: adult basic life support. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. HYPERLINK "http://www.ncbi. nlm.nih.gov/pubmed/10966662" \o "Circulation."Circulation. 2000 Aug 22;102(8 Suppl):122-59. 5. Dorph E1, Wik L, Strømme TA, Eriksen M, Steen PA Resuscitation. . Oxygen delivery and return of spontaneous circulation with ventilation:compression ratio 2:30 versus chest compressions only CPR in pigs 2004 Mar;60(3):309-18 6. TO - Field J M, Hazinski M F, Sayre M R, Chameides L,Schexnayder S M, Robin H Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation. 2010;122:S640-S656.

Keywords : cardiac arrest, cardiopulmonary resuscitation, 95 rescue breaths, chest compressions - Kalpa Pandya NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report UNILATERAL BICONDYLAR HOFFA FRACTURE WITH A FRACTURE SHAFT AND DISLOCATED KNEE AND HIP IN A MIDDLE AGED ADULT : A RARE CASE REPORT Ashwin Shetty1 , Sanath Kumar Shetty2 , Arjun Ballal3 , Nirmal Babu4 & Ravindranath Rai5 1Associate Professor, 2 Assistant Professor, 3 Postgraduate, 4 Senior Resident, 5 Professor & HOD Department Orthopaedic Surgery, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Correspondence : Arjun Ballal Postgraduate, Department Orthopaedic Surgery, K.S. Hegde Medical Academy, Nitte University Mangalore - 575 018, India. Mobile : +91 84316 44077 E-mail : [email protected] Abstract : Fracture at the distal end of the femur usually occurs in the sagittal plane. Hoffa fracture, i.e., coronal slice fracture of the condyles of the femur, is rare in adults and even rarer in children. In the case we wish to discuss here presented to our emergency room with an open knee injury due to a road traffic accident. Imaging of the right lower limb revealed an open Gustilo-Anderson type IIIB bicondylar Hoffa fracture with an anterior dislocation of knee with a comminuted patella and a shaft of femur fracture with a posteriorly dislocated hip. He underwent a successful stabilization and cannulated cancellous screw fixation of the Hoffa fracture and fixation of other injuries. Keywords : Hoffa fracture, posterior dislocation of hip, Bicondylar, cannulated cancellous screws, Supracondylar fracture of femur

Introduction: open wound over the right knee with the distal femur Fracture at the distal end of the femur usually occurs in the protruding from the wound site, with comminuted patella sagittal plane.1 Coronal shear fracture of the distal femoral fracture with complete rupture of the cruciate ligaments condyle is an unusual injury. Albert Hoffa first described and the patellar retinaculum of the knee was noted (Figure this fracture in 1904.2 1). Contamination was noted at the wound site. His affected hip was noted in flexion, adduction and internal To our best knowledge not many unilateral bicondylar rotation. The limb saturation was noted to be 100% with no Hoffa fractures have been reported till date. distal neurovascular deficits. As this kind of an injury with associated polytrauma to the He had no history of any medical complaints and had stable same limb is a very rare occurance, we would like to discuss vitals. it in our case report. Radiography revealed: Case Report: • An anterior dislocated right knee with medial and lateral A 45 year old gentleman condyle fracture of the right femur (Bicondylar Hoffa with an alleged history of Access this article online fracture), comminuted fracture right patella (Figure 2A) road traffic accident Quick Response Code • Fracture right femur at midshaft (Figure 2B) presented to us in the • Posteriorly dislocated right hip (Figure 2C) emergency room with injury to the right lower The limb was splinted and he was started on intravenous limb,12 hours after the fluids and antibiotics and was immediately rushed to the injury. On examination an operating room.

Keywords : Hoffa fracture, posterior dislocation of hip, Bicondylar, 96 cannulated cancellous screws, Supracondylar fracture of femur - Arjun Ballal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Figure 1: Open wound over the right knee exposing the bicondylar Hoffa fracture and the distal femur and comminuted fracture of patella. Figure 2A : An anterior dislocated right knee with medial and lateral condyle fracture of the right femur (Bicondylar Hoffa fracture), comminuted fracture right patella.

Figure 2B: Fracture right femur at midshaft

Figure 2C: Posteriorly dislocated right hip.

Figure 3: After external fixator application. Note the Steinmann pin Entering from the lateral tibial condyle and exiting through the medial femoral condyle holding the dislocated knee in place.

Figure 4 : Post operative x-ray of right femur showing A short femur nail insitu.

Figure 6: On post-operative day 21 the skin Figure 5: Post-operative x-ray right knee looks healthy with no signs of infection. showing reduced bicondylar Hoffa fracture with cannulated cancellous screws insitu.

Keywords : Hoffa fracture, posterior dislocation of hip, Bicondylar, 97 cannulated cancellous screws, Supracondylar fracture of femur - Arjun Ballal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

In view of the polytrauma and the contamination a staged Hoffa fracture can be associated with extensor mechanism protocol was planned. injuries3 . It usually occurs in adults and rarely affects children. The fracture results from a combination of Initially he underwent a thorough debridement of the forces: direct trauma, possibly with an element of wound site. The knee was reduced and stabilized using a abduction. Fall on a flexed knee concentrates the force in Steinmann pin from lateral tibial condyle to the medial the posterior half of the femoral condyles, which is why this femoral condyle. A knee spanning external fixator was injury is more common in two-wheeled vehicle accidents applied to stabilize the femur shaft fracture and the where the knee is in a flexed and abducted position1 . fracture of the condyles. Then a closed reduction of the hip and partial patellectomy was done (Figure 3). Letenneur et al.4 provided a classification for Hoffa fractures. Type I is a vertical fracture involving the entire Patient was maintained on epidural analgesics. Continuous condyle parallel to the posterior cortex of the femur. Type monitoring of vitals and limb saturation was done. II is a fracture of variable size, horizontal to the base of the Intravenous fluids and antibiotics were continued. condyle. They reported the best result with internal Three days later when the skin conditions improved and no fixation and the poorest results in type III. discharge was noted from the wound site, the patient was It is generally accepted that surgical stabilization is taken up for a definite fixation. necessary to achieve satisfactory function following Hoffa He underwent: femur nailing with a 11X36 short femoral fracture, the reason being that reduction of the nail (Figure 4). Open reduction and internal fixation of the fracture fragment is difficult to achieve and maintain by Hoffa fracture was done with 6.5 mm cannulated closed reduction and casting/traction techniques, due to cancellous screw fixation (Figure5). the absence of soft tissue attachment1 .

Wound inspection was done on a regular basis to look for Operative treatment provides early functional any signs of infection. He was continued on intravenous rehabilitation and also decreases the chances of antibiotics till post-operative day 10. Suture removal was osteoarthritis1 . delayed until post operative day 14. On 3 weeks after the In the literature, there are reports of arthroscopically surgery the patient was reviewed and examined, the assisted reduction and internal fixation of Hoffa fracture5 . operated site was noted to be clean with no evident signs of Arthroscopic management reduces soft tissue dissection, infection and skin looked healthy (Figure 6). blood loss, and operative time1 . Discussion : Rehan Ul Haq et al reported of a conjoint bicondylar Hoffa Hoffa fractures are rare injuries, and lateral condyle fracture in a 17 year old adult6 . fractures are more common than medial condyle fractures, probably because of physiological genu valgum; Hitesh Lal et al reported a case of unilateral bicondylar the lateral condyle is the most frequently injured Hoffa fracture in a 9 year old child1 . condyle1 .

References: 1. Hitesh Lal, Pankaj Bansal, Rahul Khare, and Deepak Mittal, 'Conjoint 4. Letenneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV (1978) Fractures de bicondylar Hoffa fracture in a child': a rare variant treated by minimally Hoffa: a propos de 20 observations. Ann Chir (Paris) 32(3–4): 213–219. invasive approach'. J Orthop Traumatol. Jun 2011; 12(2): 111–114. 5. Wallenbock E, Ledinski C (1993) Indications and limits of arthroscopic 2. Hoffa A. Lehrbuch der Frakturen und Luxationen. Stuttgart: Verlag von management of intraarticular fractures of the knee joint. Aktuelle Ferdinand Enke; 1904. p. 451. Traumatol 23(2):97–101. 3. Calmet J, Mellado JM, Garci´a Forcada IL, Gine´J (2004) Open 6. Rehan Ul Haq, Prashant Modi, IK Dhammi, Anil K Jain, Puneet Mishra. bicondylar Hoffa fracture associated with extensor mechanism 2013. Conjoint bicondylar Hoffa fracture in an adult. Indian journal of injury. J Orthop Trauma 18(5):323–325. Orthopaedics, 47(3): 302-306.

Keywords : Hoffa fracture, posterior dislocation of hip, Bicondylar, 98 cannulated cancellous screws, Supracondylar fracture of femur - Arjun Ballal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report MONOARTICULAR SYNOVITIS OF KNEE DUE TO UNRECOGNISED INTRA-ARTICULAR PLANT SPLINTER Siddharth M. Shetty1 , Vikram Shetty2 , Arjun Ballal3 & Jayaprakash Shetty4 1,2Associate Professors, 3 Post Graduate, 4 Professor, Department of Orthopaedic Surgery, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Correspondence : Arjun Ballal Post Graduate, Department of Orthopaedic Surgery, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Mobile : +91 84316 44077 E-mail : [email protected] Abstract: Synovitis of a knee secondary to penetrating splinter injuries of plant origin aren't frequently reported. Historically, it is considered aseptic and treated with removal of the intraarticular foreign body and affected synovial lining. We report a case of a 59-year-old healthy man whose left knee was injured while at work at a bamboo plantation site. He presented to us with pain and swelling of the knee for one month. He underwent diagnostic arthroscopy of the knee wherein a foreign body was identified, located and removed and near total synovectomy was done. We present this patient's case and its management with a review of the relevant literature. Keywords : Synovitis, plant splinter, knee swelling, arthroscopy, foreign body

Introduction: when accidentally his sickle cut a wound over the anterior Monoarticular synovitis of knee secondary to penetrating aspect of the knee one month ago. The wound had healed splinter injuries of plant origin are rare but a well described within two weeks without any complications but the knee entity which is usually under-recognised .1,2,3 This is pain and swelling which gradually progressed with apparently is due to the trivial nature of trauma and a very disturbing his daily activities and sleep. He complained of insidious onset of symptoms. The effusion may be sterile throbbing type of pain, which was not relieved with and is due to the irritation of the foreign body to the analgesics and rest. He had no history of fever or chills or synovial tissue3, 4 but occasionally organisms may be any other joint involvement. isolated.5 He was clinically assessed and effusion was noted at the Radiographs may be negative and MRI may show synovitis knee joint (Figure 1), with a fixed flexion deformity and without a specific pathology.6 terminally painful range of motion with local rise in temperature. The routine haematological evaluation was Arthroscopy is the most important diagnostic and normal (total count: 9200, CRP: Negative) and no infectious therapeutic procedure along with radiographic pathology could be recognised. examination in a case of suspicious history and clinical features.7 X-ray was within normal limits with early features of Access this article online osteoarthritis. MRI images showed significant effusion in Case Report: Quick Response Code the knee. Diagnostic arthroscopy of the left knee was A 59 year old gentleman performed under spinal anaesthesia. There was pale presented to us with yellow colour clear synovial fluid about 120ml which was alleged history of drained and sent for evaluation (Figure 2). Synovial tissue penetrating trauma at a was inflamed with features of unhealthy fimbriae. A brown bamboo plantation site coloured 3-4 mm long slender foreign body was identified

Keywords : Synovitis, plant splinter, knee swelling, arthroscopy, 99 foreign body - Arjun Ballal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science in the medial joint space overlying the meniscus (Figure 3) and was extracted (Figure 4). No other foreign bodies were recognised on probing the joint. Near total synovectomy of the knee was done.

Closure of the surgical site was done.

The synovial fluid analysis revealed, normal sugar and proteins. The culture reported no growth in the fluid sample. Intravenous antibiotics were stopped at five doses.

Figure 3: 3-4 mm long slender foreign body identified in the Knee exercises were started immediate post op and full medial joint space overlying the meniscus. range of motion was attained in two months and the operated knee appeared normal like the contralateral knee on review (Figure 5).

Figure 1: Left knee showing suprapatellar and parapatellar Figure 4 : 4 mm long slender foreign body after removal from the effusion. knee.

Figure 5 : At 6 weeks post-op the operated knee appears normal just like the contralateral knee

Figure 2 : Pale yellow synovial fluid drained from the knee.

Discussion and Review of Litrature: have been described in the hand, ankle, and wrist9,10,12,13 . Arthritis caused by plant thorn penetration is well known, Historically, failure to discover an organism in the joint fluid especially among children. Blackthorn or date palm thorns after a plant thorn injury led to the hypothesis, first caused synovitis is reported in most cases8 , but it can occur published in 1953, that the synovitis after these injuries from thorns of several kind of plants9,10,11 . The most was an aseptic inflammatory reaction provoked by alkaloid commonly affected joint is the knee, but similar processes compounds in the vegetable matter14 . This disease at that

Keywords : Synovitis, plant splinter, knee swelling, arthroscopy, 100 foreign body - Arjun Ballal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science time was known as “blackthorn inflammation” 15 . operating surgeon7 . This led to the recommendation to remove all the macroscopically abnormal synovial lining. In It was not until 1977 that the first positive culture specimen most instances, this will involve complete synovectomy or of synovial fluid after plant thorn injury was reported with recurrence of symptoms is possible1,7,10,16,19 .O'Connell RL, growth of Staphylococcus albus, Streptococcus Fageir MM, Addison A reported a case of synovitis of the hemolyticus, and Gram-negative rods16. Joint infection knee due to trauma by a splinter of wood and also removal caused by Pantoeaagglomerans was first reported in of the splinter by mini-arthrotomy20 .Díaz-Martín AA et al; 197817 . reported a case of arthroscopic removal of a projectile from In earlier reports, treatment consisted of arthrotomy and the knee after a gunshot wound to the knee.21 Joris F. H. removal of all thorn fragments14,15,16 . In 1980, the Duerinckx reported a case of subacute synovitis of knee advantages of arthroscopy became clear18 . Arthroscopy after a rose thorn injury22 .Muschol M, Drescher W, may allow complete observation of the joint and extraction Petersen W, Hassenpflug J published on 'Monarthritis of of the foreign body, but there still are several pitfalls. Plant the pediatric knee joint: differential diagnosis after a thorn fragments usually are too small to be seen and a reactive injury.' Wherein the misdiagnosis of a foreign body of knee hypertrophic plica can obscure the presence of an was made as monoarthritis and arthroscopic removal of intraarticular foreign body and may be missed by the the foreign body was done after confirming the diagnosis7 .

