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DOI: 10.5958/2319-5886.2015.00048.

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 27 July 2014
Research article

Coden: IJMRHS
Copyright@2014
ISSN: 2319-5886
th
Revised: 5 Dec 2014
Accepted: 5th Jan 2015

THE INFLUENCE OF PERIPHERAL NEUROPATHY AND PERIPHERAL VASCULAR DISEASE IN THE


OUTCOME OF DIABETIC FOOT MANAGEMENT A PROSPECTIVE STUDY
Sundar Prakash S1, Krishnakumar2, Chandra Prabha3
1

Assistant Professor, Department of General Surgery, Meenakshi Medical College and Research Institute, Kanchipuram.
Final year General Surgery PG, Department of General Surgery, Meenakshi Medical College and Research Institute,
Kanchipuram.
3
Final year PG, Department of Physiology, Meenakshi Medical College and Research Institute, Kanchipuram
2

Corresponding author email: drssp1967@gmail.com


ABSTRACT
Objective: Peripheral neuropathy and Peripheral Vascular Disease are the risk factors for the development of diabetic foot.
The aim of this study was to evaluate differences and predictors of outcome parameters in patients with diabetic
foot by stratifying these subjects according to the severity of these risk factors. Materials and methods: This is a
prospective study conducted in 70 patients in the age group of 30-90 years diagnosed as Type II Diabetes with
foot ulcers. After detailed clinical examination the following tests were conducted in all the patients:
Complete blood count (CBC), Haemoglobin (Hb), Random Blood Sugar (RBS), Erythrocyte Sedimentation rate
(ESR), Chest X-ray(CXR), Electrocardiography (ECG), foot X-ray, pus culture, Neuropathy testing by
Semmes Weinstein Monofilament Test and Vibration Perception Threshold and Peripheral vascularity
assessment by Duplex Doppler. Then grading of the ulcers was done using Wagner's Grade. The outcome of
the patients was assessed by recording the healing time, mode of surgery and amputation rates of the patients.
Results: A total of 70 patients with diabetic foot were consecutively included into the study (65.7% male, age
(31% in 51-60 years), mean diabetes duration (5.2 years), Ulcer Grade (37% in Grade IV), Foot lesions (45.7% in
toe), Blood sugar levels (64% in 300-400 mg/dl), Neuropathy (84%), Peripheral vascular disease (67%), major
amputation (7%) and mortality (1.4%). Conclusion: All diabetic patients should undergo testing for neuropathy
and peripheral vascular disease apart from doing other tests.
Key words: Diabetic foot, ulcers, neuropathy, peripheral vascular disease.
INTRODUCTION
Complications affecting diabetes are many with
some of the most catastrophic ones affecting the
lower extremities. Levin et al [1] estimated that 20%
of all hospital admissions for diabetes were the result
of foot problems. Warren et al[2] in their survey of the
lower extremities amputations found that 91.8% of
amputations were performed secondary to gangrene,
necrosis, ulcer, nearly one half of these patients were
diabetics. Apelquist J et al[3] in their study on

importance of wound classification in the outcome of


diabetic foot ulcer stated that the ulcer was classified
on the basis of superficial, deep, minor or major
gangrene and that the healing rate of superficial
ulcer is (88%) and deep ulcers is(78%) 57%. In
abscess and osteomyelitis it was (57%) and found that
out all there was only marginal difference in primary
healing rate between the ulcer sites.
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The remarkable pathogenesis of diabetic foot is


neuropathy, microvascular and macrovascular diseases.
Their process may occur exclusively or they may occur
together in varying degrees placing patients at risk
for morbidity such as ulceration, gangrene and
infection. This is especially true if these pathological
changes are combined with a foot deformity, making
patients more vulnerable to foot problems. Bauman et
al 4 demonstrated that only slight pressure over a fixed
bony deformity, such as a prominent metatarsal
head or a hammer toe lead to ischemic necrosis and
ulceration of skin. For this reason it is necessary to
identify the patients at increased risk. Apart from
other diabetic complications, one long term
complication of diabetes is neuropathy, which
causes foot ulceration in diabetic patients, despite
considerable research; the pathogenesis of diabetic
neuropathy remains undetermined. Current
hypothesis regarding the etiology of diabetic
neuropathy are centered on a combination of
metabolic defects secondary to higher glycaemia and
vascular changes that results in nerve hypoxia.
Evidence for hypoxia as etiology is considerable
and includes reduced endoneurial blood flow,
increased vascular resistance, and decreased
endothelial production of nitric oxide. Although
microvascular dysfunction has been mainly
implicated, the role of peripheral vascular disease
remains considerable, as it appears likely that a
decrease in total limb blood flow would potentiate
nerve ischemia. Hence both peripheral
neuropathy and peripheral vascular disease are the
commonest etiology in diabetic foot ulcer, apart from
other risk factors. Tests for neuropathy and
peripheral vascular diseases were done and the
outcome was assessed.
Aims and Objectives
1. To study the influence of peripheral neuropathy
and peripheral vascular disease in the outcome of
diabetic foot management.
2. To ascertain the risk of peripheral neuropathy and
peripheral vascular disease in diabetic patients
with diabetic foot ulcer.
3. Evaluate all patients with diabetic foot ulcer for
both peripheral neuropathy and peripheral
vascularity.
4. Assessment of outcome of the diabetic foot ulcers
regarding neuropathic/neuroischemic status.

MATERIALS AND METHODS


Prospective study was conducted in 70 patients in the
age group of 30 to 90 years diagnosed as Type II
diabetes with foot ulcer attending the diabetic OPD
and surgical units of MMCH&RI during the period
October 2011 to September 2013. Permission was
sought from Ethical Committee and Informed consents
were obtained from all the patients. All patients in the
study group had detailed clinical history of their
problem and the foot ulcers were examined in
detail.
Inclusion criteria
Patients attending MMCH&RI surgery OPD and
Diabetics clinic diagnosed as diabetic foot ulcers.
Patients above 30 years.
Not previously diagnosed as neuropathy or
having peripheral vascular diseases.
Exclusion criteria
Patients below 30 years of age.
Non-diabetic foot ulcers.
Previously diagnosed to have peripheral
neuropathy and peripheral vascular diseases.
All patients had undergone Complete blood count
(CBC), Haemoglobin (Hb), Random Blood Sugar
(RBS), Erythrocyte Sedimentation rate (ESR), Chest Xray(CXR), Electrocardiography (ECG). Neuropathy
testing was done using Semmes Weinstein
Monofilament Test (Fig 1&2) and then they were
tested for nerve conduction studies. Peripheral
vascularity was assessed clinically and also by
Duplex Doppler. After all the tests, grading of the
ulcers was done using Wagner's Grade.

Fig 1:Semmes-Weinstein monofilament

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Int J Med Res Health Sci. 2015;4(2):258-264

Fig 2:Semmes-Weinstein monofilament


Wagner Grading System:
Grade 1: Superficial Diabetic Ulcer
Grade 2: Ulcer extension
1.Involves ligament, tendon, joint capsule or fascia
2. No abscess or Osteomyelitis
Grade 3: Deep ulcer with abscess or Osteomyelitis
Grade 4: Gangrene to portion of forefoot
Grade 5: Extensive gangrene of foot
The outcome of the patients was assessed by
recording the healing time, mode of surgery, pus
culture & sensitivity and amputation rates of the
patients. All the above data were analyzed.
Statistical analysis: All the data were analyzed using
Graph Pad Prism Version 6.
RESULTS AND OBSERVATION
Sex distribution Out of 70 patients enrolled for the
study, 46 (65.7%) were males and 24 (34.3%) were
females patients. Age distribution In our study all
the patients above 30 years were included. 30% of the
patients were between 51 and 70 years of age. Fig 3
shows the details of age distribution in our study.

Fig 3: Age distribution


Duration of diabetes : Out of 70 patients enrolled in
our study majority of the patients had diabetes for 4-6

years (Table 1). The mean duration of diabetes was


5.2 years.
Table 1: Duration of diabetes
Duration
Number
(%)
(in year)
of Patients
0-2
15
21.4
2-4
14
20.0
4-6
24
34.3
6-8
8
11.4
8-10
5
7.4
10-12
1
1.4
12-14
2
2.8
14-16
1
1.4
Distribution of surgeries done previously for foot
problems: Out of 70 patients enrolled in the study,
10 (14.28%) patients had history of previous minor
amputations, 2 (2.85%) patients had history of major
amputation, 3(4.3%) had undergone other surgeries
like Debridement, I & D, Fasiotomies etc (Table 2).
Table 2: Distribution of surgeries done previously
for foot problems
Foot
Number
(%)
problems
of Patients
Minor amputation
10
14.2
Major Amputation
2
2.9
Others*
3
4.3
No previous surgeries
55
78.6
*Debridement, I & D, Fasiotomies, Minor Surgery
Predisposing external risk factors :Out of 70
patients enrolled in our study, 48 (68.5%) patients
had history of minor trauma due to bare foot walking
and ill-fitting foot wear, 3 (4.3%) had toenail
infection, 13 (18.5%) had history of thorn prick (Fig
4).

Fig 4: Predisposing external risk factors


Distribution of grades of diabetic foot ulcers: Out
of 70 patients our study diagnosed with foot
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Int J Med Res Health Sci. 2015;4(2):258-264

ulceration, grading was done based on Wagners


grading and most of the ulcers were predominantly
between grades II to Grave IV (Fig 5).

Fig 5: Distribution of grades of diabetic foot ulcers


Distribution of foot ulcers: Out of 70 patients in our
study, 32 (46%) patients had ulceration in the toes
and planter surface of toes, 28 (40%) had ulcers in
plantar surface of foot, metatarsal head, mid foot and
heel and 10 (14.0%) had ulcers in the dorsum of foot
(Table 3).
Table 3: Distribution of foot ulcers
Foot lesions

Number
of patients

(%)

Toe (Dorsal and


Plantar Surface)

32

45.7

Plantar, Metatarasal
Head,Mid Foot, Heel
Dorsum of Foot
Multiple Ulcers

28
10
0

40
14.3
0

Distribution of scores related to blood sugar


values: Out of 70 patients, 45 (64.3%) had elevated
Random Blood Sugar values ranging from 300-400
(Table 4).
Table 4: Distribution of scores related to blood
sugar values
Blood Sugar
Number
(%)
Values (RBS)*
of patients
200-300
15
21.4
300-400
45
64.3
400
10
1.4
Distribution of neuropathy: Out of 70 patients, all
were categorized for neuropathy using Semmes
Weinstein monofilament. Graph 4 shows 59 (84%)
patients suffered from peripheral neuropathy.

Fig 6: Distribution of neuropathy


Distribution of nerve conduction study scores: In
our study, majority of the patients (89.8%) had both
sensory and motor weaknesses (Table 5).
Table 5: Distribution of nerve conduction study
scores
Neuropathic
Number
(%)
type
of patients
Sensory
5
8.5
Motor
2
3.4
Sensory (+)
53
89.8
Motor
Distribution of peripheral vascular status scores:
In 70 patients, 23 (33%) had peripheral vascular
disease while in 47 (67%) it was not present(Table 6).
Table 6: Distribution of peripheral vascular status
scores
Peripheral
Number
Vascular Disease
of patients
(%)
Present
23
33
Absent
47
67
Distribution of score related to Doppler study:
According to our study, out of 23 patients, 18
(25.7%) had stenosis of peripheral arteries, 3 (4.3%)
had occlusion and 2 (2.9%) had both (Table 7).
Table 7: Distribution of score related to Doppler
study
B. Mode Duplex
Number
Doppler
of patients
(%)
Normal
47
67.1
Presence of stenosis
in peripheral arteries
18
25.7
Complete Occlusion
of peripheral arteries
3
4.3
Presence of both
stenosis and occlusion
2
2.9
of peripheral arteries
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Distribution of score categorized in ulcer groups:


In our study 36 (51.4%) patients had neuropathic foot
lesions and 23 (32.8%) had neuro-ischemia (Table 8).
Table 8: Distribution of score categorized in ulcer
groups
Categories

No. of patients

(%)

Neuropathic
36
51.4
Neuro-ischemia
23
32.8
Infection (Non-ischemic/
11
12.8
non-neuropathic)
Distribution of patients who had undergone
amputations: In our study majority of the patients
who had undergone both minor and major
amputations were in patients suffering from both
neuropathy and ischemia (Table 9). As per our
statistical analysis Chi square test was 21.40, 1 df and
the P value was <0.0001. Hence the proportion of
amputation cases among neuro-ischaemia patients
was significantly higher than the amputation cases in
neuropathy cases alone.
Table 9: Distribution of patients who had
undergone amputations
Categories

Minor
amputations
(Toe)

Major amputations
(Forefoot, BK,
AK)

Neuropathic (n=36)

4(11.1%)

Neuro-ischemia(n-23)

12 (52.2%)

4 (17.3%)

Infection(Non-ischemic
/non-neuropathic (n=9)

4 (44.4%)

1 (11.1%)

Distribution of outcome of the patients: Outcome


of the patients was calculated according to the healing
time. All patients had excellent outcome owing to
improvement in treatment modalities as seen in Table
10. Our analysis showed, Chi square 0.2658 and P
value <0.6062. Hence the treatment pattern was same
in all the cases.
Table 10: Distribution of outcome of the patients
Categories