References: 1. Cahill N, King JD. Palm thorn synovitis. J Pediatr Orthop. 1991;21:40–46. 1984;4:175–179. 11. Zoltan JD. Cactus thorn synovitis.Arthroscopy. 1991;7:244–245. 2. Cracchiolo A, Goldberg L. Local and systemic reactions to puncture 12. Blake DR, Bacon PA, Scott CA, Potter AR. Monoarthritis from injuries by the sea urchin spine and the date palm thorn. Arthritis blackthorn injury: a novel means of diagnosis. Br Med J (Clin Res Ed). Rheum. 1977;20:1206–1212. 1981;282:361–362. 3. Karshner RG, Hanafee W. Palm thorns as a cause of joint effusion in 17 13. Freiberg AA, Herzenberg JE, Sangeorzan JA. Thorn synovitis of the knee children. Radiology. 1953;60:592–595. joint with Nocardiapyarthrosis.ClinOrthopRelat Res. 4. Kelly JJ. Blackthorn inflammation. J Bone Joint Surg Br. 1993;287:233–236. 1966;48:474–477. 14. Karshner RG, Hanafee W. Palm thorns as a cause of joint effusion in 17 5. Sugarman M, Stobie DG, Quismorio FP, Terry R, Hanson V. Plant thorn children. Radiology. 1953;60:592–595. synovitis. Arthritis Rheum. 1977;20:1125–1128. 15.Kelly JJ. Blackthorn inflammation. J Bone Joint Surg Br. 6. Said HG, Masoud MA, Yousef HA, Imam HM. Multidetector CT for 1966;48:474–477. thorn (wooden) foreign bodies of the knee. KneeSurg Sports 16. Sugarman M, Stobie DG, Quismorio FP, Terry R, Hanson V. Plant thorn Traumatol Arthrosc. 2011 May;19(5):823-5. synovitis. Arthritis Rheum. 1977;20:1125–1128. Muschol M 17.Flatauer FE, Khan MA. Septic arthritis caused by 7. , Drescher W, Petersen W, Hassenpflug J. Monarthritis of the pediatric Enterobacteragglomerans. Arch Intern Med. 1978;138:788. knee joint: differential diagnosis after a thorn injury. Arthroscopy. 18. Carandell M, Roig D, Benasco C. Plant thorn synovitis. J Rheumatol. 2004 Oct;20(8):865-8. 1980;7:567–569. 8. Kratz A, Greenberg D. Pantoeaagglomerans as a cause of septic 19. Doig SG, Cole WG. Plant thorn synovitis, resolution following total arthritis after palm tree thorn injury: case report and literature review. synovectomy. J Bone Joint Surg Br. 1990;72:514–515. Arch Dis Child. 2003;88:542–544. 20. O'Connell RL, Fageir MM, Addison A. Be aware of wood in the knee. 9. Miller EB, Gilad A, Schattner A. Cactus thorn arthritis: case report and BMJ Case Rep. 2011 Dec 13;2011. review of the literature. ClinRheumatol. 2000;19:490–491. 21. Díaz-Martín AA, Guerrero-Moyano N, Salinas-Sánchez P, Guerado- 10. Olenginski TP, Bush DC, Harrington TM. Plant thorn synovitis: an Parra E. [Arthroscopic removal of an intraarticular projectile from the uncommon cause on monoarthritis. Semin Arthritis Rheum. knee]. ActaOrtop Mex. 2011 Jul-Aug;25(4):223-6.

Keywords : Synovitis, plant splinter, knee swelling, arthroscopy, 101 foreign body - Arjun Ballal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report A CASE REPORT ON STEVENS-JOHNSON SYNDROME Babu Dharmarajan1 , Sanil Varghese2 & Sachina B.T.3 1Associate Professor & HOD, 2,3 Lecturers, Department of Medical Surgical Nursing, Yenepoya Nursing College, Yenepoya University, Mangalore - 575 018, India. Correspondence : Babu Dharmarajan Associate Professor, HOD, Department of Medical Surgical Nursing, Yenepoya Nursing College, Yenepoya University, University Road, Mangalore - 575 018, India. E-mail : [email protected] Abstract: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a rare disease which is considered to be more devastating and fatal in nature. Usually symptoms may start with the involvement of epidermis and progress to the various manifestations. Early findings, symptomatic and supportive treatment will have the more positive impact on the outcome of the client. Keywords: Toxic epidermal necrolysis, skin lesion, Erythematous macules

Introduction : reactions to medication. SJS and TEN are conditions 31 year old lady admitted to the hospital with the chief characterized by erythematous macules evolving to complaints of high fever, chills, fatigue, sore throat, and epidermal detachment and mucous membrane erosions. edema over the face, lesions over the body and resembled In SJS there is less than 10% body surface area involvement, to be affected with burns. On detailed history it was in TEN more than 30% and 10-30% overlap cases are evidenced that she was admitted to some local hospital for evident1 . the treatment of fever, during the treatment she started TEN and SJS affecting approximately 1or 2/1,000,000 developing edema, lesions over the entire body; On annually, and are considered medical emergencies as they physical examination the patient is semiconscious, poorly are potentially fatal. Drugs are assumed or identified as the built, skins are peeling out, (Fig 1) whitish patches in main cause of SJS/TEN in most cases, but Mycoplasma cornea, external ear skin peals out, rhinorrea, reddish lips pneumoniae and Herpes simplex virus infections are well and bleeding, rashes over the abdomen (Fig 2) and documented causes alongside rare cases in which the restricted movements were evident. Blood investigation aetiology remains unknown. Several drugs are at "high" evidenced the decreased level of hemoglobin and platelet risk of inducing TEN/SJS viz., Allopurinol, Trimethoprim- counts; culture and hypersensitivity to amikacin, penicllin, sulfamethoxazole and other sulfonamide-antibiotics, cifrofloxacin, ciftriaxone and found to be allergic to aminopenicillins, cephalosporins, quinolones, ciprofloxacin. The diagnosis was confirmed as Stevens carbamazepine, phenytoin, phenobarbital and NSAID's of Johnson Syndrome/Toxic epidermal necrolysis. The patient the oxicam-type2 . was treated with Metronidazole 1% gel, paracetamol, pantoprazole and candid. There was a significant Treatment is primarily supportive and symptomatic. improvement was seen in Patients should be treated with special attention to airway Access this article online the patient. and hemodynamic stability, fluid status, wound/burn care, Quick Response Code and pain control. Prime care must be directed to fluid Discussion : replacement and electrolyte correction. Few physicians Stevens-Johnson advocate corticosteroids, cyclophosphamide, syndrome (SJS) and toxic plasmapheresis, hemodialysis, and immunoglobulin and epidermal necrolysis (TEN) oral lesions can be well managed with mouthwashes are severe adverse whereas topical anesthetics are useful in reducing pain and

Keywords : Toxic epidermal necrolysis, skin lesion, 102 Erythematous macules - Babu Dharmarajan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science allowing the patient to take fluids. Skin lesions should be treated as burns and areas of denuded skin must be covered with compresses of saline3 . To conclude the treatment and management of SJS/TEN should be based multidisciplinary approach.

Fig 2 : Blisters and red splotches on the face, mouth and neck

Fig 1: Showing skin peeling over the face and hemorrhagic oral mucosa

References : 1. HHF Ho, Diagnosis and Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. The Hong Kong Medical Diary. VOL.13 NO.10 OCTOBER 2008, Pp:17 2. French E Lars, Harr Thomas. Toxic epidermal necrolysis and Stevens- Johnson syndrome. Orphanet J Rare Dis. 2010; 5: 39 3. Stephen Foster C, Rola Ba-Abbad. Stevens-Johnson Syndrome Treatment & Management. Medscape.

Keywords : Toxic epidermal necrolysis, skin lesion, 103 Erythematous macules - Babu Dharmarajan NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report OCULAR MANIFESTATIONS OF APLASTIC ANEMIA FOLLOWING PLATELET TRASFUSION : A CASE REPORT Divyalakshmi K.S.1 & Kalpana B.N.2 1Senior Resident, Department of Ophthalmology, K.S. Hegde Medical Academy, Deralakatte, Mangalore - 575 018. 2Chief, Vitreo-retinal Services, Minto Ophthalmic Hospital, Bangalore - 2, India. Correspondence : Divyalakshmi K.S. Senior Resident, Department of Ophthalmology, K.S. Hegde Medical Academy, Nitte University Mangalore - 575 018, India. E-mail : [email protected] Abstract: Aplastic anaemia is a rare haemopoietic stem-cell disorder that results in pancytopenia and hypocellular bone marrow. Ocular findings are manifestations of preexisting anemia. Here we are reporting a case of aplastic anemia which presented with the ocular findings following platelet transfusion which has not been reported in literature to the best of our knowledge. Keywords : Aplastic anemia, platelet transfusion, ocular manifestations

Introduction : of patients. Supportive care includes transfusion of RBCs Aplastic anaemia is a rare haemopoietic stem-cell disorder and platelets.3 that results in pancytopenia and hypocellular bone We are reporting a case of aplastic anemia which marrow. Although most cases are acquired, there are presented with the ocular findings following platelet unusual inherited forms. The pathophysiology of aplastic transfusion. anemia is believed to be immune-mediated, with active destruction of blood-forming cells by lymphocytes. Case report: Environmental exposures, such as to drugs, viruses, and A 60 yr old elderly male diagnosed with acquired aplastic toxins, are thought to trigger the aberrant immune anemia, presented with history of sudden diminution of response in some patients, but most cases are classified as vision in both eyes of 1 week duration, worse in left eye. He idiopathic.1 had a prior history of fatigability, breathlessness on exertion with fever 2 months back. There was no preceding Aplastic anaemia is a life threatening condition. It usually history of overt bleeding manifestations, trauma, or presents with anaemia, bleeding and infection. Ocular exposure to noxious chemicals or irradiation. He was a findings are manifestations of preexisting anemia. The diabetic on treatment. A relevant family history was ocular findings include cotton wool spots, nerve fibre layer absent. He had received platelet transfusion a week before or preretinal haemorrhages, vitreous haemorrhages and he noticed the drop in vision. optic disc oedema.2 On clinical examination, he was moderately built and Aplastic anemia can be appeared pale. His vital parameters were normal except Access this article online effectively treated by that peripheral pulses were weak. Visual acuity was 6/18 in Quick Response Code stem-cell transplantation right eye and 6/60 in left eye. Anterior segment findings or immunosuppressive were unremarkable and pupillary reflex was normal. therapy. Antithymocyte Intraocular pressure by applanation tonometry was globulin and cyclosporine normal. Both eyes fundoscopy showed blurred disc restore hematopoiesis in margins with slightly tortuous vessels, extensive approximately two thirds

Keywords : Aplastic anemia, platelet transfusion, ocular 104 manifestations - Divyalakshmi K.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science superficial, deep blotchy and preretinal hemorrhages in the posterior pole with cotton wool spots and macular edema worse in left eye. Optical coherence tomography showed an incomplete PVD in both eyes with subretinal fluid worse in left eye.

Blood investigations revealed low hemoglobin levels at 6.5g%, low white cell count of 2300cells/mm3 and platelets Fig 2(a): RE OCT showing incomplete PVD and retinal thickening 17000cells/mm3. Serum glucose, electrolytes and urea, folate and vitamin B12 were normal. Screening for blood borne viruses was negative. Trephine bone marrow biopsy had revealed an aplastic marrow. He was subsequently started on cyclosporine. He had received platelets and packed cell transfusion twice. Following the third platelet transfusion patient had noticed a sudden drop in vision. Fig 2(b): LE OCT showing incomplete PVD and subretinal fluid

Discussion : Aplastic anaemia is a life threatening condition. Ocular findings are a manifestation of anemic retinopathy. It is believed that anaemia causes diminished capillary oxygenation, which increases the vessel wall permeability resulting in extravasation of blood products4 . A direct correlation between the degree of anaemia and the severity of the retinopathy has been reported.

Mansour et al have shown that 78% of cases of aplastic Fig 1 (a): RE showing hemorrhages, cotton wool spots and anemia exhibit ophthalmic manifestations. Typical macular edema ophthalmic manifestations in aplastic anemia include eyelid hematoma, subconjunctival hemorrhage, cotton wool spots, retinal nerve fiber layer hemorrhage, Roth's spots, pre-retinal hemorrhage, vitreous hemorrhage, and disc edema5 .

A case of aplastic anemia simulating central retinal vein occlusion has also been reported. In our case disc edema and vessel tortousity was not much as in central vein occlusion. Some patients with aplastic anaemia have been reported to have pseudotumour cerebi. Papilloedema associated with aplastic anaemia has been proposed to be Fig 1 (b): LE showing hemorrhages, cotton wool spots, macular due to increased intracranial pressure from anaemia- edema with exudates 7 induced cerebral hypoxia . Our case did not have any signs of raised intracranial pressure6 .

Keywords : Aplastic anemia, platelet transfusion, ocular 105 manifestations - Divyalakshmi K.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Our patient developed the visual loss and findings of days after hypotensive and anticoagulant treatment and retinopathy following an episode of platelet transfusion. blood transfusion in a young female patient diagnosed as Visual loss in our case was due to macular edema. To the HELLP syndrome7 . Possibility of hemorrhagic retinopathy best of our knowledge, similar presentation following due to vascular hyperpermeability cannot be ruled out in platelet transfusion in a case of aplastic anemia has not our case. Thus the treating clinician should anticipate been reported. Similar ocular manifestations of blurred hemorrhagic retinopathy anytime during the course of vision, retinal edema and hemorrhages were reported 10 treatment of aplastic anemia.

References: 1. Brodsky RA, Jones RJ : Aplastic anaemia: Lancet. 2005 May 7-13; 365(9471):1647-56 2. Aditi Mohla, Olugbemisola Oworu, and Colin Hutchinson: Aplastic anaemia presenting with features of raised intracranial pressure J R Soc Med. 2006 June; 99(6): 315–316 3. Young NS : Acquired aplastic anemia: Ann Intern Med 2002 Apr 2; 136(7):534-46 4. Koh A: Anaemia—more than meets the eye: Singapore Med J 1998; 39: 222 5. Mansour AM, Salti HI, Han DP, Khoury A, Friedman SM, Salem Z, Ibrahim K, Bazerbachi A, Saghir N: Ocular findings in aplastic anemia: Ophthalmologica. 2000; 214(6):399-402 6. Lubeck MJ. Papilloedema caused by iron deficiency anaemia. Trans Am Acad Ophthalmol 1959; 63: 306 7. Sedrowicz E, Dróbecka-Brydak E, Teliga-Czajkowska J : Ocular manifestations of the HELLP syndrome: Klin Oczna. 1997; 99(5):335-7

Keywords : Aplastic anemia, platelet transfusion, ocular 106 manifestations - Divyalakshmi K.S. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report A RARE CASE OF SCRUB TYPHUS MASQUERADING AS BREAST ABSCESS Pothukuchi Venkata Krishna1 , Venkata Ravikumar Chepuri2 , Sudhakar Kanumuri3 Raghavareddy Yarram4 & Sailaja Yadalla5 1Professor, 2-5 Postgraduates, Department of Medicine, Guntur Medical College Government General Hospital, Guntur, Andhra Pradesh, India. Correspondence : Pothukuchi Venkata Krishna 57-9-15, New Postal Colony, Patamata, Vijayawada - 520 010, Andhra Pradesh, India. Mobile : +91 98481 34088 E-mail : [email protected] Abstract : We are presenting a case of scrub typhus masquerading as breast abscess in a pregnant woman who attended to hospital with history of fever and breast tenderness. A high index of suspicion is necessary as it is rarely seen but easily treatable and without proper and timely treatment, serious complications may arise which carries high mortality rate. Scrub typhus during pregnancy is quite rare. The line of treatment of scrub typhus in pregnancy is also analysed. Keywords : Scrub typhus, eshcar, breast abscess

Introduction: inoculating site of the mite is pathognomic of scrub typhus. Scrub typhus is an acute febrile illness caused by Orientia Complications of scrub typhus usually develop after the tsutsugamushi (Rickettsia tsutsugamushi) which is first week of illness. Jaundice, renal failure, pneumonitis, principally a parasite of rodents and is transmitted by larval ARDS, septic shock, myocarditis and meningoencephalitis trombiculid mites (chiggers). [1] are various complications known with this disease. [1]

In India, the presence of scrub typhus and other Rickettsial For scrub typhus patients, rickettsial pox patients and some diseases has been known for several decades. During other rickettsiosis patients, an eschar 5–20 mm in diameter World War II, scrub typhus produced considerable is formed at the area bitten by mites or ticks. The area morbidity and mortality among troops deployed In bitten by trombiculid mites initially forms a papule, which Southeast Asia. However, there has been a considerable becomes a vesicle and then an ulcer, and which is finally decline in the incidence of scrub typhus in the later covered by a black eschar. The vicinity of the eschar is decades. Recent reports from several parts of India, surrounded by red erythema, and an eschar is typically including South India, indicate that there is a resurgence of formed at the time of the manifestation of symptoms. [4,5] scrub typhus. [2] The clinical symptoms of scrub typhus in Case History : pregnant women are the same as in the non-pregnant. A 21year old female with 26weeks of pregnancy admitted During pregnancy, scrub typhus may lead to spontaneous in antenatal ward with history of fever of one week abortion, stillbirth, preterm delivery and small for duration with painful swelling of right breast and body gestational age infants. [3] Access this article online pains. She had received some antibiotic treatment outside. Quick Response Code Clinical picture of Scrub There was no history of jaundice, bleeding manifestations typhus is typically or other gastrointestinal disturbances. There was a history associated with fever, of right breast abscess one and a half year back which was rash, myalgia and diffuse drained surgically. Patient was a known case of asthma. lymphadenopathy. A There was no past history of diabetes or hypertension, nor necrotic eshcar at the any recent travel history. There was no history of trauma.

Keywords : Scrub typhus, eshcar, breast abscess 107 - Pothukuchi Venkata Krishna NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

On physical examination, patient was febrile, anemic, continued. Blood sample was sent for Scrub typhus Elisa conscious and coherent. There was no jaundice and pedal test for IgM and the report came as positive. Ulcer swab edema. Patient was dyspneic with tachypnea, pulse rate which was sent for gram stain and culture was negative. On was 106/min and blood pressure was 90/60 mmHg. On second day of administration of azithromycin fever examination bilateral occasional crepitations present in subsided and oxygen saturation was improved. Two days both lungs. Oxygen saturation was 80% at room air and later, her condition improved and became normal. 93%with oxygen. Breast examination revealed tenderness in right breast with local rise of temperature along with a small ulcer along the medial aspect of the breast near the nipple and old healed surgical scar on the lateral aspect of the breast near the nipple area. Patient was treated for breast abscess with injection ceftriaxone and was referred to surgeon and physician. Surgeon advised continuation of same antibiotic treatment thinking of breast abscess. Physician advised bronchodilator inhalational therapy for bronchial asthma as oxygen saturation was low. Laboratory Figure1. : Eschar on breast investigations revealed: Hemoglobin was 8.2grams, total Discussion : count was 7000cell/cumm, platelet count was The eschar is the most useful diagnostic clue in patients 92000/cumm. Erythrocyte sedimentation rate was with acute febrile illness in areas endemic for Scrub typhus 20mm/1hour, Blood urea was 17 mg/100 ml, serum and therefore should be thoroughly examined for its creatinine was 0.6 mg/100 ml, Serum sodium-153meq/ltr, presence especially over the covered areas such as the potassium-4.3meq/ltr, Chloride-118meq/ltr, bicarbonate- groin, genitalia, infra-mammary area and axilla. [6] The 20meq/ltr. Liver function tests were normal. Viral markers typical eschar is found to be a slightly raised erythema and strip test for malaria were negative. Ultrasound breast surrounding a black necrotic center. However, for cases in revealed subcutaneous edema surrounding the area of which an eschar is formed in a warm and damp area, i.e., upper and outer quadrant, extending to the right axilla, the axilla area or the perineum, a necrotic eschar is not suggestive of mastitis. Ultrasound abdomen showed mild formed; instead, an ulcer with a shallow, purulent base hepatosplenomegaly, bilateral pleural effusion and a single surrounded by a clear, erythematous band may be formed; live foetus of 27-28 weeks. Electrocardiogram showed in such cases, the eschar could possibly be improperly tachycardia. Two Dimensional Echocardiogram showed diagnosed and may be easily overlooked. [5,7] features of hyperdynamic circulation with good ventricular function. Even after three days of antibiotic treatment Though the eschar is painless, in this case because of soft fever was not subsided and her condition did not improve. tissue of breast and probably because of secondary The ceftriaxone was replaced with Injection augmentin and infection of scrub typhus ulcer of breast, there was swelling amikacin. But there was no improvement. Repeat 2D ECHO and tenderness because of mastitis. Empiric treatment for revealed minimal pericardial effusion. Again patient was 3 days with doxycycline, 100 mg orally twice daily, or with referred to physician and transferred to acute medical care minocyline, 100 mg intravenously twice daily, or for 7 days unit. On examination we noticed small eschar over an with chloramphenicol, 25 mg/kg/d orally or intravenously ulcerated area with purulent base on the medial aspect of in four divided doses, eliminates most deaths and relapses. breast (Figure-1). We suspected scrub typhus and oral Chloramphenicol- and tetracycline-resistant strains have Azithromycin 500mg per day was given and augmentin was been reported from Southeast Asia, where azithromycin or

Keywords : Scrub typhus, eshcar, breast abscess 108 - Pothukuchi Venkata Krishna NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science roxythromycin may become the drug of choice for children, non specific clinical presentation limited awareness and pregnant women, and patients with refractory disease.[1] low index of suspicion among clinicians, and lack of Chloramphenicol is classified as class C drug. Clinical data diagnostic facilities. [2] Early diagnosis is important because indicate that chloramphenicol is safe to use in pregnancy if there is usually an excellent response to treatment and it is not circulating at the time of delivery where it may timely anti-microbial therapy may help prevent cause gray baby syndrome.[8] Ciprofloxacin, in experience complications. In developing countries with limited with pregnant women in India, is ineffective and should not diagnostic facilities, it is prudent to recommend empiric be used. [9] therapy in patients with undifferentiated febrile illness having evidence of multiple system involvement.[10] Scrub We are reporting this case of Scrub typhus with breast typhus should be listed in the differential diagnosis of acute abscess to highlight the need for strong suspicion febrile illness in pregnant women who either live in or especially in pregnant woman because of its dramatic return from endemic areas. The symptoms and signs response to treatment and keeping in mind of its severe life during pregnancy are not different from non-pregnant threatening complications. women. Treatment with azithromycin is safe during Conclusion : pregnancy.[3] Scrub typhus is grossly under-diagnosed in India due to its

References: 1. Wayne X. Shandera, Ingrid l. Roig. Viral & Rickettsial infections. In: Maxine A. Papadakis, Stephen J. McPhee, editors. Current Medical Diagnosis and Treatment, 52nded.USA: Mc Graw Hill Publishers;2013.p.1411-12 2. Vivekanandan M, Mani A, Priya YS, Singh AP, Jayakumar S, Purty S. Out Break of Scrub Typhus in Pondicherry. J Assoc Physician India 2010;58:24-28. 3. Vorapong Phupong . Pregnancy and Scrub typhus. J k Science 2010;12:85-7. 4. Berman SJ, Kundin WD. Scrub typhus in South Vietnam. A study of 87 cases. Ann Intern Med 1973;79:26–30. 5. Dong-Min Kim, Kyung Jun Won, Chi Young Park, Ki Dong Yu, Hyong Sun Kim, Tae Young Yang, et al. Distribution of Eschars on the body of Scrub typhus patients: A Prospective Study. Am. J. Trop. Med. Hyg 2006;75:955–959. 6. Kundavaram A P, Jonathan A J, Nathaniel S D, Varghese G M. Eschar in scrubtyphus: A valuable clue to the diagnosis. J Postgrad Med 2013;59:177-8. 7. Irons EN, Armstrong HE. Scrub typhus in Dutch New Guinea. Ann Intern 1947;26:201–220. 8. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.pp.345. 9. Mathai E, Rolain JM, Verghese L, et al. Case reports: scrub typhus during pregnancy in India. Trans R Soc Trop Med Hyg 2003;97:570-72. 10. Chogle AR. Diagnosis and Treatment of Scrub Typhus –The Indian Scenario. J Assoc Physician India 2010;58:11-12.

Keywords : Scrub typhus, eshcar, breast abscess 109 - Pothukuchi Venkata Krishna NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report TREATMENT OF ANKYLOGLOSSIA USING DIODE LASER – A CASE REPORT Manavi Prabhu1 , Sharath KS2 , Biju Thomas3 , Santhosh Shenoy B4 , Shamila Shetty5 1Post Graduate, 2 Professor & HOD, Department of Periodontics Srinivas Institute of Dental Sciences, 3 Professor & HOD, 4Reader, Department of Periodontics, A.B. Shetty Institute of Dental Sciences Nitte University, 5 Assistant Professor, Department of Periodontics, A.J. institute of Dental Sciences, Mangalore, India. Correspondence : Manavi Prabhu Post Graduate, Department of Periodontics, A.B. Shetty Institute of Dental Sciences Nitte University, Mangalore, India. Mobile : +91 94489 53967 E-mail : [email protected] Abstract : Lingual frenulum is the vertical fold of mucous membrane under the tongue, attaching it to the floor of the mouth. This congenital anomaly could cause diastema, difficulties in the movement of the tongue, feeding difficulties, speech disorders and various mechanical and social issues. Conventional frenectomy techniques would include the use of a scalpel, which often requires at least one suture and leads to some degree of post-operative discomfort as well as the need for a return visit to remove the suture. The main advantages of using thediode laser are that there is no bleeding; less of operative pain, no need of anesthesia, and suturing is not required, minimizing post-operative discomfort for the patient, and reducing procedure time for the practitioner. Keywords : Ankyloglossia, tongue dysfunction, diode laser.

Introduction: Many methods have been used such as scalpel surgery, Lingual frenulum is the vertical fold of mucous membrane diathermy, and lasers have been long used. The advantages under the tongue, attaching it to the floor of the mouth; of laser include a bloodless operating field, no post called also frenulum linguae. Ankyloglossiais a congenital operative infection or pain and no suturing required. The anomaly in which there is an abnormally short lingual case report discusses one case of successful management frenulum, which restricts mobility of the tongue of Ankyloglossia or tongue tie with diode laser. tip.Ankyloglossia may lead to a host of problems like infant A 30 year old male reported to the department of feeding difficulties, speech disorders, and various Periodontics, AB Shetty memorial institute of dental mechanical and social issues related to the inability of the sciences. Patient had a complaint of difficulty in stretching tongue to protrude. Lingual frenectomy is advised for the his tongue completely outside the mouth and also had management of Ankyloglossia. Based on the length of the difficulty in touching the palate with his tongue since birth. free tongue, ankyloglossia can be classified as follows: 6 Medical and dental history was taken. There was found to Clinically acceptable: normal greater than 16 mm be no relevant medical and dental history. The ENT and physical examination was found to be normal. Verbal and Class I: mild ankyloglossia 12 to 16 mm written consent were taken from the patient. On intraoral Class II: moderate examination it was found that the patient had Access this article online ankyloglossia 8 to 11 mm Quick Response Code ankyloglossia (tongue tie) and was classified to be class 1 ankyloglossia (cotlow classification 1999).There was no Class III: severe malocclussion and recession present lingual to the ankyloglossia 3 to 7 mm mandibular incisors. The patient was undertaken for a Class IV: complete frenotomy procedure under local anaesthesia with 2 % ankyloglossia: less than 3 lignocaine hydrochloride with 1: 80,000 adrenaline by mm

Keywords : Ankyloglossia, tongue dysfunction, 110 diode laser. - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science using laser method. Diode laser emitting 810 nm was used days. Patient reported increase in tongue mobility in pulsed contact mode at 1.1 joule / sec energy. Safety following surgery and healing was satisfactory. Patient did measures were taken for Dentist, assistant and patient by not experience any pain during the healing period. The wearing the recommended protective goggles. The lingual extension of the tongue outside the mouth had increased frenal attachment was released in the anterior floor of the from preoperative. The speech articulation had improved mouth. The entire procedure was painless and after surgery; the patient was able to touch the palate with encountered no bleeding; pack was placed at the end of the tip of the tongue which improved the phonetics. the procedure. Patient was recalled for follow up after ten

Pre operative images

Post operative images Discussion : seals the capillaries and lymphaticwhich reduces the Diode lasers can be used in continuous wave orgated-pulse postoperative bleeding and edema 1 .Number of modes in contact or out of contact with the tissue. The myofibroblasts found after laser treatment are found to be benefits of using laser in oral surgical procedures are less 2 . This helps in less wound contraction and scarring. significant, for the clinician as well as the patient. Laser light Because of improved healing and hemostasis, laser is monochromatic, coherent and collimated; therefore it wounds can often be left without sutures. Laser assisted delivers a precise burst of energy to the targeted area. frenectomy is believed to provide better postoperative There is more efficient incision of the tissues by laser when perception of pain and function than with the scalpel compared to scalpel, laser generates complete technique 3 . vaporization and coagulates the blood vessels. Laser has a Laser assisted lingual frenectomy is easy, showing excellent hemostatic effect that eliminates excessive bleeding, precision and less discomfort compared to conventional which creates clean surgical field, allowing increased technique. Patient did not have any complaints related to precision and accuracy and greatly improving visualization pain and bleeding Patient was comfortable and there was of surgical site. Laser wound causes less bleeding due to less bleeding. The pulsed mode was used which provided sealing of capillaries by protein denaturation and time for the tissue to cool and prevented collateral tissue stimulation of clotting factor VII. The thermal effect of laser damage 4 .High level of sterilization is maintained in diode

Keywords : Ankyloglossia, tongue dysfunction, 111 diode laser. - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science treatment which reduces the need for post-operative care report, lingual frenectomy was done by diode laser and antibiotics. technique which provided the practical benefit to the patient by reducing bleeding, increasing asepsis, Conclusion : decreasing operative and postoperative pain, swelling and Ankyloglossia or tongue-tie is a congenital condition and no requirement of suture. the treatment being simple and safe. In the present case

References : 1. DenonvillersM,Blepharoplastie,BullSocChir Paris 7 :243 :1856-1857. 2. ZeinounT,NammourS,Dourov N:Myofibroblasts in healing laser excision wounds.LasersSurg Med 28:1:74-79,2001. 3. Haytac M, Ozcelik O: Evaluation of patient perceptions after frenectomy operations:comparison of carbon dioxide laser and scalpel techniques,JPeriodontol 77:11:1815-1819,2006. 4. Kotlow L. Laser in Pediatric Surgery. Dent ClinNorth Am :2004:48:889- 922. 5. Pirnat S.Versality of an 810nm diode laser in dentistry :an overview. J Laser Health Acad 2007:4:1-9. 6. KotlowL.Ankyloglossia(tongue tie):A diagnostic and treatment quandary.Quintessence int.1999;30:259-262.