Healed *

Unhealed
**

Mortality
***

Neuropathic (n=36)

34 (94%)
20 (87%)

2(6%)
2 (9%)

1 (4.3%)

9(82%)

2 (18%)

Neuro-ischemia(n-23)
Infection(Non
ischemic/Non
neuropathic(n=9)

*with in a period of 6 months either by full primary


healing or by SSG,
**healing time more than 6 months period going for
further surgeries
***patient dead due to complication of the wounds

DISCUSSION
Aksoy et al5 in their study in Istanbul (turkey) on
diabetic foot ulcerations enrolled 66 patients of which
39 (59%) men and 27 (41%) women. In another
study by Unal et al6 on diabetic foot in 200 patients in
Karachi found that the percentages of males were 65
and female were 35. In our study also the results were
similar, males 46 (56.7%) and females 24 (34.3%).
Hence the complications of diabetic foot ulcers are
more common in males. Al Mahroos et al7 in their
study on diabetic patients with foot problems in
patients in Bahrain observed that the mean age of the
patients were 57.3 + 6.32 years. Ahmed M et al8 in
their study on evaluation of diabetic foot ulcer in 100
subjects observed that the age group of patients was
between 40 - 60 years. In our study done on 70
patients with diabetic foot ulcerations majority of the
patients fall between 51-60 years of age and mean
age of these patients was 55 + 5 years. This is
relevant to the above studies and our study proved
that the complications of diabetes are more common
in the older age group. Nalini Singh et al9 in their
study on prevalence and determinants of foot
ulceration in patients with type II diabetes observed
that the mean duration of diabetes was 4.3 years.
Kumar S et al[10] in their study on prevalence of foot
ulceration and its correlation with type II diabetes
showed that the mean duration of diabetes among the
patients was 7.4 years. In our study the duration of
diabetes was for 5.2 years, which signifies that as the
duration of diabetes increases, the foot is prone for
problems. In comparison to above studies our
patients with diabetes tend to develop foot ulceration
little earlier. Apelquist J et al3 in their study on
external risk factors for foot ulcerations and the
outcome of diabetic foot lesions in 314 patients
demonstrated that the external precipitating factors
were identified in 264 out of 314. Common factors
like ill-fitting shoes, socks, acute mechanical trauma,
stress ulcers and paronychia were named. In our
study majority of the patients had history of minor
trauma, either due to bare foot walking (or) ill-fitting
foot wear, leading to minor trauma and ulceration and
minor injuries like thorn prick. This signifies the need
for education on personal care of foot by selfexaminations and general awareness of foot problems
and measures to prevent them and stressing the
importance of proper footwear in diabetic patients.
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Imran S et al11 in their study on frequency of lower


extremity amputations in diabetes with reference to
glycaemia control and Wagner's grades in Karachi
showed the following results. Grade O, 6 patients, 10
in grade I, 13 in grade II, 14 in grade III, 18 in grade
IV and 9 in grade V. Rooh-Ul-Muqim et al12 in their
study on evaluation and management of diabetic foot
by Wagner's classification, out of the 100 cases,
grade O (6), grade I (14), grade II (25), grade IV 30,
grade V (4). In our study the results were Grade O
(1), grade I (1), grade II (24), Grade III (17), grade IV
(26) and grade V (1). This shows that most of our
patients present in later part of the disease. If they
were treated in earlier grades the results would have
been much better. Apelquist J et al3 in their study of
the long term progress for diabetic patients with foot
ulcer observed that the results of patients with lesions
in the Toe (dorsal and Plantar surface) was 51%,
plantar surface, metatarsal head and foot and heel
was 28%, Dorsum of foot 14% and multiple ulcers
was 7%, out of 314 subjects. Reiber et al13 in their
study on the burden of diabetic foot ulcers based on
severity of lesions found that 52% of patients had
lesions in toe (dorsal and plantar surface), 37% had
lesions on plantar, metatarsal head, mid foot and heel
and 11 % in the dorsum of foot. In our study, 46% of
the foot lesions were in the toes (dorsal and plantar
surface) and 40% on the plantar and metatarsal head,
mid foot and heel. This shows that the toes and sole
of feet are vulnerable to ulceration, which signifies
that the diabetic foot needs frequent self-evaluations.
Oyiboso et al14 in their study on the outcome of
diabetic foot ulcers in 194 subjects observed that
67% of the ulcers were due to neuropathy and 26.3%
were neuro-ischemic. Ramani A et al15 in their study
on etiology of diabetic foot ulceration found that
peripheral neuropathy was seen in 78 % of the
subjects and vascular insufficiency was seen in
49.3%. Kumar S et al10 in their study on prevalence
of foot ulceration in type II diabetic patients showed
that the prevalence of neuropathy was 41.6% and
prevalence of PVD was 11%. In their study 20 were
purely neuropathic 13 were neuroischemic, 5 pure
vascular and 5 unclassified.
Mohan et al16 in their study on diabetic foot
ulcerations using measures of ABPI and Doppler
estimated that 21.3% of the subjects were diagnosed
to have PVD. Rooh-Ul-Muqim et al12 in their study
on diabetic neuropathy, foot ulceration, peripheral

vascular disease and their potential risk factors


among the patient with diabetes demonstrated that
diabetic neuropathy was found in 36.6% of patients
and PVD in 11.8% of cases. In our study, 84% of the
population had peripheral neuropathy in comparison
with other studies. Our patients in the study
population had higher incidence of peripheral
neuropathy compared to their study. 33% of the
patients had presence of PVD in comparison with
other studies which is higher. In the ulcer groups the
neuropathic ulcer were more common (51.4%),
compared to the group neuro-ischemic (32.87%) and
others (12.8%). In analyzing the outcome of these
patients' in the above three groups the amputation
rates were higher in neuro-ischemic group (69.4%)
when compared to other two groups and the healing
rate was better in the neuropathic group (94%)
compared to neuro-ischemic (87%). This signifies
that the presence of neuropathy increase the chance
of foot ulceration and the presence of ischemia
worsen the presentation and which further affects the
outcome of the ulcer. Hence both play an important
role in the prognosis of the disease apart from other
associated risk factors like higher glycaemia,
infection, osteomyelitis, and deformity. From our
study we confirm that peripheral neuropathy is the
predominant factor for foot ulceration, as the
insensate foot is prone for undue trauma. The
presence of ischemia due to peripheral vascular
disease increases the morbidity and mortality of the
diabetic foot. PVD also increases the amputation
rates and reduces the healing time.
CONCLUSION
Male population (65.7%) is predominantly affected
compared to female (34.3%).
The mean age of patients in the study population
with foot ulceration was between 55 + 5 years.
The mean duration of diabetes was 5.2 years in
patients who suffered from foot ulceration.
Majority of the patients present with foot problems
with G l to G IV (Wagner's Grades).
Most of the ulceration occurs in toes, metatarsal head
and mid foot. It was more common in deformed foot
due to alteration of weight bearing.
Most of the patients had blood sugar values more
than 200. The duration of diabetics more than the
level of sugar is the cause of foot disease.
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Neuropathy was present in 84% of the population in


the study. Nerve conduction study shows majority of
the patients suffer from both sensory and motor
neuropathy.
33% of the population in the study had peripheral
vascular disease.
51.4% of the ulcer were neuropathic and 32.8%
were neuro-ischemic and 12.8% were due to infection
alone. Total amputation rate was higher (69.4%) in
the neuro-ischemic group, (66.5%) in the infection
group and lowest (11.1%) in the neuropathic group.
Healing rates were higher in neuropathic ulcers
(94%) when compared with neruo-ischemic (87%)
and others (82%).
Control of diabetes with soluble insulin with
combination of antibiotics provides a better result.
Hence apart from routine foot examination, both
neuropathy and peripheral vascularity should be
assessed in all patients with foot ulcerations.
In conclusion "Prevention is better than Cure"
Hence the insensitive diabetic foot should be
protected by proper patient education, early
assessment, which timely management and proper
design of foot wear can avoid further (or) recurrent
foot ulceration.
Conflict of Interest: Nil
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Int J Med Res Health Sci. 2015;4(2):258-264

DOI: 10.5958/2319-5886.2015.00049.1

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 26 Aug 2014
Research article

Coden: IJMRHS
Copyright@2014
ISSN: 2319-5886
th
Revised: 15 Sep 2014
Accepted: 25thJan 2015

A STUDY ON PRESCRIPTION OF ANTIBIOTICS UTILIZATION IN NEONATAL INTENSIVE CARE


AT A TERTIARY CARE CENTER
Subash KR1, Shanmugapriyan S2
1

Associate Professor, Department of Pharmacology, Sri Padmavathi Medical College for Women, Tirupati,
Andhra Pradesh, India
2
Assistant Professor, Department of Pharmacology, Meenakshi Medical college Hospital & Research Institute,
Kanchipuram, Tamil Nadu, India
*Corresponding author email: subbu2207@ yahoo.com
ABSTRACT
Introduction: The aim of this study is to analyze the utilization of antibiotics at our neonatal intensive care unit
(NICU). Neonatal sepsis is one of the most common causes of admission in NICU and the causative bacteria and
their respective sensitivity patterns based on the culture sensitive reports helps in achieving the antibiotic policy.
Methods: This study was done after obtaining the approval from Institutional Human Ethical Committee (IHEC)
of Sri Padmavati Medical College Hospital and Research Institute. The study was carried out during the period of
February 2013 to April 2013 at Department of Pediatrics, Neonatology division, the total number of antibiotics
used in neonatal intensive care unit (NICU) during the study period was identified and the percentage of the
antibiotic prescriptions, individual and fixed dose drug combinations is evaluated. Results: Ampicillin and
Gentamicin were the maximum (50%) empirically administered followed by the fixed dose combination of
Piperacillin and Tazobactam was used in nearly 16% of the babies. Conclusion: The study concludes the
prescription pattern at our neonatal intensive care unit complies with international studies and standards.
Key words: Antibiotics, Neonatology, Intensive care Unit, Prescription.
INTRODUCTION
The most common groups of drugs prescribed in
hospitals are antimicrobial agents. The major
admission particularly at neonatal intensive care unit
(NICU) is sepsis[1]. Major neonatal mortality and
morbidity worldwide is due to septicemia is a
recorded fact comprising various systemic infections
of the newborn such as septic shock, meningitis,
pneumonia, arthritis, osteomyelitis, and urinary tract
infections[2]. Empirical antibiotic therapy should
begin immediately on suspicion of septicemia
followed by cultures and sensitivity, later based on
report reevaluation of antibiotic treatment provided
Subash et al.,

can be done[3]. Prescriptions and drug utilization


monitoring can identify the problems and provide
feedback to physicians so as to create awareness
about irrational use of drugs[4]. These studies are
useful for obtaining information about drug usage
patterns and data for future reference to streamline
antibiotic policy5. Currently the data about drug usage
patterns is not satisfactory. There is lack of data on
prescription pattern studies and it is essential to
define prescribing
The present study was designed to assess and procure
a data of the prescription pattern in the NICU of Sri
265
Int J Med Res Health Sci. 2015;4(2):265-268

Padmavati Medical College Hospital and Research


Institute to assess the prescriptions pattern in the
context of their adherence to prescription format and
rationality of prescription.
MATERIALS AND METHODS
This study was done after obtaining the approval
from Institutional Human Ethical Committee (IHEC)
of Sri Padmavati Medical College Hospital and
Research Institute. The study was carried out in
collaboration with the Department of Paediatrics,
Neonatology division, The Inclusion Criteria were
Neonates suspected or diagnosed to have sepsis or
probable sepsis in newborn babies admitted in the
NICU. The exclusion criteria includes Neonates with
surgical problems, major congenital malformations,
on antibiotics or those whose mothers have received
antibiotics before delivery, were excluded from the
present study. The Study was Prospective and
observational conducted at SPMCH & RI. This study
was done from February 2013 till April 2013. During
this period, newborn babies admitted in the neonatal
intensive care unit diagnosed or suspected to have
sepsis or probable sepsis were analyzed for culture
and sensitivity pattern and choice of empirical
antibiotics. Details of obstetric history, maternal risk
factors, and physical examination were recorded
meticulously. Empirical antibiotics were started after
taking blood for culture and sensitivity and then
changed accordingly.
RESULTS
Gender Distribution male babies were at a slightly
higher preponderance (42.38%) in ratio than female
babies (57.62%) who were treated for neonatal sepsis.
The majority of babies who were admitted 90. %
were preterm as per the gestational age and more than
90% of babies had the onset of sepsis within 72 hrs of
birth .There were 61% Gram negative organism
which included Klebsiella pnemoniae, Escherichia
coli, enterobacter and pseudomonas. The rest 39%
included Gram Positive organisms Staph aureus,
Staph epidermidis in neonatal intensive care unit
during the study period 83% and 9.52% respectively
with 2.38% sterile culture(fig:1). The chief organisms
revealed in blood culture report are Klebsiella
pnemoniae and pseudomonas

The antibiotics used in NICU during the study period


were 6 antimicrobials and 2 fixed drug dose
combinations.They are Ampicillin, Gentamicin,
Cefotaxime,
Amikacin,
Ciprofloxacin,
and
Metronidazole, Piperacillin with Tazobactam and
Imipenem and Cilastin respectively (Table-1).