Keywords : Ankyloglossia, tongue dysfunction, 112 diode laser. - Manavi Prabhu NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report FEMALE PATIENT WITH A VARIANT OF TURNER SYNDROME Meenakshi A.1 , Prashanth Shetty2 , Suchetha Kumari3 , Jayarama Kadandale4 , Neetha Nandan5 1Research Associate & Lecturer, 2 Professor & Co-ordinator, 3 Professor, 4 E-Consultant, Diagnostic centre for Cytogenetics & Molecular Genetics, 5 Associate Professor, Department of Obstetrics & Gynecology, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Correspondence : Meenakshi A. Research Associate/Lecturer, Diagnostic centre for Cytogenetics & Molecular genetics, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Mobile: +91 78294 18612 E-mail : [email protected] Abstract: The X chromosome contains determinants necessary to assure normal structural growth. Deletions of proportions of the X chromosome have been reported in a huge number of patients. We report on a mosaic short arm deletion of X chromosome (Xp-) in 14-years-old female patient with short stature, low set ears and no secondary sexual characteristics, a rare Turner syndrome variant. Chromosomal analysis using GTG-banding showed in 85% of cells and 46,X,del(Xp) in 15% of cells. The Fluorescence in situ hybridization technique of the cultured cells helped to perceive low grade cell line. Hence, molecular cytogenetics methods are essential to detect low level mosaicism which is important in better counseling. Keywords : Chromosomal analysis; sex chromosome; Fluorescence in situ hybridization; molecular cytogenetics

Introduction : Case presentation: Turner syndrome is the most common sex chromosomal A 14-year-old girl was referred to our cytogenetic abnormality in phenotypic females, and results from loss laboratory for the reason that short stature, low set ears, or abnormality of the second X chromosome. The most webbed neck and no secondary sexual characteristics from common karyotype of Turner syndrome is 45,X0 in 80% of department of obstetrics and Gynecology, K S Hegde affected females and approximately the remaining 20% Hospital, Mangalore. She was second born by cesarean at may have some variants on the second X chromosome such 40 weeks of gestation to a non-consanguineous parents as an isochromosome of the long arm, ring chromosome or the mother and father being 40 and 48 year-old else small short-arm deletions or interstitial long-arm respectively. Clinical examination revealed that her height deletions [1]. was 133 cm, weight 41 kg. She had absence of secondary sexual characters, lack of axillary and pubic hair, and under The incidence of Turner syndrome is estimated to occurs in developed breast (Tanner stage - I). Ultrasonography 1in 2000 to 1in 5000 live births [2]. The main characteristics findings of pelvic organs revealed 3.8 X 0.6cms uterus, of this disorder are short stature, gonadal dysgenesis, ovaries were not visualized, no adnexal masses and no free primary amenorrhea, decreased fertility, a webbed neck, fluid noted. She has normal urinary bladder and Gall widely spaced nipples, a broad chest and anomalies of bladder, absent calculus and neoplasm. The follicular cardiac, renal and endocrine origin [1,3]. stimulating hormone (FSH) level was very high (80mIU/ml) We present a female compared to normal females (FSH-0-13mIU/ml). Access this article online patient who carries a Proband has 19 years elder sister with normal phenotype, Quick Response Code k a r y o t y p e she attained menarche and getting regular periods. Both of mos45,X[17]/46,X,del(Xp) her parents were phenotypically normal. Other illness, [3], a variant of Turner genetic disorders, mental retardation has never occurred Syndrome, with some of in the family. the typical phenotype.

Keywords : Chromosomal analysis; sex chromosome; Fluorescence 113 in situ hybridization; molecular cytogenetics - Meenakshi A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Conventional cytogenetic analysis Spectral Imaging, Germany). Metaphase cells were obtained from PHA We scored 200 interphase nuclei, among this 81% of the (Phytohemagglutinin) stimulated peripheral blood cells shown single green signal for X chromosome and lymphocytes following standard protocols. Slides were remaining 19% of the cells shown two green signals, which stained by conventional Giemsa-Trypsin-Giemsa banding authenticate the presence of second abnormal cell line (GTG) technique and 20 well spread metaphases were 46,X,del(Xp). In addition, FISH study confirms there is no analyzed microscopically. The chromosome analysis of the presence of Y chromosome. The final karyotype was given patient revealed mos45,X[17]/46,X,del(Xp)[3] (Figure 1) based on a combination of FISH analysis as well as karyotype according to the International System for conventional karyotyping. Human Cytogenetic Nomenclature (ISCN). The result described 85% of the cells has 45,X and 15% of the cell has 46,X,del (Xp).

Detection of mosaicism depends on the proportion of cells present from the additional cell lineages. In routine karyotyping, 20 cells are counted, since this number is sufficient to detect mosaicism at a level of about 5 percent. In this present case we got the second cell line more than 5 percent, even though, we decided to proceed with the FISH (Fluorescence in situ Hybridization) study to score additional number of cells and disclose exact mosaic pattern. 45,X[17]

Fluorescence in situ hybridization (FISH) Analysis: FISH analysis was performed on the same peripheral blood samples harvested for cytogenetic analysis to detect exact mosaicism. 10µl of dual-colour CEP X (Spectrum Green) and CEP Y (Spectrum Orange) probe (Vysis, USA) was applied to the sample, covered with cover slips and sealed with rubber cement. The sample and probe were co- denatured and hybridized using the ThermoBrite Denaturation/Hybridization System. The ThermoBrite unit 46,X,del(Xp)[3] was programmed to allow 5 minutes of denaturation at 73°C, followed by overnight hybridization at 37°C. Post Figure 1: GTG-banded karyogram of the patient with variant Turner syndrome. 17 cells showed a 45,X karyotype and the hybridization wash was performed in 0.4X SSC/0.1% NP-40 remaining 3 cells showed deletion Xp. at 72°C for 2 minutes) followed by a wash in 2X SSC/0.1% Discussion: NP-40 at room temperature for 1 minute. The slides were Turner syndrome variants include female individuals with air dried in the dark, then added 10µl of DAPI (4,6- partial deletions in the “p” and/or “q” arms of one X diamidino-2-phenylindole) counter stain. The FISH signals chromosome. The deletions of certain X chromosome were visualized using Vysis filter sets and an Olympus BX51 regions/genes can lead to specific phenotypic features fluorescence microscope attached to a FISH View image which are characteristic of “full” or “classic” Turner acquisition and analysis system for FISH (GENASIS, Applied syndrome and also deletions of the SHOX gene, located in

Keywords : Chromosomal analysis; sex chromosome; Fluorescence 114 in situ hybridization; molecular cytogenetics - Meenakshi A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science the PAR (pseudo autosomal region) at Xp22.33, are A region on Xp11.4 has been proposed as critical for the associated with short stature [4]. Most women with Xp development of lymphedema. Evidence of fetal deletion are short, apart from their ovarian function lymphedema is manifest as neck webbing, malrotation of indicating that other structural determinant genes ears and low posterior hair line. In our case webbing of probably lie within these Xp regions [5]. Short stature was neck and low set ears would have been noticed prenatally localized to a much smaller region midway within this and diagnosed as early as possible. The prevalence of general area between Xp11.2 to Xp22.1. In our case, congenital heart disease among patients with Turner patient has these characteristic Turner syndrome features syndrome ranges from 17–45% with no clear phenotype might be due to loss of entire “p” arm of X chromosome. genotype correlations [9]. Congenital cardiac defect and renal malformations are consistently reported in Turner If the status of ovarian function in adolescence is unclear, syndrome, with the benevolent conditions of horse shoe measurement of follicle-stimulating hormone, luteinizing kidney and duplex collecting systems being most common hormone, and estradiol levels can help to determine the [2]. Even though our patient clinical information does not need for hormone-replacement therapy (HRT). Hormone- show any risk of congenital heart defect and renal replacement therapy should be initiated at the age of anomalies, we are requesting the clinician to take special about 14 years. Earlier treatment may result in a consideration to scrutinize blood pressure for the decrement in final height. Psychosocial issues and the evaluation of cardiac anomalies. patient's maturity and wishes also need to be considered. The size of Xp deletions and corresponding genes are more The molecular mechanisms (s) responsible for gonadal severe in patients with Xp deletion, short neck was more failure with X chromosome deletions could involve the loss common among them [10]. Approximately 70% of patient of putative ovarian determinant gene(s) necessary to be with turner syndrome have learning disabilities affecting present in two copies during ovarian development. nonverbal perceptual motor and visuospatial skills, a meta- Deletions on X chromosome have been reported in a large analysis of 13 studies identified deficits in visuospatial number of patients. Deletion Xp11 region result in ovarian organization, social cognition, nonverbal problem-solving failure with menstrual function, even in those with normal and psychomotor functioning in patients [9]. Several menstruation, fertility is very rare [5]. studies of Joanne Rovert have examined the specific Structural abnormalities of X chromosome variant were mathematics difficulties in females with multidigit addition more common than the classic 45,X/46,XX karyotype all and subtraction problems, while geometry and the ability over the prior studies [6]. Among children with TS, those to deal with symbols were less disturbed. Our patient also with less X-chromosome material appear to be more have specific problem with number work, mathematics severely affected, especially if they lose paternal X- and spatial tasks and it may be helpful to make teachers chromosome material [7]. The age of the parents should aware of this in case extra support like tutoring is needed. not be associated with the formation of structural variants However many go on to further or higher education and and monosomic X chromosome patients (XO) show less enjoy full range of job opportunities. expression than those patients who have additional Xq Conclusion : copies [1]. One author described that frequency of physical Turner syndromes represent a condition with both genetic abnormalities in Turner syndrome vary with the pattern of and hormonal determinants that contribute to severe karyotype, features and majority are not karyotyped until mathematics impairments. Early recognition of Turner after the age of 11, usually due to the failure of puberty and syndrome and timely investigations should be helpful in he was concerned about the delay of diagnosis [8]. Our improving the quality of these individuals by potentially patient also diagnosed lately at the age of 14.

Keywords : Chromosomal analysis; sex chromosome; Fluorescence 115 in situ hybridization; molecular cytogenetics - Meenakshi A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science improving the adult height in those who respond to growth of short stature and FISH study is essential to detect low hormone therapy and in initiating sex hormone level mosaicism with normal X chromosomes in such replacement. Also, early detection and management of co- patients for the appropriate counseling. existing illnesses may be life saving for these patients. Acknowledgement: Physicians should discuss infertility issues and The authors wish to thank the patient and her parents for reproductive options with their patients and reassure them providing the sample and personal information. Written about their sexual function. It is important to acknowledge informed consent was obtained from the patient. The the sense of loss associated with infertility, on the part of authors are grateful to Mrs. Vani Shetty for her valuable both the patient and parents. We conclude for this study technical help. that the karyotyping is definitely helpful in the evaluation

References: 1. Christalena S, Eirini T, Olga F, Despina M, Helen F. Iridocyclitis in a Female Patient with a Variant of Turner Syndrome. J Genet Syndr Gene Ther. 2013; Volume 4, Issue 10.1000196. http://dx.doi.org/10.4172 /2157-7412.1000196 2. Bondy CA. New Issues in the Diagnosis and Management of Turner Syndrome. Reviews in Endocrine & Metabolic Disorders. 2005; 6:269- 280. 3. Ramachandram S, Keng WT, Ariffin R , Ganesan V. A mother with variant Turner syndrome and two daughters with trisomy X: a case report. Journal of Genetics. 2013; Vol. 92, No. 2. 4. Mazzaschi LP, Taylor J, Robertson SP, Love DR, George AM. A Turner Syndrome Patient Carrying a Mosaic Distal X Chromosome Marker. Hindawi Publishing Corporation Case Reports in Genetics. 2014; http://dx.doi.org/10.1155/2014/597314 5. Vundinti BR, Kerketta L, Korgaonkar S, Ghosh K, Mohanty D. Molecular Cytogenetic Evaluation of Xq Deletion Mosaicism in a Case of Primary Amenorrhea. Int J Hum Genet. 2004; 4(1): 75-76. 6. Bharath R, Unnikrishnan AG, Thampy MV, Anilkumar A, Nisha B, Praveen VP, Nair V, Jayakumar RV, Harish Kumar., Turner Syndrome and its Variants. Indian Journal of Pediatrics. 2010; Volume 77, DOI- 10.1007/s12098-009-0226-7 7. Rovet J. Turner Syndrome: Genetic and Hormonal Factors Contributing to a Specific Learning Disability Profile. Learning Disabilities Research & Practice. 2004; 19(3), 133–145. 8. Chander NV, Ahmed EF. Turner's Syndrome Variant with Three Cell Line Mosaicism and Ring X Chromosome (45, X /46,X r(X)(p21 q25)/46,Xx) in A Saudi Patient. Bahrain Medical Bulletin. 2001; Vol.23, No.1. 9. Sybert VP and McCauley E. Turner's Syndrome. N Engl J Med. 2004; 351:1227-38. 10. Ogata T, Muroya K, Matsuo N, Shinohara O, Yorifuji T, Nishi Y, Hasegawa Y, Horikawa R, Tachibana K. Turner Syndrome and Xp Deletions: Clinical and Molecular Studies in 47 Patients. The Journal of Clinical Endocrinology & Metabolism. 2001; 86(11):5498–5508.

Keywords : Chromosomal analysis; sex chromosome; Fluorescence 116 in situ hybridization; molecular cytogenetics - Meenakshi A. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Case Report RESISTANT CANDIDA PNEUMONIA IN TWO PATIENTS WITH CHRONIC KIDNEY DISEASE

Baikunje S1 , Upadhyaya VS2 , Hosmane GB3 & Rama Prakasha S4 1Associate Professor & HOD, Department of Nephrology, 2,3,4 Assistant Professors, 2 Department of Radiology, 3Pulmonary Medicine, 4 Department of Medicine, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. Correspondence : Shashidhar Baikunje Associate Professor & HOD, Department of Nephrology, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. E-mail: [email protected] Abstract : Patients with chronic kidney disease are at increased risk of sepsis and infection is the second leading cause of death in dialysis patients. Primary candida pneumonia is extremely rare and there is very little data on its treatment and outcome in chronic kidney disease patients. We report resistant candida pneumonia in two patients with chronic kidney disease. Both patients were successfully treated with anidulafungin which is a newer echinocandin. The current recommendation is not to treat candida isolated from sputum or bronchoalveolar lavage specimens. But our cases demonstrate that in the relevant clinical setting, positive sputum cultures cannot be ignored and prompt treatment can be lifesaving in this condition with high mortality. Both the patients developed generalized pigmentation which resolved in a few weeks which, to the best of our knowledge has never been reported with this drug before. It is unknown whether this adverse effect is limited to patients with chronic kidney disease.

Keywords : Anidulafungin, Candida pneumonia, Chronic Kidney Disease.

Introduction : days duration. He had clinical and radiological evidence of Patients with chronic kidney disease (CKD) are at higher risk left lower lobe pneumonia. (Fig.1a). His baseline creatinine of infection compared to general population. Infection- was 6 mg/dl (MDRD eGFR 10 ml/min/1.73 m2 ) which had related hospitalizations contribute substantially to excess deteriorated to 11.96 mg/dl (eGFR 4ml/min/1.73m2 ). His morbidity and mortality in patients on dialysis, and haemoglobin was 7.2 g/dl and total leucocyte count was infection is the second leading cause of death in this 13,900 /cu.mm with neutrophil count of 90%. He was population. (1) Patients who have CKD and do not require initiated on haemodialysis. He was empirically treated with renal replacement therapy also seem to be at higher risk of azithromycin and cefoperazone/sulbactum combination infection compared with patients without CKD; however, and the latter was changed to meropenem due to lack of data about such patients are very limited. Annual mortality response. After six days of antibiotic therapy he continued rates in the dialysis population are increased by 10-fold for to be pyrexial, hypoxic and his x-ray showed no change. He pneumonia and 100-fold for sepsis compared with the grew heavy growth of candida (species not specified) in his general population (2) . There is sparse data on primary sputum which was resistant to triazole group of candida pneumonia in CKD antifungals. Blood culture was negative. He was initiated Access this article online patients and their outcome. on anidulafungin which lead to complete radiological Quick Response Code resolution in two weeks (Fig.1b). He tolerated the Case 1: A 54 year old male treatment very well but developed generalized with adult polycystic kidney hyperpigmentation which resolved after a month of disease was admitted with discontinuing the drug. He remained on long term fever, breathlessness and maintenance dialysis. productive cough of four

Keywords : Anidulafungin, Candida pneumonia, 117 Chronic Kidney Disease. - Shashidhar Baikunje NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Case 2: A 74 year old male with long standing hypertension and CKD stage 3 (baseline creatinine 1.8 mg/dl, MDRD eGFR 37ml/min/1.73 m2 ) presumably secondary to hypertensive nephrosclerosis was admitted with right upper quadrant pain and fever since three days. His serum creatinine had deteriorated to 3.13(MDRD eGFR 20 ml/min/1.73 m2 ). His haemoglobin was 12.9g/dl and he had neutrophilic leucocytosis with total count of 19600 /cu.mm with 92% neutrophils. Liver function tests were mildly deranged with total bilirubin of 2.2 mg/dl (Direct 1 mg/dl, Indirect 1.2 mg/dl), ALT of 54 U/l with normal AST and alkaline phosphatase. Ultrasound scan showed distended gall bladder with multiple calculi with minimal pericholecystic collection. A diagnosis of acute calculous Figure 1a : Chest radiograph on admission shows left lower lobe consolidation. cholecystitis was made. He had mild hypoxia and preoperative chest radiograph showed atelectasis at the right base. This was thought to be secondary to his abdominal pathology. He was empirically treated with piperecillin/tazobactum and metronidazole and he underwent open cholecystectomy on day three of admission under general anaesthesia. Postoperatively he had pyrexia, neutrophilic leucocytosis and hypoxia. He developed bibasal consolidation with moderate pleural effusion on the right which was aspirated to exclude empyema. His kidney function deteriorated and he was started on haemodialysis. Sputum culture grew heavy growth of resistant candida (species not specified). His blood culture was sterile but pus from the gall bladder grew Figure 1b : Follow up radiograph in two weeks which shows pseudomonas which was fully sensitive. In spite of the complete resolution. appropriate antibiotic cover for six days he had persistant patients. The only accepted criterion for the definitive pyrexia, neutrophilic leucocytosis, worsening hypoxia and diagnosis of candida pneumonia is histologic chest x-ray changes. He was initiated on anidulafungin with demonstration of the fungus in lung tissue because excellent clinical response. His fever, neutrophilia and positive cultures cannot distinguish between true infection hypoxia improved, kidney function recovered back to and either colonization or sample contamination with baseline but complete radiological resolution took four oropharyngeal secretions. (3) A retrospective analysis from weeks. This patient also developed generalized Spain concluded that nonneutropenic patients with hyperpigmentatation which completely resolved in about isolation of candida species from bronchoscopic samples, four weeks after he finished the antifungal therapy. even in high concentrations, are unlikely to have invasive Discussion : candidiasis. (4) Another study showed that for sputum Pneumonia due to candida is extremely rare. There is very culture, the sensitivity, specificity, and the positive and little literature available on candida pneumona in CKD negative predictive values were 85%, 60%, 42%, and 93%,

Keywords : Anidulafungin, Candida pneumonia, 118 Chronic Kidney Disease. - Shashidhar Baikunje NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science respectively; for bronchoalveolar lavage culture, these positive sputum cultures cannot be ignored and prompt values were 71%, 57%, 29%, and 89%, respectively (5) . treatment can be lifesaving in this condition with high However, sputum culture was the key in initiating therapy mortality which can be as high as 84% (3) . Since 2004, several in both our patients who had negative bacteriological new antifungal agents have become available which are cultures and no response to broad spectrum antibiotics. effective against candida resistant to azoles. Anidulafungin, a newer echinocandin, has potent activity against candida The most common thin-section CT findings of pulmonary species and it showed superior clinical and microbiologic candidiasis are multiple nodular opacities, often bilateral response compared with fluconazole.(8) But the experience which was present in 88% of patients in a study which with this drug in the setting of CKD is limited and in our included 17 hematopoietic stem cell transplant recipients cases it was well tolerated except the reversible with proven pulmonary candidiasis.(6) Areas of air-space generalized skin pigmentation which both the patients consolidation were identified in 65% patients and areas of developed. To our knowledge, this has never been ground-glass opacity were seen in 35%. Even though CT reported before. scan was not carried out, one of our patients showed changes of unilateral lower lobe consolidation and the To conclude, fungal pneumonia needs to be considered in other patient had bilateral lower lobe consolidation with any immunosuppressed individual presenting with right sided effusion on chest x-ray. Pleural effusion was pneumonia poorly responding to standard treatment. reported in 3 out of 17 patients in the above mentioned Sputum culture is considered not very helpful in the study. diagnosis of candida pneumonia but in the relevant clinical setting, positive culture should not be ignored. Finally, Very little data is available on the therapy and outcome of even though anidulafungin can be extremely effective and patients with candida pneumonia and none in the CKD well tolerated, reversible skin pigmentation can be an population. The current recommendation is not to treat adverse effect. Whether this side effect is limited to candida isolated from sputum or BAL specimens. (7) But our patients with CKD is unknown and more studies are needed cases demonstrate that in the relevant clinical setting, to address this issue. References : 1. US Renal Data System: USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2007. 2. Sarnak MJ, Jaber BL: Pulmonary infectious mortality among patients with end-stage renal disease. Chest 2001; 120 :1883. 3. Haron E, Vartivarian S, Anaissie E, Dekmezian R, Bodie GP. Primary Candida pneumonia. Experience at a large cancer center and review of the literature. Medicine (Baltimore) 1993;72:137. 4. Rello J, Esandi ME, Díaz E, Mariscal D, Gallego M, Valles J. The role of Candida sp isolated from bronchoscopic samples in nonneutropenic patients. Chest 1998;114:146. 5. Kontoyiannis DP, Reddy BT, Torres HA, Luna M, Lewis RE, Tarrand J, Bodey GP, Raad II. Pulmonary candidiasis in patients with cancer: an autopsy study. Clin Infect Dis 2002;34:400. 6. Franquet T, Müller NL, Lee KS, Oikonomou A, Flint JD. Pulmonary candidiasis after hematopoietic stem cell transplantation: thin-section CT findings. Radiology. 2005;236:332. 7. Pappas PG, Kauffman CA, Andes D, Benjamin DK Jr, Calandra TF, Edwards JE Jr, Filler SG, Fisher JF, Kullberg BJ, Ostrosky-Zeichner L, Reboli AC, Rex JH, Walsh TJ, Sobel JD. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48:503. 8. Reboli AC, Rotstein C, Pappas PG, Chapman SW, Kett DH, Kumar D, Betts R, Wible M, Goldstein BP, Schranz J, Krause DS, Walsh TJ. Anidulafungin Study Group:Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med. 2007;356:2472.

Keywords : Anidulafungin, Candida pneumonia, 119 Chronic Kidney Disease. - Shashidhar Baikunje NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Review Article ROLE OF PHYTOCHEMICALS IN ORAL POTENTIALLY MALIGNANT DISORDERS : A REVIEW Ananya Madiyal1 , Vidya Ajila2 , Subhas G Babu3 , Shruthi Hedge4 , Harini Keshavaiah5 & Priyadharshini Alva M6 1,6Post Graduates, 2 Reader, 3 Professor & HOD, 4,5 Lecturers, Department of Oral Medicine & Radiology, 5 Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018, India. Correspondence : Ananya Madiyal Post Graduate, Department of Oral Medicine and Radiology, A.B. Shetty Memorial Institute of Dental Sciences Nitte University, Mangalore - 575 018, India. Mobile : +91 95388 40189 E-mail : [email protected] Abstract : Oral cancer is a major global health concern and poses a challenge to diagnostic and therapeutic aspects of healthcare services. Various oral lesions like leukoplakia, erythroplakia, lichen planus and oral submucus fibrosis categorized as orally potential malignant disorders have shown increased incidence of malignant transformation. Free radicals are highly reactive chemical species with capacity to damage nucleic acids, proteins and lipids and bring about changes of clinical significance. Antioxidants help in scavenging these free radicals and prevent disease progression. Naturally occurring phytochemicals play an important role in preventing oxidative stress and protect the cells from damage by free radicals. Keywords : Antioxidants, phytochemicals, oral potentially malignant disorders, chemoprevention

Introduction : country.3 National Cancer Registry, 2003 identified that the Oral cancer is a major global health concern with increasing spectrum of the diseases in the country lies in states like prevalence and high levels of mortality. It poses a major Uttar Pradesh, Madhya Pradesh, Bihar, Maharashtra, challenge to diagnostic and therapeutic aspects of the Gujarat, Andra Pradesh, Karnataka and Tamil Nadu. healthcare services. Oral and pharyngeal cancers, grouped Variation in incidence depends upon geographic location together constitute the sixth most common cancer in the and adverse habits. world.1 The annual estimated incidence of oral cancer Prognosis of oral cancer is generally poor with a five year stands at about 275,000 and pharyngeal cancer at about survival rate of less than 50%4 Local recurrences as well as 130,300, excluding nasopharyngeal cancers in developing lymph node metastasis occur in a significant number of the countries.2 The areas characterised by high incidence rates affected people while distant metastasis is often rare. for oral cancer include South and South-East Asia ( Sri Various oral lesions like leukoplakia, erythroplakia, lichen Lanka, India, Taiwan and Pakistan), parts of western ( planus and oral submucous fibrosis are known to have an France) and Eastern Europe ( Hungary, Slovakia and increased risk of progressing into malignancy. These Slovenia), parts of Latin America and the Caribbean ( Brazil, lesions are collectively termed as 'oral potentially Uruguay and Puerto Rico) and in the Pacific regions (Papua malignant disorders'. WHO in 2005 defined oral potentially New Guinea and Access this article online malignant disorder as 'the risk of cancer being present in a Melanesia)1 Oral cancer is Quick Response Code pre-cancerous lesion or condition, either at the time of one of the most common initial diagnosis or in the future'5 The term conveys that not forms of malignancies in all of the lesions described under it will turn into cancer but India with a prevalence instead, it blankets a family of morphologic alterations that varying from 11% to 52% of will potentiate some of the lesions into a malignant all diagnosed cancers in the transformation. WHO first classified oral potentially

Keywords : Antioxidants, phytochemicals, oral potentially malignant 120 disorders, chemoprevention - Ananya Madiyal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science malignant disorders as potentially malignant lesions and due to genetic predisposition or due to irreparable potentially malignant conditions (table 1)6 in 1978. A oxidative damages to the DNA that cause mutations. classification based on eitiology of the lesion was later Antioxidants are essential in reducing this oxidative stress given by Anthony George et al in 2011 (table 2)7 by scavenging free radicals and thereby reducing mutations, changes in enzyme activity and lipid It is a well-established fact that virtually all oral cancers are peroxidation of cellular elements. preceded by visible clinical changes in the oral mucosa usually in the form of red or white patches.8 Early diagnosis Cancer therapeutics mainly concentrates on the final stage of these potentially malignant disorders help in avoiding of the disease. This limits its preventive potential. Refocus high levels of morbidity and mortality associated with of management of cancer from the end point to the these lesions. Oxidative stress has always been associated progression of the disease is essential as these with the development of a wide variety of diseases. It is a interventions will prevent, inhibit and reverse the process process derived from the inability of the body's of carcinogenesis thereby reducing the long term effects on endogenous antioxidant defences to scavenge free such individuals. Early detection and treatment of oral radicals. Free radicals are highly reactive chemical species potentially malignant disorders will provide a better characterized by short half-life and are made up of a single standard of life to individuals affected by oral cancers. atom or groups of atoms that form a molecule with a free Phytochemicals electron.9 This electron is responsible for the high reactivity The word phytochemicals is derived from the Greek word of free radicals. When free radical derived oxidative 'Phyto' meaning plant. More than 5000 different types of damage to nucleic acid, proteins and lipids of extra cellular phytochemicals have been identified but they remain just a and cellular matrix is observed, it produces damages of small percentage of the total number of such plant clinical importance. Dietary antioxidants can reduce the chemicals. Phytochemicals are defined as 'bioactive non- risk of cancer. Phenolic compounds derived from a variety nutrient plant compounds in fruits, vegetables, grains and of fruits and vegetables show anti-inflammatory and anti- other plant foods that have been linked to reducing the risk cancer effect. Supplements of phytochemicals including of major chronic diseases'.13 carotenoids and flavonoids demonstrate chemopreventive and chemoprotective activity especially in the cellular Some of the major phytochemicals are: proliferation phase. 1. Beta-carotene Rationale behind the use of antioxidants in management Approximately 16% of the ingested beta-carotene is of oral potentially malignant disorders transformed to retinol by a two-step process in the Generation of reactive oxygen species by biologic systems intestinal mucosa. It is absorbed by the lymphatics and is either by normal metabolic pathways or as a consequence not taken up by the extra hepatic tissues like bone marrow, of exposure to chemical carcinogens contributes to the blood cells, spleen, adipose tissue, lungs, muscles and multi-stage process of carcinogenesis.10 Some examples of kidney.14 The possible protective effects of beta carotene is antioxidants include Vitamin C (Ascorbic acid), Vitamin E attributed to its antioxidant action by trapping free (Alpha tocopherol), retinol, retinoids and beta-carotene. In radicals, particularly peroxyl and hydroxyl which are 1981 it was discovered that there was an association involved in aging and carcinogenesis. It also increases cell between low serum beta carotene levels and cancer.11 mediated immune response due to increased monocyte There exists an inverse relationship between the levels of expression and increased response of tumour necrosis these antioxidants in the diet and in the serum and the factor alpha. Lower than expected levels of serum beta probability of development of cancer.12 Cancer develops carotene have been seen in men who smoke cigarettes and