39%

G.Negative
G.Positive
61%

Fig1: Prevalence of isolated bacteria in neonatal


sepsis
Table 1: Prescription pattern of antibiotics in
NICU
Sl.
Antibiotics
Number of
No
Prescription %
n =250
1
Ampicillin
55
21.73
2
Gentamicin
55
21.73
3
Amikacin
50
20.10
4
Cefotaxime
28
11.43
5
Ciprofloxacin 16
06.52
6
Metronidazole 04
01.63
% -percentage of antibiotic utilization
Table 2: Prescription pattern of Fixed dose drug
combination Antibiotics in NICU
Sl. Antibiotics
Number of
%
No
Prescription
n =250
1
Piperacillin + 39
15.76
Tazobactam
2
Imipenem +
3
01.08
Cilastin
% -percentage of antibiotic utilization
Among the prescribed antibiotics Ampicillin,
Gentamicin and Amikacin were utilized high at
21.73%, 21.73 and 20.10% respectively, followed by
Cefotaxime 11.43%, ciprofloxacin 6.52%, and
266

Subash et al.,

Int J Med Res Health Sci. 2015;4(2):265-268

Metronidazole 1.63%. Among the fixed Dose drug


combinations piperacillin with tazobactam 15.76%
and Imipenem with cilastin 1.08%.
DISCUSSION
The infant mortality rate of India is 47/1000 live
births, of which 70 % of deaths is in neonatal period
with sepsis being one of the leading causes of
death[6].
In our study, both male and female babies were
equally affected and babies who had late onset
neonatal sepsis were predominantly male. This was
similar to a study conducted by Remington et al[7].
The present study revealed 92.85% were preterm as
per the gestational age. This is a main indicator that
preterm babies are more prone for neonatal sepsis
than the term babies and more than 90% of babies
had the onset of sepsis within 72 hrs of birth,
similarly in a study conducted by Sidiropoulus et
[8]
al ., neonatal sepsis was much predominant in
preterm babies and showed significant reduction in
mortality rate. In our study also neonatal sepsis rate
was found more than 90 % in preterm and low birth
weight babies.
The blood culture reports established Klebsiella in 4
cases followed by Pseudomonas in 2 cases. But major
portion of the isolate were sterile, confirming the
chief organisms Klebsiella and pseudomonas in our
neonatal intensive care unit during the study period.
This result adds strength to empirical treatment
provided. This was similar to a study conducted in
Bangalore by Shenoi et al[9]. Another study done by
Viswanathan et al in 2011 at Vellore, reported
Klebsiella as the chief organism causing neonatal
sepsis followed by Staphylococcus aureus[10].
The total numbers of antibiotics used in our NICU
during the study period were 6 individual drug and 2
fixed dose drug combinations. Of the 250
prescriptions, Ampicillin and Gentamicin were the
maximum with each 40 in number as they were
started empirically. This was followed by Amikacin
and Cefotaxime based on the progress of clinical
features like cyanosis, feeding difficulty, breathing
difficulty (grunting), fast breathing (respiratory rate
>60 bpm), abnormal behavior and fever/temperature
>38C. Ciprofloxacin and metronidazole were
initiated only if the culture and sensitivity report

Subash et al.,

demands its use and not empirically for a period of 10


days.
The fixed dose combination of Piperacillin and
Tazobactam was used in 29 babies ie for nearly 16%
of the babies. Another fixed dose combination of
Imipenem and Cilastin was given for 2 babies
because of resistant strains. The above prescription
pattern of antibiotics was similar to study on
antibiotic utilization pattern done by Fanos V et
al[11].. Another study done by Liem et al [12]. by
collecting data from all tertiary care NICU s of
Netherlands, reported that 6 out of 10 NICUs used
extended-spectrum penicillins (amoxicillin and
amoxicillin/clavulanic acid), b-lactamase-resistant
and sensitive penicillins (flucloxacillin and
benzylpenicillin, respectively), amino glycosides
(gentamicin and amikacin), cephalosporins(1st and
3rd generation) and glycopeptides (vancomycin and
teicoplanin). The limitations of the study are small
group and seasonal infections may vary where in this
observation is done during a short period and not
throughout the year.
The study of antibiotic utilization pattern showed that
lactam group of antibiotics, cephalosporins and
amino glycosides were used more in our NICU.
CONCLUSION
The study concludes the prescription pattern at our
neonatal intensive care unit complies with
international studies.
ACKNOWLEDGEMENT
We are thankful to Department of Paediatrics, NICU
Staff and Medical record Section staff of Proposed
Sri Padmavathi medical College Renigunta for their
co-operation.
Conflict of Interest Nil
REFERENCES
1. Lawn JE, Cousens S, Zupan J; 4 million neonatal
deaths: Lancet; 2005:365:891900
2. Kaistha N, Mehta M, Singla N, Garg R, Chander
J. Neonatal septicemia isolates and resistance
patterns in a tertiary care hospital of North India.
J Infect Dev Ctries.2009; 41: 55- 7.
3. Yurdakk M. Antibiotic use in neonatal sepsis.
Turk J Pediatr 1998; 40: 17- 33.
267
Int J Med Res Health Sci. 2015;4(2):265-268

4. Pradhan SC, Shewade DG, Shashindren CH, et


al. Drug utilization studies. Natl Med J Ind. 1:
1988, 185-189.
5. Marshner JP, Thurmann P, Harder S, et al. Drug
utilisation review on a surgical intensive care
unit. Int J Clin Pharmacol Ther. 1994, 32:447-51.
6. Park K. Health information and basic medical
statistics. Parks textbook of Preventive and
Social Medicine, 21st ed. 529, 2012.
7. Remington JS, Klein JO. Infectious Diseases of
the Fetus and Newborn Infant 5th Ed. WB
Saunders, Philadelphia 2000; Page no.
8. Boehme U, Sidiropoulos, Muralt GV, et al.
Immunoglobulin supplementation in prevention
and treatment of neonatal sepsis; Pediatric
Infectious disease journal;1986;5: 193-95
9. Shenoi A, Nagesh NK, Maiya PP, Bhat SR,
Subba Rao SD. Multicenter randomized placebo
controlled trial of therapy with intravenous
immunoglobulin in decreasing mortality due to
neonatal sepsis; Indian Pediatr.J; 1999;36 (11)
:1113-8
10. Viswanathan R, Singh AK, Basu S, Chatterjee S,
Sardar S, Isaacs D; Arch Dis Child Fetal
Neonatal Ed. 2012 ;97(3):182-7
11. Fanos V, Cuzzolin L, Atzei A, and Testa M.
Antibiotics and antifungals in neonatal intensive
care units: a review. J Chemother. 2007; 19(1):5
20.
12. Liem TBY, Krediet TG, Fleer A, Egberts TCG,
Rademaker CMA. Variation in antibiotic use in
neonatal intensive care units in the Netherlands.
J. Antimicrob. Chemother. 2010 Jun 1;
65(6):12705.

268
Subash et al.,

Int J Med Res Health Sci. 2015;4(2):265-268

DOI: 10.5958/2319-5886.2015.00050.8

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 10 Jan 2015
Accepted: 16th Mar 2015

EVALUATION OF RISK FACTORS FOR PRETERM DELIVERY AND CREASYS RISK SCORING
Anand Nalini I1, *Modi Nikunj K2, Sharma Hariom M 3
1

Professor, Department of Obstetrics and gynecology, 2 Assistant Professor, Department of Biochemistry, GGG
Hospital & M P Shah Govt. Medical College, Jamnagar, Gujarat, India
3
Professor & Head, Department of Biochemistry, Sir T Hospital & Govt. Medical College, Bhavnagar, Gujarat,
India
*Corresponding author: Modi Nikunj K Email: nikunjmodi86@yahoo.in
ABSTRACT
Background: Preterm birth is a poorly understood domain so it is a one of the most serious problem encountered
in case of pregnant women. Because of the incomplete knowledge of biochemical and molecular reasons for
preterm birth, many authors have shown interest in various predicting risk factors of preterm birth. Aim: This
study was undertaken to know risk factors for preterm delivery and to investigate the usefulness of the most
widely used creasy scoring system in identifying the high risk group of women at the tertiary care center of India.
In this study also included observation of perinatal mortality and morbidity associated with preterm deliveries.
Material and Methods: In the present study of 175 women who gave birth to preterm babies, detail history was
taken. Then all the Data were statistically analyzed based on percentage. Result: Preterm delivery is particularly
affected by precipitating of some risk factors (Hb, weight, parity of mother etc.). Conclusion: so we can say that
such risk factors acting as a precipitating factor for preterm deliveries. Awareness of such risk factors is essential
to plan public education programs and to consider appropriate perinatal care options for women at potentially
higher risk for preterm delivery.
Keywords: Preterm birth, Creasy scoring, Perinatal death
INTRODUCTION
One of the most important unresolved issues
currently confronting obstetricians is the prevention
of preterm birth (birth before 37 completed weeks of
gestation). Preterm birth is, worldwide, the most
challenging problem in obstetrics, but the prevention
of prematurity has been difficult and ineffective
because of its multifactorial and partly still unknown
etiology. Identification of those women who are
likely to deliver before term requires use of simple
diagnostic tools that can be applied to both
asymptomatic and symptomatic pregnant women. [1]
Many healthcare providers collect data on pregnant
women for assessment of preterm birth risk. Current
technology makes possible collection of a plethora of
Nalini et al.,

data, yet a perinatal healthcare provider has no access


to a general, reliable and valid method of preterm
birth assessment. [2] Babies born before the 34th week
of pregnancy, have the highest risk for early death
and enduring health problems, but recent research has
shown that even preterm infants (at 34 to 36 weeks of
pregnancy) have greater health risks than fullterm
babies. [3]
The treatment of preterm labor, preterm delivery, and
premature birth are not only major problems in
obstetrics and pediatrics but also have major
economic, psychological, and social impact. Most
existing methods to assess preterm birth are based on
risk scoring, done manually. These methods are
269
Int J Med Res Health Sci. 2015;4(2):269-273

between 17% and 38% predictive in determining


preterm birth. This range of accuracy is obviously not
satisfactory. Some authors conclude that-in generalmanual risk screening tools are not sufficient to be
used in the prediction of preterm labor. [2] To improve
the outcome of these very preterm neonates, we need
to expand our knowledge of the etiology, prevention,
and treatment of preterm labor and preterm delivery.
However, the rate of preterm delivery has not
decreased in the past 30 years Goldenberg et al.,
2008, mainly because of failure to identify the highrisk group during routine prenatal care. [4] To identify
women at risk of spontaneous preterm birth,
clinicians use prior preterm birth, multiple pregnancy
and prior cervical surgery as major risk factors.
Useful clinical risk factors in predicting spontaneous
preterm birth in nulliparous women with a singleton
pregnancy are scant, except for a history of prior
cervical surgery. [5]
So the present study was with the aim of first, to see
the effectiveness of the routine creasy risk scoring
system in predicting the high risk group in local
population and second, to find out the common high
risk factors like Hb, weight, parity of mother
associated with preterm labor.
MATERIALS AND METHODS
The department of Obstetrics and Gynecology, of
Shri M. P. Shah Govt. Medical College and Guru
Govindsinh General Hospital, Jamnagar, carried out
the present study. Informed consent was taken from
all individual subjects included into the study. In the
present study of 175 women, who gave birth to
preterm babies (in 1 yr duration) were included and
classified as at low, medium or high risk for preterm
labor according to the Creasy scoring system which is
based on socioeconomic factors, previous medical
history, daily habits, as well as aspects of the current
pregnancy. [6] This scoring system is extensively used
to identify preterm delivery. Socioeconomic class is
assessed by Prasads social classification. All other
term pregnancy was excluded from the study. The
gestational age was assessed from the date of last
menstrual period, provided she had regular ovulatory
cycle previously. In others, clinical examinations like
fundal height date of quickening, appreciation of fetal
heart by stethoscope and ultrasonographic
measurements were used for gestational age
determination. Anthropometric measurements of the

mother including weight, height were carried out by


using standard techniques. Other data of
socioeconomic status, personal history, past medical
surgical, obstetric history and prenatal care were
collected by interviewing the patients. Hospital
records were also abstracted for relevant data and
used for cross-check the reliability of information
obtained during the interview.
Physical examination, Blood pressure and
hemoglobin by standardized acid haematin method
were also done. Anemia in this study was defined as
hemoglobin < 10 g/dl on one or more occasion.
Chronic or pregnancy induced hypertension was
defined as a blood pressure greater than 140/90
mmHg repeatedly, and, if the women also had
proteinuria than pre-eclampsia was considered to
exist. After delivery the newborn was examined
within 6 hours and fetal maturity was assessed. Then
all the Data were statistically analyzed based on
percentage.
RESULTS
Finding of the present study are as under
First the relationship with the age of mother (in yrs)
and preterm delivery compared, in that the age group
are divided in < 20 yrs, 21-25 yr, 26-30 yr, 31-35 yr,
36-40 yrs and >40 yrs, out of them majority of
preterm delivery was noticed in 21-25 yrs of age
group. That is of 87 out of 175 preterm deliveries.
Then the incidence was gradually declined with
increase age. Then relationship with the gestational
age of mother (in wks) and preterm delivery
compared (Table 1), in that most of the preterm
deliveries occurred in 31-34 weeks of pregnancy.
Table: 1 Relationship of Gestational age with
Preterm delivery.
Gestational
No
of
preterm Percentage
age (in wks) delivery
(out of 175)
<30
19
10.8 %
31-34
85
48.5 %
35-37
71
40.7 %
Then out of 175 preterm delivery, 76 were primi
while 99 are multipara in that 94 were multipara and
05 were grand (>4) multipara. One of the important
relationships of weight and preterm delivery (Table
2), in that 153 preterm delivery seen in < 55 kg wt

270
Nalini et al.,

Int J Med Res Health Sci. 2015;4(2):269-273

(out of them 28 have < 45 kg wt) and only 22 have


preterm delivery with more than 55 kg weight.
Table: 2 Relationship of Maternal Weight and
Preterm delivery.
Maternal
Weight (in Kgs)
< 45
45-55
>55

No of preterm
delivery(out of 175)
28
85
22

Percentage
16 %
71.4 %
12.6 %

In relation to the antenatal care 118 were unbooked


and 57 were booked. In our study approximately 49%
births were females and 51% males. According to
socio economical class (Table 3), majority of preterm
delivery was noticed in low socioeconomic class
(84.57%) and that is of 148 out of the 175, and
remaining 15.43% from middle class.
Table: 3 Relationship of Socioeconomic class and
Preterm delivery.
Socioeconomic
Class
High
Middle
Low

No of preterm
delivery(out of175)
27
148

Percentage
15.4 %
84.6 %

with Hb level < 10 g/dl (in that 25 have Hb < 8.0


g/dl).
According to past history 29 have previous h/o of
abortion, 20 have H/o preterm delivery and 09 have
previous H/o both.
In this study, according to creasy risk scoring system
(primi + multi) (Table 4), in that (31 +3 = 34 in low
risk), (21 + 8 = 29 in medium), (24 + 88 = 112 in
high risk).With twin pregnancy (175 + 13 = 188)
child born. Out of them 49 were still birth, 55
neonatal deaths and hence making 104 prenatal
deaths.
Table: 4 Creasy scoring and distribution by
Parity.
Total
Gravida Low
Medium
High
risk
risk
risk
76
Primi
31
21
24
99
Multi
03
08
88
17
Total
34
29
112
DISCUSSION

Fig1: Relationship of Hb level and Preterm


deliveries.
According to Hb (Fig. 1) only 8 women have preterm
delivery with Hb > 10 g/dl, and rest of the women

The importance of preterm delivery as a major public


health problem is easily demonstrated by virtue of its
contribution to total perinatal mortality contributing
50% to 70% of all perinatal deaths in most data
sets.[7] Early detection of preterm labour is difficult
because initial symptoms and signs are often mild and
may occur in normal pregnancies. Thus, many
healthy women will report symptoms during routine
prenatal visits, whereas others destined for preterm
birth may dismiss the early warning signs as normal
in pregnancy. The traditional criteria for preterm
labour (persistent contractions accompanied by
progressive cervical dilatation and effacement) are
most accurate when contraction frequency is six or
more per hour, cervical dilatation is 3 cm or more,
effacement is 80% or more, membranes rupture, or
bleeding occurs. [8] Though preterm birth occurs in
approximately 5-15% of all deliveries, it accounts for
the major bulk of perinatal and especially postnatal
deaths. The risk of neonatal morbidity and mortality
mainly depends on the gestational age at delivery.
Survival rate increases with an increasing period of
gestation. In a developing country like ours, where
intensive care facilities are often unavailable,
mortality figures would be much higher at a lower
gestation period at delivery. [1] Some biochemical
markers like fetal fibronectin, the thrombin cascade,

Nalini et al.,

Int J Med Res Health Sci. 2015;4(2):269-273

In the present study of preterm delivery, 19 cases of


PET pre eclamptic toxemia, 18 cases of PROM premature rupture of membrane, 18 cases of APH
(ante partum haemorrhage), 13 cases of twin
pregnancy, 11 cases of UTI - urinary tract infection,
07 cases of Eclampsia were noticed. While some
cases of fever, heart disease, cerebral malaria,
hydroamnios,
jaundice,
anemia,
congenital
anomalies, uterine anomaly and uterine prolapsed.
And 62 are from the unknown reason. In this study
out of 175, 13 were twin delivered.

0% Hb > 10 g/dl 5% Hb 08 - 10 g/dl

Hb < 08 g/dl

14%

81%

271

and maternal salivary estriol measured in


asymptomatic women with and without risk factors
for preterm birth. [8]
In our study majority of preterm births were in
mothers of age group 21-25 years and that was
gradually decreasing with increasing age. It is
comparable to many similar studies like Molly Phillip
et al. and Trivedi et. Al. inspite of very high incident
of prematurity among teenage patients, the total
number of patients in this group remains low because
of decreasing trend of teenage marriage and late age
of marriage. Higher incident of prematurity in the
older patients is likely to be due to malnutrition,
anemia, increase physical work load and increased
incidence of medical and obstetric complications. [9]
Also presence chorioamnionitis, bacterial vaginosis,
urinary tract infection were significantly associated
with preterm labor. [10] Fibronectin, an extracellular
matrix protein, acts as the glue that attaches the
fetal membranes to the underlying uterine decidua. A
positive fibronectin test (50 ng/mL or more) in a
patient with symptoms suggestive of preterm labor
has been associated with an increase in the likelihood
of birth before 34 weeks and birth within 714 days
of the test. [8]
In our study preterm birth in primipara, multipara and
grand multipara were 43.4%, 53.7% and 2.95%
respectively. This result is somewhat similar to other
work reported on this aspect. [11] In grand multipara it
is combined effect of parity, preexisting poor
maternal nutrition, anemia less spacing between two
pregnancies, lack of antenatal care, associated
medical and obstetric complication etc. also play a
role. The distributions of preterm births by gestational
age observed in the present study are quite
comparable to those of jose et.al. [10, 11]
The delivery probability profile incorporates data on
fetal fibronectin, cervical length by ultrasound and a
past history of preterm delivery to generate standard
pregnancy survival curves. This information might
also help in developing patient-specific strategies to
help prevent prematurity. [12]
It is observed that almost 87.5% preterm births were
from mothers with pregnancy weight of less than 55
kg. in another study from India 52.5% preterm births
were in mothers having weight of less than 45 kg.
Pre-pregnancy weight of mother and weight gain
during pregnancy also affects the birth weight. [13]

The effect of regular antenatal care on the incidence


of preterm birth observed in the present study is
compared with some of the other studies. Incidence
of preterm birth is markedly less in booked cases as
compared to unbooked cases (who attended less than
3 antenatal care or none). Greenberg noted that
prenatal care had a greater impact on pregnancy
outcome in socially disadvantages women, a group of
women who often obtain less prenatal care. [14] The
prevention can be based on at risk approach (a)
Patient at high risk of preterm labour should be
monitored carefully and (b) Patient with warning
signs will go through prophylactic treatment like
antibiotics, tocolytics, bed rest etc. to prevent preterm
birth.
The higher frequency of preterm births in lower
social class might have been due to a number of
factors. More than two thirds of the patients admitted
to our hospital are from these social classes. Secondly
those who are economically at disadvantages might
be worse off as regards health, physique, knowledge
and nutrition. Present study data and that reported by
other studies clearly indicate that socio-economic
status has got direct and profound influence in the
preterm labor and birth. [15, 16, 17]
Anemia has been documented to result in higher
incidence of low birth weight babies as well as higher
preterm births. Anemia could lead to T and B cell
suppression and resulting immune suppression could
lead to increased susceptibility to infection. [18]
Similar results are also reported by kandeparker et al.
with 54% cases having Hb less than 10.0 g%. [11]
In agreement with other studies [19] we found that
history of previous abortion and previous preterm
delivery increase the risk of preterm delivery in next
pregnancy.
The ability of creasys score in predicting Preterm
birth is significant but it also has its limitations when
applied in Indian context, where no. of other
parameters do play a major role in predicting Preterm
birth. This study present that maternal age,
socioeconomic class, parity, past history are
important risk factors for Preterm birth. If added to
the present scoring system they will greatly improve
the predictability of the scoring system in Indian
context. Similar study was also found by another
author in India. [20]
The total perinatal deaths were 104 (49 still birth + 55
neonatal death) giving an incidence of 55.3 %

Nalini et al.,

Int J Med Res Health Sci. 2015;4(2):269-273

272

perinatal mortality. As compared to western studies it


is much higher. This is due to the fact that they have
lower rate of preterm birth and much better neonatal
services including intensive care units for preterm
and low birth weight babies. Regarding neonatal
death our results are comparable with Khandeparkar
el al study. [11]

6.
7.

CONCLUSION
Our data in this study shows the correlation with
various risk factors to the preterm birth. From the
present study, it is concluded that to make creasy risk
score more specific and effective in the Indian
context, it should be modified by giving higher score
to women with low socioeconomic status, low
pregnancy weight, physical work during pregnancy
and low maternal age. A slightly modified scoring
system needs to be devised for Indian population.
More elaborate information about the components of
the scoring system is required for understanding the
need to devise it in Indian context.

8.

9.
10.

11.
12.

ACKNOWLEDGEMENT None
Conflict of Interest Nil

13.

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15.
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17.
18.
19.
20.

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DOI: 10.5958/2319-5886.2015.00051.X

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 18 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 20 Dec 2014
Accepted: 24th Jan 2015

ACCURACY OF LOW BIRTH WEIGHT AS PERCEIVED BY MOTHERS AND FACTORS


INFLUENCING IT: A FACILITY BASED STUDY IN NEPAL
*Shakya KL1, Shrestha N2, Bhatt MR3, Hepworth S4, Onta SR5
1,3

Department of Community Medicine and Public Health, 5Deans Office, Institute of Medicine, Tribhuvan
University, Kathmandu, Nepal
2
Valley College of Technical Sciences, Purbanchal University, Kathmandu, Nepal
4
Department of Health, University of Bath, Nepal
*Corresponding author email: karuna201@gmail.com
ABSTRACT
Introduction: Birth weight is a key predictor for risk of childhood illnesses and chances of survival; however in
developing countries less than half of newborns are weighed at birth. In Nepal, only 36% of children born were
weighed at birth. Nearly two thirds (63%) of deliveries take place at home and birth weight may not be known for
many babies, the mothers estimate of the babys size at birth could be used as an alternative. Aim and
Objective: This study assessed the accuracy of low birth weight as perceived by mothers and factors influencing
whether their perceptions were accurate. Methods: The study wasa facility based descriptive study carried out in
four hospitals with sample size of 1533. Hospital nurses interviewed mothers using a pre-tested tool. Data was
entered into EpiData 3.1 and analyzed using SPSS version 17 software package. Results: A total of 1533 mothers
were interviewed of which 75 did not respond. An overall 75% mothers accurately identified actual low birth
weight; and 25% mother perceived normal for actual low birth weight. Less percent of mothers <20years
(sensitivity=0.74), illiterate (sensitivity=0.74), and primigravida (sensitivity=0.74) identified actual low birth
weight than mothers 20years (sensitivity=0.75), literate (sensitivity=0.75) and multigravida (sensitivity=0.77).
Conclusion: The study concluded that 75% mothers recognized actual low birth weight of newborn, and 25%
mothers perceived normal for actually low birth weight. The percentage of women accurately identifying actual
low birth weight was slightly lower among mothers <20years, illiterate and primigravida as compared to mothers
20years, literate and multigravida.
Keywords: Lowbirth weight, Mothers perception, Facility based study, Nepal
INTRODUCTION
Birth weight indicates the health status of both
newborn and mother. Low Birth Weight (LBW), less
than 2.5 kg[1]. is the consequence of small maternal
size at conception; low gestational weight gain;
premature delivery; and pregnancy among younger
women2; and can have consequences on increasing
newborn morbidity and mortality[2]. Additionally,
knowing the birth weight can help providers and
family to take care of newborn at right time.
Shakya et al.,