Keywords : Antioxidants, phytochemicals, oral potentially malignant 121 disorders, chemoprevention - Ananya Madiyal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science consume alcohol. Low levels of beta carotene is associated c. Xanthine Oxidase with increased risk of oral cancer.11 An abundance of beta- Xanthine dehydrogenase, an enzyme present under carotene has been found in a variety of yellow and green physiologic conditions is changed to xanthine oxidase fruits and vegetables.13 during ischemic conditions. During reperfusion, xanthine oxidase reacts with molecular oxygen thereby producing 2. Lycopene superoxide free radicals. Flavonoids scavenge these Lycopene is one of the most potent antioxidant and has superoxide molecules thus resulting in less oxidative been hypothesised to prevent carcinogenesis and injury.22 atherogenesis by protecting critical biomolecules like lipids, lipoproteins and DNA.15 Lycopene suppresses d. Leukocyte Immobilization carcinogen induced phosphorylation of regulatory During ischemia and inflammation, leukocytes which are proteins such as p53 and Rb anti-oncogenes and stops cell freely moving along the endothelial wall are acted upon by 16 division at G0 -G 1 cell cycle phase. It also reduces cellular endothelium derived mediators and complement factors proliferation induced by potent mitogens like insulin-like and adhere to the endothelial wall and stimulate growth factors in various cancer cell lines.17 It exhibits degranulation of neutrophils. Flavonoids cause a decrease highest physical quenching rate constant with singlet in the number of immobilized leukocytes and total serum oxygen. Lycopene is a bright red pigment found in complement. They also cause a decrease in the tomatoes and other red fruits like red carrots, watermelons degranulation of neutrophils and mast cells and provide a and papayas.18 protective action during reperfusion by modulation of receptor directed calcium channels in the plasma 3. Flavonoids 23 membrane. Flavonoids are a group of plant derived phenolic compounds that have been identified to have antioxidant One of the best described group of flavonoids, quercetin is property to reduce the risk of development of chronic found in abundance in onions, apples, broccoli and berries. diseases. Flavonoids have an additive effect to the The second group, narigin is found in citrus fruits. endogenous scavenging systems19 . Flavonoids belonging to the catechin group are found primarily in green and black tea as well as in red wine. The They have different functions in the antioxidant system last group of flavonoids, anthocyanins are found in like: 18, 24 strawberries, grapes, wine and tea. a. Direct Radical Scavenging Role of phytochemicals in the prevention of cancer Flavonoids stabilize the reactive oxygen species by reacting Free radicals are constantly produced in the body as a with the reactive compound of the radical thereby result of normal metabolic processes. The key to producing a less reactive radical. Few flavonoids directly maintaining health is achieving a balance between free scavenge superoxide while others scavenge radicals and antioxidants. Over production of free radicals 20 peroxynitrites. causes oxidative damage to cell membrane lipids, proteins b. Nitric Oxide and DNA leading to cancer production. To prevent or slow Nitric oxide produced by macrophages reacts with free down the oxidative stress induced by free radicals, radicals producing peroxynitrite which can react with low sufficient amounts of antioxidants should be consumed. density lipoproteins thereby producing irreversible injury Phytochemicals like carotenoids and flavonoids help to to the cell membrane. Flavonoids scavenge nitric oxide as prevent cellular systems from oxidative stress and may also 13 well as peroxynitrite thus reducing the amount of oxidative lower the risk of chronic disease. Phytochemicals have a damage.21 complementary and overlapping mechanism of action like

Keywords : Antioxidants, phytochemicals, oral potentially malignant 122 disorders, chemoprevention - Ananya Madiyal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science scavenging of free radicals, regulation of gene expression in high as 300 mg per day for years with only carotenodermia cell proliferation and differentiation, inhibition of as a side effect. Clinical trials use doses considerably less expression of oncogenes, induction of tumor suppressor than 300 mg per day as beta-carotene levels are minimally gene expression, modulation of enzyme activity in elevated when the dose is substantially increased and the detoxification and regulation of hormone metabolism.25,26 possibility of carotenodermia is reduced.28 There was absence of side effects in patients supplemented with 26- Natural phytochemicals present in fruits and vegetables 120 mg of beta-carotene per day.29 A combination of beta- have strong antioxidant and anti-proliferative activities. carotene with vitamin A or retinoids has showed some The synergistic effect of various phytochemicals is success in the treatment of oral leukoplakia.30 Alpha- responsible for its beneficial effect. Individual antioxidants tocopherol in doses as high as 3200 mg per day have been produce varying degrees of tumor regression only at very well tolerated by adults without any signs of toxicity.31 high doses which is frequently associated with toxicity. At Supplements are more effective in achieving high plasma lower doses they may be ineffective or stimulate the alpha-tocopherol levels than diet modifications. It plays an growth of tumour cells.27 Therefore the use of a single important role in protecting the cell membranes from lipid antioxidant has no therapeutic or clinical significance. peroxidation. Administration of 800 IU of alpha-tocopherol Protection against free radicals can be enhanced by per day for 24 weeks shows some clinical response in consuming a mixture of dietary antioxidants thereby patients with oral potentially malignant disorders.31 16 mg avoiding the toxicity associated with high doses or growth of lycopene in divided doses has shown improvement in stimulation associated with low doses. mouth opening and burning sensation in patients with oral Antioxidants in therapeutics of oral lesions submucous fibrosis.18 Oral supplementation of 4-8 mg of In general, pre-malignant lesions are not lethal by lycopene given over a period of eight months showed themselves and are associated with low risk of malignant significant reduction in hyperkeratosis in patients with oral transformation. The goal of cancer therapeutics is not only leukoplakia with no clinical signs of toxicity.32 treatment of cancer but also the suppression and reversal A practical strategy for people who want to optimize their of pre-malignant lesions. The possible use of antioxidants health through diet modification is by increasing the in oral mucosal lesions include the following:27 consumption of fruits, vegetables and whole grains that 1. Prevention of lesions in high risk individuals with are rich in antioxidants. A combination of orange, apple, mucosa that clinically appears normal with no history of grape and blueberry has displayed a synergistic effect in pre-malignant or malignant lesion. delivering these antioxidants in sufficient quantities. The 2. Treatment of pre-malignant oral lesions. phytochemicals present in food differ in their molecular 3. In patients who had pre-malignant or malignant lesions size, polarity and solubility which may affect their that have been successfully treated, in order to prevent bioavailability and distribution in various macromolecules, recurrence of the treated initial lesion or to prevent the subcellular organelles, cells, organs and tissues. This development of a secondary or a separate primary. synergistic and additive effect of whole foods has been proposed to be responsible for their potent antioxidant Non-surgical management of pre-cancerous lesions should and anticancer effects.13 be considered, especially if they involve a large surface area and in medically compromised patients. It also provides Summary : additional advantages of being non-invasive, relatively cost Normal metabolic processes produce free radicals in the effective and ease of application. Patients with body. This mechanism is accentuated in the presence of dermatologic disorders receive doses of beta-carotene as precipitating factors such as smoking or alcohol

Keywords : Antioxidants, phytochemicals, oral potentially malignant 123 disorders, chemoprevention - Ananya Madiyal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Table 1 Potentially Malignant Disorders Potentially Malignant Lesions Oral submucous fibrosis Leukoplakia Actinic keratosis Erythroplakia Lichen planus Palatal lesions in reverse smokers Discoid lupus erythematosus

Table 2 High risk Lifestyle related Infections Immunodeficieny Inherited disorders Leukoplakia Smokeless tobacco keratosis Hyperplastic Solid organ Xeroderma candidiasis transplantation pigmentosa Erythroplakia Reverse smoker's palate Viral (HPV, HIV, Graft versus host Dyskeratosis EBV, HBV, HSV) disease congenita Oral submucous fibrosis Actinic chelitis Tertiary syphilis Chronic cutaneous Epidermolysis lupus erythematosus bullosa Erosive lichen planus Bloom syndrome Fanconi's anemia consumption. This causes generation of excess of free change. Newer analogues of synthetic retinoic acid show radicals. A balance between oxidative free radicals and better efficacy of treatment with less instances of toxicity. antioxidants is maintained in the body by oxygen While surgical management remains the mainstay of scavengers. In cases where there is an excess of free radical treatment of oral potentially malignant disorders, use of production, these scavenging systems are overwhelmed antioxidants, particularly newer analogues are gaining and fail to reduce the oxidative stress. This causes damage importance as non-invasive treatment options. to the cell membrane phospholipids and cell organelles Chemoprevention with these agents is useful in advanced and is termed as oxidative damage. Pre-cancer, cancer and disease or in an adjuvant setting in combination with other chronic diseases are mainly caused as a result of this surgical management, steroid hormones and cytotoxic oxidative damage. Use of antioxidant supplements shows chemotherapy that are currently available as treatment for promise in the resolution of such potentially malignant patients with oral potentially malignant disorders. disorders. No single antioxidant can replace the health benefits of a Phytochemicals show a synergistic function when diet with a complex mixture of phytochemicals derived supplemented along with other antioxidants. Use of a from a combination of various fruits, vegetables and whole single antioxidant at levels that can suppress or cause grains. Phytochemical extracts from such fruits and regression of pre-malignant lesions may produce features vegetables have strong antioxidant and antiproliferative of toxicity like carotenodermia and hypervitaminosis. effects and a major part of the total antioxidant activity is Hence a combination of various antioxidants should be from the combination of these phytochemicals. Diet used for the treatment of such disorders. Before making modifications along with dietary supplements, the decision to use antioxidants for treatment, it is critical neutraceuticals and functional foods can help prevent the to obtain histopathologic diagnosis of the lesion. Lesions development and progression of diseases like cancer. diagnosed as hyperkeratotic will take considerable amount Further research on the health benefits, efficacy and safety of time before showing clinical signs of improvement while of phytochemicals in whole foods is warranted. lesions diagnosed as dysplastic may not show any positive

Keywords : Antioxidants, phytochemicals, oral potentially malignant 124 disorders, chemoprevention - Ananya Madiyal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

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Keywords : Antioxidants, phytochemicals, oral potentially malignant 125 disorders, chemoprevention - Ananya Madiyal NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Review Article EMBRYONIC CYSTS, SINUSES AND FISTULAE OF BRANCHIAL ORIGIN Arunachalam Kumar Professor, Department of Anatomy, K.S. Hegde Medical Academy, Nitte University Mangalore - 575 018, India. Correspondence : Arunachalam Kumar Professor, Department of Anatomy, K.S. Hegde Medical Academy, Nitte University, Mangalore - 575 018, India. E-mail : [email protected] Abstract : This brief review hopes to provide basic embryological and anatomical information on location, cause and identification of congenital developmental anomalies related to formation of pharyngeal (branchial) arches to paediatricians, otolaryngologists, obstetricians and neonatologists. The pathological manifestations due to neglect or oversight of these development defects have potential to cause a wide range of clinical disorders. Correct and timely recognition of these congenital developmental defects and their redress through appropriate surgical and clinical interventions require clinicians to possess a rudimentary grasp of embryological processes Keywords : branchial, cysts, sinuses, fistulae

Introduction : This malformation discussed here are in their order of Early recognition and correct diagnosis of congenital lateral frequency of occurrence. cervical dysgenic embryological structures require that a 1. Branchial cysts paediatrician have a thorough knowledge of embryology. 2. External sinuses Congenital birth and developmental malformations, 3. Internal sinuses especially those involving the head and neck may, require 4. Pharyngo – cutaneous fistulae specialised surgical interference. This paper attempts an 5. Accessory or aberrant glandular structures. overview of the 'side of the neck' developmental 6. Other associated anomalies embryopathies1 . Branchial cysts As early as the 5th week of growth, the 5 mm embryo shows The branchial cysts consist of almost 75% of all the lateral discernible branchial or pharyngeal arches at the cranial cervical vestiges. The salient features of these cysts are: end of its foregut and surrounding area2, 3 . Despite the a) Almost always unilateral complexity and specificity of the differentiation of ecto- b) No familial incidence endo-mesodermal entities, there are surprisingly a very c) Constancy of position low percentage of congenital defects in these areas. d) Predominantly unilocular F r e q u e n c y e) Lined in majority of cases by stratified squamous Access this article online notwithstanding this cells. Quick Response Code review may aid the novice clinician embryonic These cysts lie at about the level of hyoid, on the carotid vestiges. The scope of this sheath deep to the anterior margin of the paper is limited to the sternocleidomastoid. Though most cysts are encapsulated pouch / cleft complex only completely, some may have an upper or lower pedicle or (endoderm / ectoderm). both. When present the upper pedicle extends from the

Keywords : branchial, cysts, sinuses, fistulae - Arunachalam Kumar 126 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science supramedial part of the branchial cyst towards the pharynx d) An extension from the palatopharyngeus invests the passing between the external and internal carotid arteries, sinuses lateral to the XII (Hypoglossal) nerve. e) The lining epithelium is of the respiratory type, ciliated or pseudostratified columnar. The inferior pedicle, if present, extends to the medical edges of the sternocleidomastoid attaching itself to the Complete pharyngocutaneous fistulae skin at variable levels, as low as the clavicle. Pediculation of These fistulae present in the under mentioned a branchial cyst can be confirmed through the application characters of gentle traction on the cyst: Dimpling of the skin or a) Opening in the same anatomical plane as the internal pharyngeal wall or both, confirms the attachment of a and external sinuses. superior, inferior or both pedicles to the cysts. b) Inflammatory changes frequent c) Bilateral in about a third of cases External sinuses d) Familial disposition recorded The distinguishing characteristics of the external sinuses e) Predominantly of the stratified squamous lining are: epithelium, through often towards the pharyngeal a) Present at birth termination, showing ciliated columnar respiratory b) These sinuses open in the lower third of the neck type cell lining. along anterior border of the sternocleidomastoid. Whilst most often the tracts of these complete fistulae are c) Secondary infections and inflammations are uniform dimension transversely, they may not common uncommonly show a distended cyst suspended between d) Bilateral in about a third of cases. two patent small calibre tracts extending to either side. e) When unilateral, more common in the right side. f) Familiar incidence common Other branchial and associated anomalies g) More often seen in the female than the male. Cervicoaural fistulae h) Histologically the epithelium is of the stratified a) Rare squamous cells type. b) Superiorly open into the external auditory meatus c) Inferiorly open into the skin over angle of the Deep sinuses extend upwards between the external and mandible internal carotid arteries, resembling in their extension, to d) The posterior belly of the digastric muscle lies deep to the superior pedicle of the branchial cyst. The calibre of the the course of the tract of these fistulae. track is uniform along the length of the sinus, except when the sinus possesses an umbelliform upper extremity. The Branchial cartilages trumpet shaped external sinus may be confused with the Strictly speaking though these inclusions are not of either inferiorly pediculated branchial cyst. A search for a patent ecto or endodermal germ origin, cartilaginous nodules are lower extremity of the tract should confirm the possibility occasionally found within the wall of branchial cysts or of external sinus. fistulae or even as unassociated findings situated in the cervical skin. Branchial cartilaginous nodules have been Internal sinuses often discovered in or about the tonsil or in the tongue. The features of these sinuses are somewhat ambiguous They are considered as vestiges of the second arch cartilage a) Their frequency is not known. (Reichert's). b) Most are symptomless and remain undiagnosed c) They open into the fauces, posterior to the palatine Cervical auricles tonsil Tags of skin, sometimes protruding from cutaneous orifices

Keywords : branchial, cysts, sinuses, fistulae - Arunachalam Kumar 127 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science of sinuses or fistulae are known as cervical auricles. These Discussion : unusual auricles, when present, show bilaterality and a It is embryologically understandable that, excluding the familial preponderance. first cleft to (ectodermal) and first pouch (endodermal) which form the external auditory meatus and the Associated anomalies tubothympanic recess respectively, vestigial remnants are Branchial fistulae are sometimes associated with facial or at least theoretically possible from all the other pouches cervical anomalies. Preauricular sinuses, accessory and clefts. Indeed, all known lateral cervical vestiges can be auricles, (auricular tubercles), hemithyroid or unilateral easily correlated to defective derivations there from4 . sternocleidomastoid are examples of some of these remote malformations. One school of embryologists however, believes that all brachial cysts are remains of non-regressed epibranchial Aberrant or accessory glandular vestiges vesicles of epibranchial placodes which are thickened Vesicular, canalicular or acinar gland tissues often seen ectodermal patches overlying the dorsal extreme of the normally attached to the foetal thymus or parathyroid may arches. They play a role in the formation of the cranial sometimes persist in the neonate. These vesicular nerve ganglia, especially the facial nerve in man and the structures may distend resembling a branchial cyst. The glossopharyngeal and vagal ganglia in lower vertebrates. persistent tissue is said to represent secondary buds or ducts from foetal thymus or parathyroid. In frequency, the first arch remnants form only 5% of cases seen while the remaining 95% are defects from the 2nd arch. Accessory parathyroids have been described as intra – The remaining arches rarely produce any recognizable parathyroidal, intrathymic or even in the anterior developmental defects.5, 6 mediastinum. Mediastinal parathyroid must be suspected when the usual parathyroids are of normal dimension in Whatever the rationale and theory surrounding the hyperarathyroidics. appearance of the congenital lateral cervical vestiges, the specificity of their location, distinct histopathological The thymus may in the part or completely remain features and definable anatomical relations are giveaways undescended. A normal thymus may show an accessory that every clinician should be familiar with, especially those cervical portion or even aberrant thymic nodules. from specialties that most often and most intimately Intrathyroide thymic tissue has also been recorded. comes into contact with the age groups that manifests the branchial lateral cervical developmental anomalies

References : 1. Arunachalam Kumar (1988) Vestigeal cysts, sinuses and fistulae of branchial origin, Karnataka Paediatric Journal, 2; 1; 9-12, 1988 2. Willis RA., in The Borderland of Embryology and Pathology, Butterworth, London, 1962, 442 3. Warwick R. and Williams PL., in Gray's Anatomy, London. 35th Ed. 1973 4. Hamilton W. J. and Mossman HW., in Human Embryology, IV Ed. Macmillan, U. K., 1976 5. Acierno SP, Waldhausen JHT (2007), Congenital Cervical Cysts, Sinuses and Fistulae. Otolaryngol Clin N Am, 40, 161–176 6. Waldhausen JHT (2006) Branchial cleft and arch anomalies in children. Semin Pediatr Surg. 15:64–9.

Keywords : branchial, cysts, sinuses, fistulae - Arunachalam Kumar 128 NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science Review Article A REVIEW OF CURRENT CONCEPTS IN BRUXISM – DIAGNOSIS AND MANAGEMENT Krishna Prasad D1 , Archana Ashok Swaminathan2 & Anupama Prasad D.3 1Professor & H.O.D, 2 Post Graduate, 3 Lecturer, Department of Prosthodontics and Crown & Bridge, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018, India. Correspondence : Krishna Prasad D. Professor & H.O.D, Department of Prosthodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University, Mangalore - 575 018, India. E-mail : [email protected] Abstract: Bruxism, which can be considered as an umbrella term for clenching and grinding of teeth, is the commonest of the many parafunctional activities of the stomatognathic system. Bruxism can occur during wakefulness or during sleep and each has a different set of causative factors. The early diagnosis and management can prevent the breakdown of the dentition and pain in the orofacial region. Although various treatment modalities are present, the successful management of bruxism lies in the precise diagnosis and isolation of the etiology. Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current concepts in bruxism, Review of bruxism

Introduction : 'Sleep Bruxism' (SB). Tooth grinding is an activity of significance to the dental Awake bruxism is linked to life stress caused by familial specialist because of breakage of dental restorations, tooth responsibility or work pressure. Sleep Bruxism is an oro- damage, induction of temporal headache and mandibular behaviour that is defined as a stereotyped temporomandibular disorders.1 movement disorder occurring during sleep and Bruxism, which can be considered as an umbrella term for characterized by tooth grinding and/or clenching.4 Sleep clenching and grinding of teeth, is the commonest of the bruxism was recently classified as sleep related movement many parafunctional activities of the stomatognathic disorder according to recent classification of Sleep system.2 The term Bruxism originates from the Greek word Disorders. brychein, which means to grind. It was later adopted as Prevalence rate of Awake and Sleep Bruxism is about 20% 'Bruxism' to describe gnashing and grinding of the teeth and 8–16% respectively in adult population.5 Awake occurring without a functional purpose.2 bruxism occurs predominantly among females while no Bruxism can occur during wakefulness or during sleep. The gender difference is seen for sleep bruxism.6 Onset of Sleep American Academy of Sleeping Disorders proposed the Bruxism is about 1 year of age soon after the eruption of terms Sleep and Awake Bruxism. Bruxism during daytime is deciduous incisors.7 The disorder appears more frequently commonly a semi in the younger population.7 The prevalence in children is Access this article online voluntary 'clenching' between 14 to 20%. Quick Response Code activity and is also known Causes of bruxism : as 'Awake Bruxism' (AB) or Bruxism is said to have a multifactorial etiology. Diurnal Bruxism (DB).3 Central /Patho-Physiological factors: Bruxism during sleep As bruxism often occurs during sleep, the physiology of either during daytime or sleep has been studied in depth, particularly the 'arousal during night is termed as

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 129 concepts in bruxism, Review of bruxism - Krishna Prasad D. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science response' in search of possible causes of disorder. assess sleep bruxism demonstrated that daytime time clenching could significantly be explained by experienced 'Arousal response' is a sudden change in the depth of the stress, although experienced stress and anticipated stress sleep during which the individual either arrives in the were unrelated to sleep bruxism as recorded with lighter sleep stage or actually wakes up. This response is ambulatory devices.12 accompanied by body movements, increased heart rate, respiratory changes and increased muscle activity. A study Peripheral Factors : showed 86% of bruxism episodes were associated with For an effective management of bruxism, establishment of arousal response along with involuntary leg movements.8 harmony between maximum intercuspation and centric relation is required.13

CENTRAL However recent literature on this subject now agrees FACTORS that there is no or hardly any relationship between clinically established bruxism and occlusal factors in adults.14

Assessment and Accurate interpretation of bruxism: Although bruxism is not a huge handicap, it can influence BRUXISM the quality of human life, especially through dental problems, such as tooth wear leading to inefficiency of PSYCHOSOCIAL PERIPHERAL INFLUENCES FACTORS mastication, pain in the facial region and tooth fractures. Hence early identification and preventive measures go a long way to protect the occlusion.

This indicates that bruxism is a part of arousal response. Some of the methods of assessment are as follows:

Acute use of dopamine precursors like L-dopa inhibits bruxism activity and chronic long term use of L-dopa results 9 in increased bruxism activity. Amphetamine which CLINICAL QUESTIONNAIRES increases the dopamine concentration by facilitating its FINDINGS release has been observed to increase bruxism.10 Nicotine stimulates central dopaminergic activities which might explain the finding that cigarette smokers report bruxism MASTICATORY MUSCLE 9 INTRA ORAL two times more than the non-smokers. ELECTRO APPLIANCES MYOGRAPHIC Psycho social Factors : RECORDING Extensive studies have been conducted regarding the role of psychosocial factors in the etiology of bruxism but none Questionnaires: of these are determinative due to the absence of large Questionnaires are adjuncts in both research and clinical scale longitudinal trials. situations. This method can be applied to large population but the limitation is the subjective nature of the response. Bruxers differs from healthy individuals in the presence of Most bruxism episodes are not accompanied by noise. So a depression, increased levels of hostility and stress large percentage of adults and children are unaware of sensitivity.11 Bruxing children are more anxious than non their bruxism activity and thus fails to identify themselves bruxers. A multifactorial large scale population study to as the bruxers.15

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 130 concepts in bruxism, Review of bruxism - Krishna Prasad D. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

QUESTIONNAIRE FOR DETECTING BRUXER16 factor to tooth wear. All modalities usually interact with each other to cause wear. Has anyone heard you grinding your teeth at night ? So the evaluation of tooth wear for determining actual Is your jaw ever fatigue or sore on awakening in the morning ? bruxism is disputable and hence it is difficult to estimate Are your teeth or gums ever sore on awakening the degree of contribution of bruxism to tooth wear alone. in the morning ? Do you ever experience temporal headache on awakening Intra-oral appliance: in the morning ?

Are you ever aware of grinding your teeth during the day? Bruxism activity can be measured using the intra-oral appliance and is classified into two groups.21 Are you ever aware of clenching your teeth during the day?

Clinical evaluation : INTRAORAL APPLIANCE Clinical Evaluation

Clinical Tooth Wear Examination Observation of wear Measurement of bite Tooth wear is assumed to be synonymous to bruxism. facets of the force loaded on the intra-oral appliance intra-oral appliance Several studies have demonstrated a positive relationship17 between tooth wear and bruxism but others show negative Some studies describe a repetitive wear pattern on the results.18 Guidelines that help to identify bruxism.19 occlusal splint,22 while other studies noted that Various systems for the classification and measurement of parafunctional nocturnal dental activity on full-arch tooth wear have been introduced. One of the many occlusal stabilization splints resulted in wear, which was classifications is the Tooth-Wear Index which categorises both asymmetric and uneven.23 However the accuracy of based on incisal and occlusal wear and was developed to these methods has not been ascertained. investigate the prevalence and severity of tooth wear. Bruxcore plate : Guidelines that help to identify bruxism.19 The Bruxcore Bruxism-Monitoring Device (BBMD) is an intra-oral appliance that measures sleep bruxism activity Report of tooth grinding or tapping objectively.24 The Bruxcore plate evaluates bruxism activity Presence of tooth wear seen within normal range of jaw movements or at eccentric position by counting the number of abraded microdots on its Presence of masseter muscle hypertrophy on surface and by scoring the volumetric magnitude of voluntary constraction abrasion.24 Complain of masticatory muscles discomfort, fatigue of stiffness in the morning A recording device has been designed for sleep bruxism, an Tooth or teeth hypersensitive to cold air or liquid intra-splint force detector (ISFD), which uses an intra-oral Clicking or locking of temporomandibular joint appliance to measure the force being produced by tooth contact onto the appliance.25 The force is detected using a Tooth wear is a cumulative record of both functional and thin, deformation-sensitive piezoelectric film, which is parafunctional activities and various factors such as age, embedded 1–2 mm below the occlusal surface of the gender, diet and bruxism are associated with tooth appliance. It was confirmed, that the duration of bruxism 20 wear. Erosion by aerated drinks is a major contributing events during simulated bruxism, i.e. clenching, grinding,

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 131 concepts in bruxism, Review of bruxism - Krishna Prasad D. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science tapping and rhythmic clenching, evaluated with the ISFD, analyser with a biofeedback function (Grindcare, was correlated with that of the masseter EMG.25 Medotech,Denmark) was developed as a detector and biofeedback device for sleep bruxism.31 The ISFD did not correctly capture force magnitudes during sustained clenching because of the characteristic of the It is a type of contingent electrical stimulation (CES). piezoelectric film, i.e. this transducer is best at detecting It enables the online recording of EMG activity of the rapid changes in force, not static forces.ISFD was not anterior temporalis muscle, online processing of EMG suitable for detecting the magnitude of force during signals to detect tooth grinding and clenching and also steady-state clenching behaviour.25 biofeedback stimulation for reducing sleep bruxism activities.31 Masticatory muscle Electromyographic recording : One among the plethora of assessment tools, the EMG Although scientific confirmation is needed, it is considered recording has been used to measure actual sleep bruxism as one of the potent devices for detecting and also for activity directly. The main advantage is that the bruxism managing sleep bruxism. can be measured without intra-oral devices, which may The portable EMG recording system allows multiple-night change natural bruxism activity. recording in a natural environment for the subject with Portable EMG recording devices : minimal expense. Since the 1970s, sleep bruxism episodes were measured Polysomnography : over a period of time in patients' homes with the use of Polysomnographic (sleep laboratory) recordings for sleep battery-operated EMG recording devices.26 Criteria for the bruxism includes electroencephalogram, detection of sleep bruxism with the portable EMG EMG,electrocardiogram and thermally sensitive resistor recording system have been suggested but their validity in (monitoring air flow) signals along with simultaneous a large population has not yet been confirmed.27 The audio–video recordings.32 isolation of sleep bruxism is difficult because of other confounding oro-facial activities (e.g. coughing and The sleep laboratory setting offers a highly controlled mumbling).Also, other sleep disorders cannot be ruled out recording environment, hence other sleep disorders (e.g. for e.g. micro arousal, tachycardia and sleep-stage shift.28 sleep apnoea and insomnia) can be ruled out and sleep bruxism can be distinguished from other orofacial activities The recording the heart rate was suggested as one of the (e.g. myclonus, swallowing and coughing). compensatory measures for improving the accuracy of sleep bruxism recognition. A surface EMG electrode with a Management of Bruxism: built-in buffer-amplifier and a cordless type of EMG Currently no specific treatment exists which can stop sleep measurement system was developed as well, to improve bruxism, even though many methods including prosthetic the accuracy of recordings.29 treatment, have been tried over the years. A handful of therapies have been suggested including behaviour Miniature self-contained EMG detector analyser : modification such as habit awareness, habit reversal A miniature self-contained EMG detector–analyser (Bite- therapy, relaxation technique and biofeedback may Strip) was developed as a screening test for moderate to eliminate awake bruxism. high level bruxers.30 Its salient feature is that the number of bruxism events can be objectively estimated by simply Occlusal therapy : attaching it to the skin over the masseter muscle. Management of bruxism via occlusal therapy enlists the aid of occlusal interventions and occlusal appliances. Recently, a miniature self-contained EMG detector–