Globally,15.5%ofallbirthsarebornwithLBW. Among
them 95.6% areindeveloping countries[3]. About 80%
intrauterine growth retarded (IUGR) newborns who
are LBW and full term are born in Asia[3]. Nepal has
an overall 21% LBW2 and little variation in different
studies, 12.76%[5], 21.6%[6], 11.9%[7]; similar to
prevalence of LBW in India 23%[7], 21.5%[9],
12.8%[7], and 17.3%[10]. More than half of infants in
the developing world are not weighed after birth[1] as
274
Int J Med Res Health Sci. 2015;4(2):274-280

they born at home[1,11,12] and thus will not have a


recorded birth weight. In the past, most estimates of
LBW for developing countries were based on data
compiled from health facilities, these estimates did not
cover the weight of newborns who were born out of a
health facility[1]. Since birth weight may not be
known for many babies, the mothers estimate of the
babys size at birth was also obtained[13].
Nepal has taken the percentage of newborns with
LBW as one of the indicators to demonstrate
achievement of nutritional wellbeing, maintenance of
a healthy life and socioeconomic development of the
nation. Many nutritional policies; principles; and
strategies are based on this indicator, such as,
increased nutrition monitoring and counseling
services at antenatal checkup to reduce LBW[2].
Hence, it is important to take birth weight of newborn
and, where formal measurements are unavailable,
validate the accuracy of mothers perception of birth
weight as a possible alternative source of data.
However, studies on validation on perceived birth
weight is not available for Nepal in our knowledge,
and mothers perception about the size of baby has
not been properly verified as a reliable estimate of
birth weight. We questioned that is mothers
perception on weight of newborn is correct? Is her
perception on weight of newborn is affected by her
socio-demographic background? This study aimed to
assess accuracy of birth weight perceived by mothers
against actual birth weight recorded in hospital; and
to find out any associated determinants.
MATERIAL AND METHODS
The study was approved by Institutional Review
Board of Institute of Medicine, Maharajgunj Medical
College. We also received approval from each
hospital board; and consent from each mother before
data collection. Hospital nurses interviewed mothers
once they were comfortable following delivery. After
interviewing, nurses gave information to mothers on
breast feeding; keeping newborn warm, special care
for infants who were LBW using Kangaroo mother
care, family planning, and baby immunization. This
was a hospital based descriptive study, carried from
August 2012 to February 2013. We chose hospitals
for this study as hospitals routinely record weight of
newborn and therefore provided a comparison against
which the accuracy of mothers perception on LBW
could be assessed. We carried out this study in 4

hospitals: Tribhuvan University Teaching Hospital


(TUTH), and Paropakar Maternity and Womens
Hospital located in central Kathmandu; Seti Zonal
Hospital in Kailali district, far western region of
Nepal, 723 km away from Kathmandu city; and
Dhulikhel Hospital in Kavre district, 30 km away
from Kathmandu city. We chose these hospitals
purposively to represent geographical scope from far
western plain area to central hill areas.
Women within the reproductive age of 15-45 years
were the target population for this study. The
sampling unit was mothers who were recently
delivered, had completed 37 weeks of gestation,
single not multiple births and having a live birth. The
dependent variable for this study was perceived birth
weight, and independent variables were mothers age,
education, and gravida.
Sample size, data collection, management and
analysis: The sample size was calculated using
statistical formula14, 15,, at 95 percent confidence
level; 25% of LBW based on birth weight by birth
size11, and 2% confidence interval. Hence, sample
size calculated using this formulae, SS = 1800 For
sample size finite population, where, population =
10350 (total average deliveries in 4 hospitals);
SS=sample size=1800; the sample size calculated
were1533. The tool was a structured questionnaire
with open and close ended questions. We asked to
mothers on how she felt the weight of her baby; what
her estimation was for NBW measurement in her
idea; and what causes small baby if she felt her baby
was small. Prior to collecting data, we did pre-test of
questionnaire in TUTH hospital and made corrections
as required from pre-test. Hospital nurses who
worked in maternity ward were trained in the study
tool and data collection techniques. Trained hospital
nurses briefed mothers of the objective of study; then
interviewed mothers who met selection criteria using
the pre-tested tool before they were told birth weight
of their newborn baby in their respective duty shift
from August 2012 to September 2013. The actual
birth weight of the newborn was taken from the
hospital maternity register.
Data entry program was developed in EpiData 3.1
and checked for any inconsistencies; analyzed using
the SPSS version 17 computer software package
through running simple frequency, descriptive cross
tabulations. Sensitivity and specificity was calculated.
The sensitivity is the proportion of actual LBW in the
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Int J Med Res Health Sci. 2015;4(2):274-280

selected sample who are accurately identified as


LBW by the mothers; and the specificity is the
proportion of actual normal birth weight (NBW) of
newborn who are so identified by the mothers[14,16,17,
18]
.
RESULTS
We interviewed 1533 mothers regarding their
perception on birth weight of newborn, 75 mothers
did not response.
Maternal age and perceived LBW: Referring to
table 2, out of 1458 mothers, 205 (14.1%) mothers
were age <20 years and 1253 (85.9%) were age
20years. Among the mothers who were <20 years
(205), 84 (41%) mothers delivered LBW babies.
Among them (84), 62 (73.8%) mothers accurately
perceived weight of their newborn baby as low for
actual LBW. Of the remaining 121 women <20 years
who delivered NBW babies, 9 (7.4%) mothers
perceived weight of their newborn baby as low, for
actual NBW. Similarly, among mothers age of 20
years, 404 (32.2%) delivered LBW baby, 849
(67.8%) delivered NBW baby. Among 404, 302
(74.8%) mothers perceived weight of their newborn
baby was low for actual LBW baby. Out of 849, 64
(7.5%) mothers perceived weight of their newborn
baby as low for actual NBW. Mothers were better at
estimating NBW rather than LBW.
Maternal education and perceived LBW: Out of
1458, total of 142 (9.7%) mothers were illiterate,
1316 (90.3%) mothers were literate. Among the
illiterate mothers, 57 (40.1%) delivered LBW babies
and 85 (59.9%) had NBW babies. Out of 57, 42
(73.7%) mothers perceived weight of their newborn
baby as low for actual LBW. Out of 85, 9 (10.6%)
mothers perceived weight of their newborn baby as
low for actual NBW. Among literate mothers, 431
(32.8%) delivered LBW babies and 885 (67.3%)
delivered NBW babies. Out of 431, 322 (83.4%)
mothers perceived weight of their newborn baby as
low for actual LBW. Out of 885, 64 (16.6%) mothers
perceived weight of their newborn baby as low for
actual NBW. So, illiterate women were less likely to
be accurate in identifying LBW than literate women
(83.4% vs. 73.7%).
Gravida and perceived LBW: Out of 1458, 956
(65.6%) were primigravid mothers and 502 (34.4%)
were multigravid mothers. Out of 956 primigravid
mothers, 347 (36.3%) delivered LBW babies and 609
Shakya et al.,

(63.7%) had NBW babies. Out of 347, 256 (87.7%)


mothers perceived weight of their newborn baby as
low as for actual LBW. Out of 609, 36 (12.3%)
mothers perceived weight of their newborn baby as
low for actual NBW. Among 502 multigravid
mothers, 141 (28.1%) delivered LBW babies and 361
(71.9%) delivered NBW babies. Out of 141, 108
(74.5%) mothers perceived weight of their newborn
as low for actual LBW. Out of 361; 37 (25.2%)
mothers perceived weight of their newborn baby as
low for actual NBW.
Overall diagnostic indicators of LBW: As an
overall (table number 1), out of 1458, 488 mothers
gave LBW babies, 970 mothers gave NBW babies.
Out of 488 mothers, 364 (74.6%) accurately
diagnosed baby as LBW and 124 (25.4%) diagnosed
as normal for actual LBW. Out of 970, 73 (7.5%)
mothers diagnosed birth weight as low, and 897
(92.5%) diagnosed as normal for actual NBW babies.
We found that 75% mothers identified actual LBW
babies (sensitivity=0.75), 93% mothers identified
actual NBW babies (specificity=0.93). Twenty five
percent mothers perceived NBW for actual LBW;
whereas, 8% mothers perceived LBW for actual
NBW babies.
Table 1: Concordance between low birth weight
and perceived birth weight in two categories
Perceived
birthweight

Actual
LBW (%)

Actual
NBW (%)

Total (%)

Low

364 (74.6)*

73 (7.5)

437 (30)

Normal

124 (25.4)

897 (92.5)**

1021 (70)

Total

488

970

1458

*sensitivity at 95% CI (0.71-0.78), ** specificity at


95% CI (0.91-0.94)
Maternal profile and diagnostic indicators of
LBW: We found (table #2) there were no remarkable
differences in relation to maternal age and education
with diagnostic indicators on LBW (sensitivity and
specificity). Seventy four percent mothers age <20
years (sensitivity=0.74 @ 95% CI: 0.64-0.82); and
75% mothers age 20 identified actual LBW babies
(sensitivity=0.75 @95% CI: 0.70-0.78). Seventy four
percent illiterate mothers (sensitivity=0.74 @ 95%
CI: 0.61-0.83) identified actual LBW and for literate
mothers were 0.75 (at 95% CI: 0.70-0.79), and 0.93
(at 95% CI: 0.91-0.94) respectively.
Our study revealed that diagnostic indicators were
varied slightly as differences in number of gravida.
Seventy four percent primigravid mothers
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Int J Med Res Health Sci. 2015;4(2):274-280

(sensitivity=0.74 @ 95% CI: 0.69-0.78), and 77%


multigravida mothers (sensitivity=0.77 @95% CI:

0.69-0.83) identified actual LBW.

Table 2: Number of mothers with their profile, perceived low birth weight, and diagnostic indicators
Perception of
Diagnostic Indicators
Maternal
Actual
Actual
Total
mother on
Factors
LBW (%)
NBW (%)
(N=1458)(%) Sensitivity* Specificity*
birth weight
Low
62 (73.8)
9 (7.4)
71 (34.6)
0.74
0.93
Age <20 years Normal
22 (26.2)
112 (92.6)
134 (65.4)
(0.64-0.82)
(0.86-0.96)
Total
84 (41.0)
121 (59.0)
205 (14.1)
Low
302 (74.8)
64 (7.5)
366 (29.2)
0.75
0.92
Age 20 years Normal
102 (25.3)
785 (92.5)
887 (70.8)
(0.70-0.78)
(0.90-0.94)
Total
404 (32.2)
849 (67.8)
1253 (85.9)
Low
42 (73.7)
9 (10.6)
51 (35.9)
0.74
0.89
Illiterate
Normal
15 (73.7)
76 (89.4)
91 (64.1)
(0.61-0.83)
(0.81-0.94)
Total
57 (40.1)
85 (59.9)
142 (9.7)
Low
322 (83.4)
64 (16.6)
386 (29.3)
0.75
0.93
Literate
Normal
109 (11.7)
821 (88.3)
930 (70.7)
(0.70-0.79)
(0.91-0.94)
Total
431 (32.8)
885 (67.3)
1316 (90.3)
Low
256 (87.7)
36 (12.3)
292 (30.5)
0.74
0.94
Primigravida
Normal
91 (13.7)
573 (86.3)
664 (69.5)
(0.69-0.78)
(0.92-0.96)
Total
347 (36.3)
609 (63.7)
956 (65.6)
Low
108 (74.5)
37 (25.5)
145 (28.9)
0.77
0.90
Multigravida
Normal
33 (9.2)
324 (90.8)
357 (71.1)
(0.69-0.83)
(0.86-0.92)
Total
141 (28.1)
361 (71.9)
502 (34.4)
*calculated at 95% CI
DISCUSSION
This study assessed and analyzed perceived LBW and
the maternal factors that influence on her perception
on LBW. We asked mothers on her perception on
birth weight before she was told weight of her
newborn. We did not cover home based deliveries
because the birth weight was not recorded in home
delivery and thus cannot validate the perception of
mother on LBW. We also did not include multiple
births, preterm and still birth. Next, we are not aware
of this kind of study conducted in Nepal before. It
could be a unique study for Nepal. Though Nepal
Demographic health Survey (NDHS) uses mothers
perception to identify low or normal birth weight, but
to date there has been no study to determine whether
this is an accurate proxy indicator. This study fills
that gap.
A study conducted in Korea to identify factors
affecting the validity of self-reported data on health
services from community health survey; and in some
other countries have done similar studies using
diagnostic indicators [11, 12, 19, 20]; UNICEF and WHO

did LBW country, regional and global estimates in


2004[1]; and an evaluation of international estimates
and updated estimation procedure11 were resources
for this study.
However, whilst it is important to know an accurate
birth weight; data on it is often difficult to obtain in
those countries where most babies are born at home,
similarly in Nepal[13,21]. Many infants are never
weighed at birth. Eighty-eight percent of newborns in
Pakistan, and 70% in India in central and other
Asia[11] were not weighed, while those weighed at
birth are often not recorded. Nepal has been also
facing a similar problem to assess an accuracy of
birth weight as it is not recorded in home deliveries.
It is difficult to evaluate the accuracy of birth weight
data because there are hardly any comparable
registration data available[12]. In Nepal, those
available data showed that only 4% children are
reported to be very small at birth, 12% were reported
to be smaller than average, and 84% were reported to
be average or larger in size on verbal autopsy[13]. Our
study revealed that 75% mothers identified actual
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Int J Med Res Health Sci. 2015;4(2):274-280

LBW (sensitivity=0.75). In other word, 91% mothers


recognized actual NBW (specificity=0.91). Hence, it
showed that fewer mothers could recognize actual
LBW in compare to actual NBW. We would like to
suggest here that the next study could be why more
mothers could identify NBW rather than LBW? We
also found that 25% mothers perceived normal for
actual LBW babies which is crucial from a
programmatic viewpoint.
In Nepal, birth weight is still not given a priority by
family. An awareness on LBW among women who
delivered during last year in Nepal was only 12.4%
[22]
. A similar kind of study conducted in Cameroon
found that specificity for LBW (92.9%) was much
higher than sensitivity (59.9%) and the negative
predictive value (96.1%) was much higher than the
positive predictive value (44.4%)[23]. Further analysis
of data from DHS India showed that among babies
who were reported as weighing <2500 grams, 53%
were perceived by mothers as less than average size
at birth and among babies who were reported as
weighing 2500 grams, 91% babies were perceived
by mothers as average or more than average size at
birth. These numbers suggest that mothers
perception about size at birth was reasonably
reliable[24].
Accuracy of perception of mothers on birth weight is
influenced by her education, number of gravida, and
her age. Maternal age, educational level correctly
predicted just over 35% of LBW[20]. Blanc and Ward
law examined these assumptions and documented that
the characteristics of infants with numerical birth
weights were not representative of all births[11]. Births
that were weighed were more likely to involve
mothers who were better educated and resided in
urban areas. They were also more likely to be in a
medical facility and with assistance from skilled
health personnel. These characteristics are generally
associated with higher birth weights and, therefore,
the resulting estimates were still likely to
underestimate the level of LBW[11]. We found that
younger mothers age <20 years had difficulty in
identifying LBW (sensitivity=0.74) as compared to
older mothers age 20 years (sensitivity=0.74). The
study conducted in Nepal showed 85% mothers age
between 20-34 estimated their childs birth weight
was average or normal[13]; maternal age was
significantly related to the incidence of LBW[8].

Our study revealed that 75% literate mothers


recognized actual LBW, which was slightly higher
than 74% illiterate mothers recognized actual LBW.
In other words, 93% literate mothers identified NBW
against 89% illiterate mothers who recognized NBW.
Studies in Nepal showed that awareness on LBW
among women who completed secondary education;
and who completed higher than it, was15.0% and
18.8% respectively in Nepal[22]; 86% mothers having
School Leaving Certificate and above estimated their
childs birth weight was average or normal[13].
Literate mothers can read health messages and
understand easily the advice given by health
providers. The report shown that literate mothers
visited health provider more for ANC check-ups as
well13. The occurrence of LBW decreased with rising
education level of the mother[8,25],. So, the accuracy of
perception of mothers is more among literate mothers
than illiterate mothers. A study conducted in
Cameroon found that concordant descriptions were
associated with higher education (P = 0.008) and
delivery in a health unit (P = 0.025) [23]. Analysis of
population-based data from 10 centers in Burma,
Thailand, China and Vietnam, have also shown a
strong associations with LBW were found with
maternal education[26].
The knowledge of mother on health increase as she
delivers more. The study found that frequency of
LBW infant is high at birth order 1 and 29. Our study
revealed that recognition of actual LBW was higher
among multigravida mothers (sensitivity=0.77) than
in primigravida mothers (sensitivity= 0.74).
Mothers perception of birth weight as a proxy
indicator: There is a strong debate on the use of
mothers estimate of birth weight in developing
countries where there is low formal measurement
data. A possible solution to it is to use a proxy
variable13; putting question on size of the infant at
birth (i.e. low, normal or high). This approach is
being used in DHS and Multiple Indicator Cluster
Surveys. In these surveys, mothers are asked to
classify the size of their newborn[12].
In many countries, birth weight information is
collected through applying retrospective surveys [27]
especially in DHS. Cambodia, Kazakhstan and
Malawi the responses to this question using DHS
surveys, were assessed to indicate the relationship
between birth weight and mothers perception12. The
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Int J Med Res Health Sci. 2015;4(2):274-280

results indicated that mothers perception on size of


newborn is a good proxy for birth weight12. Other
surveys such as Multiple Indicator Cluster Surveys,
Pan Arab Project for Child Development and
Reproductive Health Surveys, a question is asked to
the mother regarding the size of her child at birth,
which has been considered as a proxy indicator for
birth weight11. Further analysis of data from DHS
India suggest that mothers perception about size at
birth was reasonably reliable[24].
As in other developing countries, still two-thirds of
births (63%) take place at home in Nepal[25]. Only
36% of children were weighed at birth as the majority
of births do not take place in a health facility in
Nepal13. Nepal DHS has been using verbal autopsy
from mothers on their newborn babys size; and birth
weight was recorded in the questionnaire if available
from either a written record or the mothers recall.
Since birth weight may not be known for many
babies, the mothers estimate of the babys size at
birth was also obtained and useful proxy for the
weight of the child[26].
Based on our study, 93% mothers recognized actual
normal birth weight, and 75% mothers recognized
actual LBW, and still 25 percent mothers could not
recognize actual LBW. Hence, perceived birth weight
could be used as proxy indicator when birth weight
data are not available. We noticed that proxy
indicator could be more reliable if mother were
literate, aged 20 years. A study conducted in
Cameroon indicated that recall of size, in
Cameroonian women and in other low resource
settings, should be used only in the absence of other
sources of data [27]. A further similar study among
mothers who delivered in home with an intervention
of birth measurement is recommended to cover
broader area and to ensure accuracy of perceived
birth weight.
CONCLUSION
An overall, 75% mothers recognized actual LBW,
and still 25% mothers perceived normal were actual
LBW babies, which is crucial from programmatic
view. A percent of identifying actual LBW was
slightly lower among mothers <20 years, illiterate and
primigravid as compared to mothers 20 years,
literate and multigravida. Mothers perception on
birth weight can be considered as proxy indicator for

Shakya et al.,

birth weight of newborn as and when birth weight is


not available.
ACKNOWLEDGEMENTS
We are grateful to University Grant Commission
(UGC), Sanothimi, Bhaktpur for providing grant for
this study; Seti Zonal Hospital,Kailali; TUTH,
Kathmandu;Paropakar Maternity and Womens
Hospital, Kathmandu; Dhulikhel Hospital, Kavre for
permitting us to collect data; thankful to the
respective team in each hospital for collecting data
for this study; and also thankful to Department of
Community Medicine and Public Health, Institue of
Medicine, Maharajgunj for technical and logistic
support.
Conflict of Interest: Nil
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data. BMC Public Health, 2011; 11: 403.
25. Hirve SS, Ganatra BR. Determinants of low birth
weight: a community based prospective cohort
study. Indian Pediatr, 1994;31(10): 1221-5.

26. Golding J, Shenton T. Low birth-weight and preterm delivery in South-east Asia. The WHO
International
Collaborative
Study
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Hypertensive Disorders of Pregnancy. Soc Sci
Med, 1990;30(4): 497-502.
27. Tomeo CA. Reproducibility and validity of
maternal recall of pregnancy-related events.
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Int J Med Res Health Sci. 2015;4(2):274-280

DOI: 10.5958/2319-5886.2015.00052.1

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 10 Dec 2014
Accepted: 30th Jan 2015

WATER ADSORPTION CHARACTERISTICS OF NEW DENTAL COMPOSITES


Rafed. M Al-Bader1,*Kareema M.Ziadan2, M. S Al-Ajely3
1

PhD. student, College of Dentistry, 2 Professor in polymer physic, Department of Physics, college of science,
University of Basrah, Basrah, Iraq.
3
Professor in polymer, Department of Chemistry, college of Education, University of Mosul, Mosul, Iraq.
*Corresponding author email: profkmziadan@gmail.com
ABSTRACT
Water sorption of dental composites affects dimensional stability, mechanical properties and bonding strength
with tooth structures. The diffusion coefficient of water through the resin should be identified. Methods: Ten new
composites fillings (M1-M10) were prepared from new Fluoroaluminosilicate powder composition and
BisGMA/TEGDMA together with the related compounds such as tri ethylene glycol dimethacrylate, N,NDimethyl amino ethyl methacrylate and Camphorquinone. Five disk shapes were prepared for each composite
using a stainless steel mold 15 mm in inner diameter and 1 mm in thickness, according to ISO 4049, the curing of
each composite disk for 40 sec. Each disk was immersed separately in water for 90 day all at (37 1). Water
sorption and solubility were calculated by using these measurements, Diffusion coefficients were also measured
with the solution of Ficks second law. Results: The water sorption (g/mm3) after 90 day immersion ranged from
14.98 g/mm3 (0.90) for M10 to 36.81g/mm3 (0.46) for M6. The solubility ranged from 3.3 g/mm3 (0.90) for
M6 to 8.55 g/mm3 (0.31) for M7, the equilibration time for water sorption was reached at 20 day. M6 had the
highest diffusion coefficient 6.25 10-9 cm2/s (3.46). Conclusion: This investigation revealed that M6 composite
filling was the best one due to the lowest water solubility while the other investigated fillings showed moderate to
high solubility values but all are in accordance with the International Standard ISO 4049.
Keywords: Water sorption, Solubility, Composites, Diffusion coefficient, Calcium Fluoroaluminosilicate.
INTRODUCTION
Materials left for long time in the oral environment
will undergo an interaction with oral fluids. Visible
light-curable polymeric composites are now routinely
used as filling materials for dental restorations. These
materials are based on polydimethacrylate matrix
resins along with silane-coated inorganic fillers. They
possess many advantages such as mechanical
properties comparable to commercial dental
amalgams and dental ceramics, excellent esthetic
quality and the ability to bond to enamel surface.
However, in aqueous environment they absorb water
and release unreacted components.
There are two different mechanisms that occur when
the previously mentioned dental restorative materials
Kareema et al.,

are exposed to or stored in water: the first is gaining


weight from water uptake, and the second is losing
weight from dissolution in water[1].
Water sorption has been studied in several glassy
polymers used in dentistry. Composite resins[2,3], soft
lining and poly(methyl methacrylate) denture bases[4]
have all been shown to absorb water and, at the early
stages, this sorption follows Ficks law of diffusion.
Studies have mostly been focused on determining the
water sorption characteristics of epoxy-based
polymers [5-7]. However, data are scanty on the resins
that are employed as adhesives for bonding to
hydrated dentin.
The importance of composite-water interaction has
been acknowledged in the ISO standard 4049 which
281
Int J Med Res Health Sci. 2015;4(2):281-286

states that the maximum values for water sorption and


concurrent solubility for resin-based materials
(composites and cements). In order to comply with
this ISO standard, resin-based materials must
have water sorption and solubility values equal or
lower than 40 micrograms per cubic millimeter
(sorption) and 7.5 micrograms per cubic millimeter
(solubility) for specimens 15 mm in diameter and 1
mm thick[8].
Fluoride (F-) releasing restoratives are frequently
studied because the F- ions could increase the
dissolution resistance of the tooth structure, enhance
remineralization and hinder demineralization[9,10].
Efforts have been made to develop a composite
consist of an aluminosilicate glass matrix modified
with other elements, and they contain large quantities
of fluorine. Calcium Fluoroaluminosilicate glass
powder is treated with a fluoride in an amount of
from 0.01 to 5 parts by weight based on 100 parts by
weight of the glass powder, The Calcium
Fluoroaluminosilicate glass powder of the
investigation is improved in not only physical
properties such as crushing strength but also mixing
workability without impairing the inherent
characteristics thereof for the dental use[11]. So
Calcium Fluoroaluminosilicate glass will be suitable
as filler for resin-based dental composites because it
is interact with the bone structure makes them useful
materials for bone replacement in implants, naturally
radiopaque and highly resistant to moisture.
The aim of the present study is to determine the water
sorption characteristics of light-cured resins made
from new composites of Calcium Fluoro
aluminosilicate glasses filler with various weight
ratios.
MARERIAL AND METHODS
The compositions of the 10 composite resins tested,
The ethoxylated bisphenol A glycol dimethacrylate
Bis_GMA was purchased from Sigma Aldrich (UK)
and TEGDMA (triethylene glycol dimethacrylate)
manufactured from Sigma Aldrich (UK), N,NDimethyl aminoethyl methacrylate (DMAEMA) and
camphor Quinone (CQ) were purchased from Aldrich
(UK), Those materials were used to prepare the
monomer phase.
Calcium fluoroaluminosilicate glass was synthesized
and sintered in our laboratory [12]. It was ball-milled
and sieved to powder with a particle size < 25 m.