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 132 concepts in bruxism, Review of bruxism - Krishna Prasad D. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

Biofeedback soft splints.35 'Nociceptive Trigeminal Inhibition (NTI) Bruxism during Behaviour wakefulness modifacation Clenching Suppression System'—a small anterior splint Sleep bruxism that is supposed to be effective amongst others in the management of bruxism.36 No evidence for the NTI splint's Occlusal Therapy Occlusal Pharmacological long-term efficacy or safety is available so far. Interventions approach Occlusal appliances Management of In a study, it was shown that occlusal splint treatment Bruxism resulted in a decrease in nocturnal EMG activities in about half of the patients, while in another half of the patients, no change or even increase in EMG activity was observed.37 Occlusal interventions : A study has tried to justify the effects of occlusal However, due to the scarcity of Randomised Control Trial adjustment on the myoelectrical activity of the jaw-closing on the efficacy of occlusal splints in the management of 33 muscles. However, their brief daytime EMG recordings of bruxism, it is prudent to limit the use of oral splints in the postural activity and maximal voluntary clenching cannot management of bruxism to the prevention or limitation of be interpreted in terms of bruxism. dental damage that is possibly caused by the disorder.

Other authors have stated that occlusal rehabilitation Behaviour modification : further mutilates the dentition beyond what bruxism has Psychoanalysis, hypnosis, progressive relaxation, 34 created. meditation, self-monitoring, sleep hygiene and habit reversal have been prescribed for the management of At present, the current insights into the etiology of bruxism bruxism. Giving autosuggestion before falling asleep such that the disorder is mainly regulated centrally and not as 'I will wake up if I grind my teeth' is reported by peripherally, future research on this category of psychoanalysts to help the bruxer become aware of the management strategies for bruxism seems futile. habit, even while asleep. Unfortunately, autosuggestion Occlusal appliances : lacks scientific strength and is not recommended. By far, the treatment regime which has withstood the test More general relaxation techniques including meditation of time is the procedure of splint therapy. Occlusal are supposed to produce a sense of self-esteem and appliances are useful adjuncts in the management of sleep control over one's body. bruxism but do not cure bruxism. Occlusal splints are commonly used to prevent tooth wear caused by bruxism. Biofeedback and cognitive behavioural therapy : Biofeedback is based on the principle that bruxers can Literature describes the clinical and laboratory procedures 'unlearn' their behaviour when aware of their adverse jaw for the various types of splints. These splints have different names (e.g. occlusal bite guard, bruxism appliance, bite What plate, night guard, occlusal device) and slightly different you think appearances and properties, but in essence most of them are hard acrylic-resin stabilization appliances, mostly worn in the maxillary arch. BIOFEEDBACK Hard splints are generally preferred over soft splints (e.g. soft splints are more difficult to adjust than hard ones) to What What you do you feel prevent inadvertent tooth movements and because hard splints are more effective in reducing bruxism activity than

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 133 concepts in bruxism, Review of bruxism - Krishna Prasad D. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science muscle activities. This technique has been applied for injections of BOTOX during a time period of 20 weeks.44 The bruxism during wakefulness as well as for sleep bruxism. study suggested that drugs that have paralytic effect on the muscles through an inhibition of acetylcholine release at While awake, patients can be trained to control their jaw the neuromuscular junction (botulinum toxin) decreases muscle activities through auditory or visual feedback. For bruxism activity especially in severe cases with sleep bruxism, auditory, electrical, vibratory and even taste comorbidities like coma, brain injury, Huntington's disease stimuli can be used for feedback. and autism. Bruxism during wakefulness : Discussion : One of the early publications on the use of biofeedback in Research focusing on the relationship between bruxism the management of bruxism during wakefulness was given and prosthetic therapy is scarce.2 There's no conclusive in 1976.38 It described an EMG technique that provides evidence that any prosthetic therapy can eliminate auditory feedback from muscle activity letting him know bruxism and likewise, no evidence to support that bruxism the degree of muscle activity or relaxation that is taking is caused by prosthetic therapy. place. Several authors and studies have been mentioned while Bruxism while sleeping: listing the current concepts in the diagnosis and In 1986 a technique was developed which used contingent management of bruxism. Despite of this, currently no arousal from sleep with actual awakenings.39 Few other treatment exists that can stop bruxism. Studies require techniques used a taste stimulus to awaken the patient.40 randomised control studies over a larger population before Other researchers in 2001 came up with the vibratory being considered as the norm. stimulation based inhibition system for nocturnal bruxism.41 As far as intra oral devices are concerned, the major problem is that subjects have to wear these devices and In a demonstration of concept study, in 2003, the effect of this may change the original bruxism activity. contingent electrical lip stimulation on sleep Bruxism was evaluated.42 In the use of polysomnography, one major limitation is that a change in the environment for sleep may influence the In 2011, a study of the effect of electromyogram actual behaviour of bruxism. Another is the expense as biofeedback on daytime clenching behaviour in subjects multiple nights/ recording is to be taken for the occurrence with masticatory muscle pain was published.43 of sleep bruxism varies over a number of nights. Electromyogram (EMG) biofeedback training was performed for a patient, consecutively for 5 days, to Handicaps in each technique come in various forms such as ascertain its effect on the regulation of daytime clenching when a sound blast was applied as the aversive stimulus. behaviour. Their study concluded that daytime clenching The sound stimulus wakes up the patient, who is then was reduced in the short-term with the help of an EMG supposed to switch off the sound, thus cutting off their biofeedback system under natural circumstances. bruxing and resume his/her sleep. The awakenings are a major disadvantage of such approaches because sleep Pharmacological management : disruption may lead to serious side effects like irritability, The pharmacological management of bruxism has been excessive daytime sleepiness and exhaustion. studied increasingly over the past decades. In the pharmacological approach, although some seem A study involving 18 subjects with severe Bruxism was promising, they all need further efficacy and safety conducted with the administration of a total of 241 assessments before clinical recommendations can be made.

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 134 concepts in bruxism, Review of bruxism - Krishna Prasad D. 1. Lavigne, G. J., Khoury, S., Abe, S., Yamaguchi, T., & Raphael, K. Bruxism physiology and pathology: an overview for clinicians. Journal of oral rehabilitation, 2008; 35(7), 476-494. 2. Johansson A,Omar R, Carlsson G Bruxism nd prosthetic treatment: A critical review Journal of Prosthetic Research 2011,55;127-136 3. AASM (2005) International classification of sleep disorders, 2nd edn. American Academy of Sleep Medicine, Westchester 4. De Laat A, Macaluso GM Sleep bruxism as a motor disorder. Mov Disord 2002 17(suppl):S67–S69 5. Glaros AG. Incidence of diurnal and nocturnal bruxism. J Prosthet Dent 1981, 45:545–549 6. ICSD—International Classification of Sleep Disorders: Diagnostic and Coding manual. Diagnostic Classification Steering Committee, Thorpy, Chairman, Rochester, MN: American Sleep Disorders Association 1990 7. Sari S, Sonmez H. The relationship between occlusal factors and bruxism in permanent and mixed dentition in Turkish children. J Clin Pediatr Dent 2001 25:191–194 8. Macaluso, G. M., Guerra, P., Di Giovanni, G., Boselli, M., Parrino, L., & Terzano, M. G. Sleep bruxism is a disorder related to periodic arousals during sleep. Journal of dental research, 1988; 77(4), 565-573. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

wear in young adults over a two-year period. J Prosthet Dent 1997, Dis Fac Oral Pain 1992 6:71–81 77:313–320 33. Holmgren K, Sheikholeslam A Occlusal adjustment and myoelectric 17. Knight DJ, Leroux BG, Zhu C, Almond J, Ramsay DS A longitudinal study activity of the jaw elevator muscles in patients with nocturnal bruxism of tooth wear in orthodontically treated patients. Am J Orthod and craniomandibular disorders. Scand J Dent Res 1994 102:238–243 Dentofac Orthop 1997 112:194–202 34. Greene CS, Klasser GD, Epstein JB 'Observations' questioned. J Am 18. Baba K, Haketa T, Clark GT, Ohyama T. Does tooth wear status predict Dent Assoc 2005,136:852–853 ongoing sleep bruxism in 30-year-old Japanese subjects? Int J 35. Okeson JP The effects of hard and soft occlusal splints on nocturnal Prosthodont 2004,17:39–44 bruxism. J Am Dent Assoc 1987,114:788–791 19.Kato T, Thie NM, Montplaisir JY, Lavigne GJ Bruxism and 36. Boyd JP Improving TMD treatment and protecting restorative orofacialmovements duringsleep.DentClinNAm 2001, 45:657–684 dentistry. Dent Today 1998, 17:144 20. Johansson A, Johansson AK, Omer R, Carlsson GE. Rehabilitation of the 37. Clark GT, Beemsterboer PL, Solberg WK, Rugh JD. Nocturnal worn dentition. J Oral Rehabil 2008, 35:548–566 electromyographic evaluation of myofascial pain dysfunction in 21. Baba K, Clark GT, Watanabe T, Ohyama T. Bruxism force detection by a patients undergoing occlusal splint therapy. J Am Dent Assoc 1979, piezoelectric film-based recording device in sleeping humans. J Orofac 99:607–611 Pain 2003; 17:58–64 38. Mittelman J Biofeedback: new answer to dental pain. Dent Manag 22. Holmgren K, Sheikholeslam A, Riise C. Effect of a fullarch maxillary 1976, 16(21–22):26–27 occlusal splint on parafunctional activity during sleep in patients with 39. Cherasia M, Parks L. Suggestions for use of behavioural measures in nocturnal bruxism and signs and symptoms of craniomandibular treating bruxism. Psychol Rep 1986; 58:719–722 disorders. J Prosthet Dent 1993 69:293–297 40. Nissani M .Can taste aversion prevent bruxism? Appl Psychophysiol 23. Korioth TW, Bohlig KG, Anderson GC Digital assessment of occlusal Biofeedback 2000; 25:43–54 wear patterns on occlusal stabilization splints: a pilot study. J Prosthet 41. Watanabe, Baba, Yamagata. A vibratory stimulation based inhibition Dent 1998 80:209–213 system for nocturnal bruxism. J P D 2001;85:233-235 24. Pierce CJ, Gale EN Methodological considerations concerning the use 42. Nishigawa, K., Kondo, K., Takeuchi, H., & Clark, G. T. (2003). Contingent of bruxcore plates to evaluate nocturnal bruxism. J Dent Res 1989, electrical lip stimulation for sleep bruxism: a pilot study. The Journal of 68:1110–1114 prosthetic dentistry, 89(4), 412-417. 25. Takeuchi H, Ikeda T, Clark GT A piezoelectric film-based intrasplint 43. Watanabe, A., Kanemura, K., Tanabe, N., & Fujisawa, M. Effect of detection method for bruxism. J Prosthet Dent 2001 86:195–202 electromyogram biofeedback on daytime clenching behavior in 26. Rugh JD, Solberg WK Electromyographic studies of bruxist behaviour subjects with masticatory muscle pain. Journal of prosthodontic before and during treatment. J Calif Dent Assoc 1975 3:56–59 research, 2011;55(2), 75-81. 27. Ikeda T, Nishigawa K Criteria for the detection of sleep associated 44. Tan, E. K., & Jankovic, J. O. S. E. P. H. Treating severe bruxism with bruxism in humans. J Orofac Pain 1996, 10:270–282 botulinum toxin. J Am Dent Assoc, 2000;131(2), 211-6. 28. Kato T, Thie NM, Huynh N, Miyawaki S, Lavigne GJ. Topical review: 45. Ommerborn MA, Schneider C, Giraki M, Schafer R Handschel J, Franz sleep bruxism and the role of peripheral sensory influences. J Orofac M, Raab WH. Effects of an occlusal splint compared with cognitive- Pain 2003, 17:191–213 behavioural treatment on sleep bruxism activity. Eur J Oral Sci 2007; 29. Yamaguchi T, Mikami S, Okada K. Validity of a newly developed 115(1):7-14 ultraminiature cordless EMG measurement system. Oral Surg Oral 46. Pjetursson BE, Lang NP. Prosthetic planning on the basis of scientific Med Oral Pathol Oral Radiol Endod 2007; 104:e22–e27 evidence. J Oral Rehabil 2008;35:72-79 30. Minakuchi H, Clark GT The sensitivity and specificity ofminiature 47. Lindquist LW,Carlsson GE, Jemt. A prospective 15 yr follow up study of bruxism detection device. J Dent Res 2004 ; 83 mandibular implant fixed prosthesis- clinical results and marginal 31. Jadidi F, Castrillon E, Svensson P Effect of conditioning electrical bone loss. Clin Oral Implants res 1996;7:329-36 stimuli on temporalis electromyographic activity during sleep. J Oral 48. Yip KH, Smales RJ, Kaidonis JA. Differential wear of teeth and Rehabil 2007 34:152–159 restorative materials: clinical implications. Int J Prosthodont 32. Velly-Miguel AM, Montplaisir J, Rompre PH, Lund JP, Lavigne GL. 2004;17:350-6 Bruxism and other orofacial movements during sleep. J Craniomandib

Keywords : Bruxism, Sleep bruxism, Awake bruxism, Current 136 concepts in bruxism, Review of bruxism - Krishna Prasad D. NUJHS Vol. 4, No.4, December 2014, ISSN 2249-7110 Nitte University Journal of Health Science

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