The particle size distribution was measured using a


BET analysis (CHEMBET 3000 QUANTA
CHROME). The average particle size was 2.64 m.
This Calcium fluoroaluminosilicate glasses was
treated with -methacryloxypropyltrimethoxy-silane
(-MPS) known as A-174 which was supplied by
Sigma Aldrich (UK).
Preparation of composite: Ten types composites
formulations,containing the resins BisGMA/TEGD
MA in a w/w ratio of 70/30 as the base resins. Resins
were activated for visible light polymerization by CQ
(0.5 wt %) and DMPT (0.5 wt %). Matrix resins were
loaded (76 wt% ~ 60% Vol) and were then silanized.
This Calcium Fluoroaluminosilicate glasses hand
mixing. The compositions of the studied dental
composites are shown in Table 1. Water absorption
was determined on disc specimens, 15 mm diameter
and 1 mm thick, for up to 90 days using the method
outlined in ISO 4049. The discs were prepared
between glass plates and were cured by exposure to
dental curing lamp for 40sec on each side. Samples
were measured, weighed and placed in individual
sealed containers of water at 37C. The specimens
were removed from the storage water at regular
intervals, blotted dry and re-weighed. After 90 days
specimens were placed in a desiccator containing dry
silica gel and re-weighed at regular intervals over a
period of 2 weeks.
Table1: Composition (W%) of Calcium Fluoroaluminosilicate Glass
Glass

SiO2

Al2O3

M1

22

18

M2

22

19

M3

29

M4

CaF2

Al2PO4

AlF3

NaF

22

15

23

10

39

13

16.6

34.2

9.9

5.3

35

25

20

M5

39.52

23.6

13.65

3.62

9.7

9.91

M6

24.3

27.5

14.0

19.1

15.1

M7

33.9

17.5

15

10

M8

56.5

33.5

M9

48.9

29.1

15

M10

36.3

22

12

15.6
10
7

14.3

6.4

Preparation of specimens: Water sorption and


solubility tests were determined according to the
specification standard for composite (ISO 4049:
2000). Specimen discs approximately 150.2 mm in
diameter and 10.1 mm in thickness were fabricated
282

Kareema et al.,

Int J Med Res Health Sci. 2015;4(2):281-286

in an aluminum mold between two glass slides they


were irradiated for 40sec on each side using a quartz
tungstenhalogen light-curing unit (Optilux 500,
Demetron Research Corporation, Danbury, CT,
USA). The light-curing unit had an exit-window
diameter of 8 mm and was operated at 400 mW/cm2
with the curing tip placed 1 mm from the glass plate.
Four specimen discs were prepared for each for the
ten experimental resin formulations. The thickness of
the samples was measured accurately at three points
using a micrometer. Also their diameters were
measured, and their volumes were then calculated in
mm3.
water sorption and solubility: All the specimens
were placed in a desiccator and transferred in a
preconditioning oven at 37C. After 24 hrs they were
removed, stored in the desiccator for 1 hr and
weighted to an accuracy of 0.0001 g using a KERN
770 Germany. This cycle was repeated until a
constant mass (m0) was obtained. Following, the
discs were immersed in distilled water at 37C. At
fixed time intervals they were removed, blotted dry to
remove excess water, weighted and then back to the
water. The time intervals were more during the first
four day, preceding daily as the uptake slowed at
more extended intervals. The uptake of water was
recorded until there was no significant change in
weight, i.e. equilibrium was attained. This took about
30-40 days.
Sorption, desorption, and material net loss
percentages were calculated as follows:
=

(1)

(2)

Where M1 is the weight of the sample after immersion


and M2 is the original weight of the sample before
immersion.
Diffusion coefficients: According to the Ficks Law,
the equation for diffusion in three dimension, when
the diffusion coefficient D is constant, is expressed as
=

Here, x (m), y (m), z (m) is the coordinates, c (%) is


the concentration where of the diffusing species at
time t (s) is the time, and D (m/s) is the diffusion
coefficient. For the one-dimensional model of linear

flow of mass in the solid bounded by two parallel


planes, the differential equation is expressed as
follows:
=

(3)

The differential equation is solved for the region h<x<h with zero initial concentration of water and
with surfaces x=h kept at constant concentration c0
for t > 0: It should be noted here that the solution to
the Ficks second law (Eq. (3)) might alternatively be
expressed as
=

+ 2

=2

(1)

2(

(4)

where Mt was the mass uptake (g) at time t (s), Me


was the mass uptake (g) at equilibrium, l was the
specimen thickness (cm) such that D is the diffusion
coefficient (cm2s-1) calculated from the gradient of
Mt/Me against t1/2. If the uptake Mt is measured at
convenient intervals of time until equilibrium is
reached, then a plot of M M against t1/2 should
provide a straight line for the earlier stages with the
slope, S

For which

RESULTS

=2

/4

(4)

All of the studied composite resins increased in


weight during immersion in water. The means of the
percentage values for sorption, solubility and
diffusion coefficient of the ten different types of
Calcium Fluoroaluminosilicate materials were
illustrated in Figure 1. During sorption, M9 and M10
showed significantly lower and no significant
differences among them respectively, While M6, M5,
M2 and M1 showed the highest sorption, which is
lower than those required by ISO 4049 standard, 40
g/mm3. Water solubility also showed differences
within the studied groups. Four main groups of
fillings can be classified: M9, M10, showed moderate
solubility while M4 showed less than the above two
283

Kareema et al.,

Int J Med Res Health Sci. 2015;4(2):281-286

M1, M3, M8 were the filling materials with the


highest mean water solubility value .Finally M6 was
found the best filling.
For all studied composites, the equilibration time for
water uptake was of the order of 15-20 days
depending on material and the volume of specimens.
The rate of change in weight over the selected time
intervals is presented in Figure 2 for all studied
composites. Figure 3 the plots of Mt/Me versus
square root of time, it can be seen that the plots are
almost linear for M10 composites. The plots had
linear increase in earlier stage and became balanced
at the end of the process when the composites were
completely saturated, that mean no more water can be
absorbed or desorbed by the studied composites. The
diffusion coefficients controlled process was
confirmed by the linear part. Figure 4 shows the
diffusion coefficients of the studied resins ranged
between 0.87 and 6.2 10-10cm2/sec for M10 and M6
respectively.

Fig. 3: Mt/M against t1/2 (sorption) for M10 composites


after immersion in water.

Fig.4:Mean diffusion coefficients


composite materials tested.

values

for

DISCUSSION

Fig. 1: Mean water sorption (g/mm3) and water


solubility obtained for composite materials (teeth
filling) tested.

Fig. 2: Changes in weight over 90 days for


composite materials.

The water sorption and solubility of dental restorative


materials are of considerable clinical importance and
cannot be neglected. Several data for water sorption
and solubility for composite materials have been
published, but it is difficult to correlate them as the
results are often for different time periods and are
expressed in different units. Moreover comparisons
are difficult to make due to differences in reported
specimen size, since different sizes of specimen will
take different periods of time for water to completely
infiltrate throughout the polymer matrix. Water
molecules are able to diffuse through the inter-chain
spaces of the resin matrix because of their smaller
size of radius, which is less than 0.158 nm and
smaller than the inter-chain spaces [13]. According to
ISO 4049:2000 standard for dental restorative resins,
a resin in order to be suitable for use as dental
material must show water sorption lower than 40
g/mm3 and solubility lower than 7.5 g/mm3. The
284

Kareema et al.,

Int J Med Res Health Sci. 2015;4(2):281-286

values of water sorption for all studied composites,


except that M6, are within the range of the ISOs
standard. On the contrary, the values of solubility are
within the range of the ISOs standard only for resin
M7. Several factors, such as the polymeric matrix
composition, filler particle type, mean particle sizes,
and the degree of curing reached after the
polymerization reaction can influence the solubility
and sorption behavior of dental resin composites
[14,15].
The studied resins used in this study have a
great similarity in the filler particle content
approximately 60% by volume. The Low water
sorption values of resin are due to the method of
preparation of Calcium Fluoroaluminosilicate glass,
Filler particle size which was within 1 to 2 m[12].
While the water solubility range was found between
2.9 8.1 g/mm3 .These results were similar to those
obtained by Oysaed and Ruyter (1.4 9.0 g/mm3)
[16]
.
Plots of Mt/M against t1/2 Figure 3 for M10 filling
(similarly for all studied resin) were linear in the
initial stages of absorption and desorption cycles,
which shows that the uptake process for these
composites is diffusion controlled. The diffusion
coefficients which have been determined in this study
is within the range of 0.76.2 10-10 cm2/sec figure 4,
in good agreement with other works and comparable
to those reported for composite resins soaked in
water, despite the difference in the form of the water
and hence in the driving force for sorption [3,17].

CONCLUSIONS
In this work, we conclude that the sorption and
solubility values are in accordance with the ISO
4049:2000. The studied dental material (teeth filling)
has shown that they have optimal physico-chemical
properties for an adequate behavior in the oral
aqueous environment, making it suitable for indirect
composite restorations.
ACKNOWLEDGMENT
Rafed M. extend his appreciation to Dr M. Atai for
his assistance and consultation in this work, thanks to
university of Basrah Dentistry College for their help.
Conflict of Interest: Nil

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7. Li L, Yu Y, Wu Q, Zhan G, Li S. Effect of
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8. ISO4049. Dentistry-resin-based lling materials:
7.9 water sorption and solubility. 2000.
9. Kielbassa A, Schulte-Monting J, Garcia-Godoy
F, Meyer-Lueckel H. Initial in situ secondary
caries formation: effect of various fluoridecontaining restorative materials. Operative
dentistry. 2002;28(6):765-72.
10. Ling L, Xu X, Choi G-Y, Billodeaux D, Guo G,
Diwan R. Novel F-releasing composite with
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11. Akahane
S,
Hirota
K, Tomioka
K.
Fluoroaluminosilicate glass powder for dental
glass ionomer cement. Google Patents; 1988.
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Glass Compositions Based on CalciumFluoroaluminosilicate for dental composite.
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dental resins. Biomaterials. 2003;24(4):655-65.
Mortier e, jager s, alain d. influence of filler
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Int J Med Res Health Sci. 2015;4(2):281-286

DOI: 10.5958/2319-5886.2015.00053.3

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
st
Received: 21 Nov 2014
Research article

Coden: IJMRHS
Revised: 20th Dec 2014

Copyright @2014
ISSN: 2319-5886
Accepted: 27th Jan 2015

CARCINOMA CERVIX SCREENING A CLINICOPATHOLOGICAL STUDY


*Vissa Shanthi1, Bhavana Grandhi2, Nandam Mohan Rao3, Byna Shyam Sundara Rao4, Vangala
Chidananda Reddy5, Swathi Sreesailam6
1,3,4

Associate professor, 2,5,6Assistant Professor, Department of pathology, Narayana Medical college and
Hospital, Nellore, Andhrapradesh, India

*Corresponding author email: santhijp@gmail.com


ABSTRACT
Background: Cervical carcinoma, the pathogenesis of which includes multiple factors was the leading cause of
death 50 years ago and the mortality rate has been reduced to two thirds due to the effective screening by Pap
smears which detected the cancers and precancerous conditions. Objective: The study was undertaken to analyze
the routine cervical cancer screening on an age specific basis and to study the various predisposing factors of
cervical carcinoma. Methods: We conducted an observation study on 1000 patients. The cervical smears collected
were examined and predisposing factors were studied in these patients. Results: 1000 women above 20 years of
age group were screened. There were 242 cases(24.2%) of dysplasia of which 133 cases (13.3%) were of mild
dysplasia, 59 cases (5.9%) were of moderate dysplasia and 50 cases (5%) were of severe dysplasia. 29 cases
(2.9%) showed invasive carcinoma. There were 564 (56.4%) inflammatory smears and 168 (16.8%) normal
smears. Maximum number of dysplasias and carcinomas were found in the age group above 40 years. These
patients were from low income group, had no formal education, attained menarche at the age of 13-14 years,
married at the age of 15-17 years, had three or more children and had marital life for more than 30years.
Conclusion: Cervical cytology has been main stay of prevention and early diagnosis of cervical carcinomas. Due
to its simplicity and low cost, pap smears can be used for mass screening. Cervical carcinoma has multiple
etiological factors which play role in its pathogenesis.
Key words: Pap smear, Cervical carcinoma, Cytology
INTRODUCTION
Cervical carcinoma is the sixth most common
visceral cancer in women and contributes to 5% of all
cancer deaths in women worldwide. It accounts for
approximately 15% of all cancers diagnosed in
women world wide1. In the developing world 1.7
million cases of carcinoma cervix and 5-13 million
cases of precancerous lesions were recorded 2,3. The
highest crude mortality rate is recorded in Southern
Africa. In North America, Western Europe and
Australia, the incidence of cervical cancer is low 4.
China has the least mortality rate 1. Death rate due to
the cervical cancer has declined in the recent years

Shanthi et al.,

due to early detection of cancers and precancerous


conditions. Cervical cancer screening by pap smears
has reduced the morbidity due to cervical cancer by
53%. Susceptibility of cervical cancer for prevention
by screening programme is determined by its high
prevalence, a long detectable preclinical phase and
benefit from early treatment. The Pap smear
screening test if carried out properly is sufficiently
sensitive and has high specificity, is of low cost and
low risk to the patient 5.
Mass cytological screening has shifted the
presentation of cervical carcinoma from the clinical
287
Int J Med Res Health Sci. 2015;4(2):287-293

to the preclinical stage. Though the incidence of


cervical cancer has decreased significantly since
1960, age specific rates; however show an increase in
young women, particularly those aged 25-29 years. It
is not due to less effective screening of the younger
population but the rise in incidence would be due to
predisposition to risk factors 6. In this study we tried
to analyze the predisposing factors for carcinoma
cervix and the age related incidence of cervical
cancer in around Tirupathi.
MATERIAL AND METHODS
This cross sectional study includes 1000 patients who
attended the gynecologic outpatient department in our
hospital during the period of two years. Institutional
ethical committee approved the study protocol.
Informed consent was obtained from all the study
participants. Pap smear from 1000 patients who were
in the age group above 20 years was collected. The
etiological and risk factors like age, parity, age at
menarche, age at marriage, use of oral contraceptive
pills, socio economic status and educational status of
patients whose smears showed dysplastic changes
were studied. The patients whose smears showed only
inflammatory changes without dysplasia were
excluded.
Smears were obtained from the patients with the help
of Aylesbury spatula7. These smears were stained
with Papanicolaou stain. Patient was placed in

dorsal lithotomy or left lateral position. Nonlubricated (self-retaining) speculum


was
introduced into the introitus to visualize the
cervix. Aylesbury spatula is placed in position
and rotated in 3600 clock wise direction, so that
sample from the ectocervix and endocervix
including squamocolumnar junction are obtained.
Specimen is spread evenly on glass slides. The
smears collected were fixed in 95% of isopropyl
alcohol for 15-30 minutes. These smears are
stained with Papanicolaou stain. Smears of the
patients which revealed dysplastic cells on
microscopic examination were studied in detail.
Patients which revealed dysplastic cells on
microscopic examination were studied in detail.
OBSERVATION AND RESULTS

Shanthi et al.,

Cervical smears from 1000 women aged above 20


years who attended gynaecology out patient
department were studied .A detailed history was
recorded which included age, age of menarche,
married life, number of pregnancies, age of last child,
duration of menopause, use of oral contraceptive pills
(OCPs), tobacco chewing or cigarette smoking,
socio-economic status and educational status of
women. The gynecological symptoms and clinical
status of cervix was also studied. The women were
grouped in 9 groups depending upon the age and
various cytological features were studied (Table 1).
There were 242 cases (24.2%) of dysplasias, of which
133 cases (13.3%) were of mild dysplasia, 59 cases
(5.9%) were of moderate dysplasia and 50 cases (5%)
were of sever dysplasia. 29 cases (2.9%) showed
invasive carcinomas. There were 564 (56.4%)
inflammatory smears and 168 (16.8%) normal smears
(Table 1).
Highest incidences of mild and moderate dysplasia
were seen in the age group of 40-50 years. Severe
dysplasia and carcinomas were seen in the age group
of 50-60 years. One case of invasive carcinoma was
noted in the age group of 20 -30 years (Table 1).
Maximum cases of invasive carcinoma, mild
dysplasia, moderate dysplasia and severe dysplasia
were noted in the menopausal age group when
compared to reproductive age group (Table 2).
Epithelial changes in relation to age at menarche were
studied and the highest incidence of dysplasia was
noted in patients who attended menarche at the age of
13 years and invasive carcinoma in the patients who
attained menarche at the age of 14 years (Table 3).
When the incidence of dysplasia in relation to the age
at marriage was studied, it showed highest incidence
of moderate, severe dysplasia and carcinoma in the
patients who were married at the age of 15-17 years
(Table 4). The incidence of carcinomas was found to
be high in patients who had marital life of 31years
and above (Table 5). The study on parity of these
patients showed that highest incidence of invasive
carcinoma, moderate and severe dysplasias were
noted in women who had three or more children. In
nulliparous women only three cases were found to
have mild dysplasia but there were no cases of
moderate, severe dysplasia and invasive carcinoma
(Table 6). Epithelial abnormalities in relation to
economic status were also studied, which showed that
incidence of dysplasia and invasive carcinomas was
288
Int J Med Res Health Sci. 2015;4(2):287-293

maximum in the lower income group (Table 7) and


these patients did not have formal education (Table
8).
Most of the patients with dysplasias presented with
irregular vaginal bleeding and invasive carcinomas
presented as post menopausal bleeding (Table 9). On
clinical examination, mild and moderate dysplasia

cases presented as cervical erosion where as the cases


with severe dysplasia and carcinoma presented as
either growth on cervix or bleeding on touch (Table
10).Though the cigarette smoking, tobacco chewing
and use of immunosuppressive drugs are considered
as risk factors, in our study it did not reveal
significant correlation (Table 11).

Table 1: Epithelial abnormalities in relation to age


Age in
years

Total

Normal
smears

Inflammatory
smears

LSIL Mild
dysplasia

20-30

203 (20.3%)

31-40

24 (2.4%)

150 (15%)

25 (2.5%)

2 (0.2%)

2 (0.2%)

304 (30.4%)

53 (5.3%)

187 (18.7%)

36 (3.6%)

14 (1.4%)

11 (1.1%)

3 (0.3%)

41-50

287 (28.7%)

51 (5.1%)

148 (14.8%)

44 (4.4%)

22 (2.2%)

13 (1.3%)

8 (0.8%)

51-60
61 and
above

128 (12.8%)

22 (2.2%)

17 (1.7%)

11 (1.1%)

14 (1.4%)

9 (0.9%)

78 (7.8%)

15 (1.5%)

11 (1.1%)

10 (1%)

10 (1.0%)

9 (0.9%)

56 (5.6%)
23 (2.3%)

HSIL Moderate
severe dysplasia

Invasive
carcinoma

P<0.001.
Table 2: Epithelial abnormalities in menopausal and reproductive age group women
Age groups

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate Severe


dysplasia

Invasive
carcinoma

Menopausal

449 (44.9%)

90 (9%)

192 (19.2%)

73 (7.3%)

37(3.7%)

33 (3.3%)

24 (2.4%)

Reproductive

551 (55.1%)

75 (7.5%)

372 (37.2%)

60 (6%)

22(2.2%)

17 (1.7%)

5 (0.5%)

P<0.001
Table 3: Epithelial abnormalities in relation to age at menarche
Normal

Inflammatory

LSIL mild

HSIL Moderate

Invasive

smears

smears

dysplasia

severe dysplasia

carcinoma

Total

Age at menarche
in years
10-11 Years

40 (4%)

4 (0.4%)

24 (2.4%)

2 (0.2%)

5 (0.5%)

5 (0.5%)

12 years

276 (27.6%)

38 (3.8%)

153 (15.3%)

43 (4.3%)

17 (1.7%)

21 (2.1%)

4 (0.4%)

13 years

418 (41.8%)

69 (6.9%)

230 (23%)

64 (6.4%)

25 (2.5%)

23 (2.3%)

7 (0.7%)

14 years

185 (18.5%)

39 (3.9%)

114 (11.4%)

13 (1.3%)

7 (0.7%)

3 (0.3%)

9 (0.9%)

15 years and above

81 (8.1%)

15 (1.5%)

43 (4.3%)

11 (1.1%)

5 (0.5%)

3 (0.3%)

4 (0.4%)

P<0.005
Table 4: Epithelial abnormalities in relation to age at marriage
Age at
marriage
10-14 yrs
15- 17 yrs
18yrs and
above

Total
151
(15.1%)
406
(40.6%)
443
(44.3%)

Normal
smears
31 (3.1%)

Inflammatory
smears
69 (6.9%)

LSIL Mild
dysplasia
21 (2.1%)

HSIL Moderate severe


dysplasia
16 (1.6%) 8 (0.8%)

Invasive
carcinoma
6 (0.6%)

50 (5.0%)

210 (21 %)

55 (5.5%)

33 (3.3%)

39 (3.9%)

19 (1.9%)

84 (8.4%)

285 (28.5%)

57 (5.7%)

10 (1 %)

3 (0.3%)

4 (0.4%)

P<0.001
Table 5: Epithelial abnormalities in relation to marital life
289
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Int J Med Res Health Sci. 2015;4(2):287-293

Married life

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate
severe dysplasia

Invasive
carcinoma

0-5 years

41 (4.1%)

7 (0.7%)

30 (3%)

4 (0.4%)

6-10 years

93 (9.3%)

18 (1.8%)

58 (5.8%)

15 (1.5%)

2 (0.2%)

11-20 years

267 (26.7%)

31 (3.1%)

187 (18.7%)

32 (3.2%)

5 (0.5 %)

10 (1%)

2 (0.2%)

21-30 years

285 (28.5%)

48 (4.8%)

165 (16.5%)

37 (3.7%)

19 (1.9%)

13 (1.3%)

3 (0.3%)

31 years and
above

314 (31.4%)

61 (6.1%)

124 (12.4%)

45 (4.5%)

33 (3.3%)

27 (2.7%)

24 (2.4%)

P<0.001
Table 6 Epithelial abnormalities in relation to parity
Parity

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate
severe dysplasia

Invasive
carcinoma

56 (5.6%)

22 (2.2%)

31 (3.1%)

3 (0.3%)

83 (8.3%)

17 (1.7%)

51 (5.1%)

11 (1.1%)

1 (0.1%)

3 (0.3%)

2
3and
above

368 (36.8%)

53 (5.3%)

240 (24%)

53 (5.3%)

11 (1.1%)

8 (0.8%)

3 (0.3%)

493 (49.3%)

73 (7.3%)

242 (24.2%)

66 (6.6%)

47 (4.7%)

39 (3.9%)

26 (2.6%)

P<0.001
Table 7: Epithelial abnormalities in relation to economic status
Economic
status
Lower income
group
Middle income
group
Upper
group

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate severe


dysplasia

Invasive
carcinoma

701
(70.1%)

119 (11.9%)

374 (37.4 %)

83 (8.3%)

50 (5%)

47(4.7%)

28 (2.8%)

289
(28.9%)

42 (4.2%)

185 (18.5%)

49 (4.9%)

9 (0.9%)

3 (0.3%)

1 (0.1%)

10 (1%)

4 (0.4%)

5 (0.5%)

1 (0.1%)

Total

income

P<0.001
Table 8: Epithelial abnormalities in relation to education status
Education status
No Formal
education
Primary
education
Higher education

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

665 (66.5%)

HSIL Moderate
severe dysplasia

Invasive
carcinoma

103 (10.3%)

345 (34.5%)

88 (8.8%)

52(5.2%)

50 (5%)

27 (2.7%)

279 (27.9%)

51 (5.1%)

180 (18%)

39 (3.9%)

7 (0.7%)

2 (0.2%)

56 (5.6%)

11 (1.1%)

39 (3.9%)

6 (0.6%)

P<0.001
Table 9: Epithelial abnormalities and gynecological symptoms
290
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Clinical
symptoms

Total

Normal
smears

Leucorrhoea

307 (30.7%)

Dysuria
Irregular
vaginal bleeding
Post menopausal
bleeding
Pain in Lower
abdomen
Mass per vagina
Routine
check up

Inflammatory
smears

LSIL Mild
dysplasia

HSIL Moderate
severe dysplasia

Invasive
carcinoma

16 (1.6%)

219 (21.9%)

56 (5.6%)

13(1.3%)

2 (0.2%)

1 (0.1%)

35 (3.5%)

8 (0.8%)

24 (2.4%)

3 (0.3%)

192 (19.2%)

15 (1.5%)

90 (9%)

31 (3.1%)

25(2.5%)

24(2.4%)

7 (0.7%)

71 (7.1%)

1 (0.1%)

13 (1.3%)

8 (0.8%)

8 (0.8%)

22(2.2%)

19 (1.9%)

194 (19.4%)

41 (4.1%)

121 (12.1%)

23 (2.3%)

8(0.8%)

1 (0.1%)

78 (7.8%)

25 (2.5%)

39 (3.9%)

7 (0.7%)

5(0.5%)

2 (0.2%)

123 (12.3%)

59 (5.9%)

58(5.8%)

5 (0.5%)

1 (0.1%)

P<0.001
Table 10: Epithelial abnormalities in relation to clinical lesions
Clinical lesions

Erosion cervix
Hypertrophied
cervix
Suspicious cervix
(growth/ bleeding
on touch)

Total

Normal
smears

230 (23%)

Inflammatory
smears

6 (0.6%)

LSIL mild
dysplasia

137 (13.7%)

HSIL Moderate
severe dysplasia

55 (5.5%)

19 (1.9%)

Invasive
carcinoma

13 (1.3%)

63 (6.3%)

10 (1%)

34 (3.4%)

12 (1.2%)

5 (0.5%)

1 (0.1%)

1 (0.1%)

82 (8.2%)

3(0.3%)

10(1%)

10 (1%)

32 (3.2%)

27 (2.7%)

Senile vaginitis

41 (4.1%)

9 (0.9%)

22 (2.2%)

4 (0.4%)

4 (0.4%)

2 (0.2%)

Polyp

4 (0.4%)

1 (0.1%)

2 (0.2%)

1 (0.1%)

155 (15.5%)

5 (0.5%)

123 (12.3%)

18 (1.8%)

8 (0.8%)

1 (0.1%)

87(8.7%)

29(2.9%)

40 (4%)

12(1.2%)

5(.5%)

1 (0.1%)

338 (33.8%)

105(10.5%)

203 (20.3%)

21 (2.1%)

8 (0.8%)

1 (0.1%)

Endocervicitis
Prolapsed
Normal

Table 11: Epithelial abnormalities in relation to risk factors


Risk factors

Total

Normal
smears

Inflammatory
smears

LSIL mild
dysplasia

HSIL Moderate severe


dysplasia

Invasive
carcinoma

Cigarette smoking

Tobacco chewing

105(10.5%)

16 (1.6%)

41 (4.1%)

18 (1.8%)

12 (1.2%)

10 (1%)

8 (0.8%)

Immunosuppressive
drugs

1 (0.1%)

1 (0.1%)

DISCUSSION
The etiology of cervical neoplasia, which is
considered to be the third most common cancer in
women, has been studied epidemiologically for over
150 years 8. Epidemiologically cervical cancer
behaves like a sexually transmitted disease and is
more common in women who have multiple sexual
partners 9, or whose partners are promiscuous 10 and
is absent in virgins. Epidemiological data has shown

that cervical carcinoma is caused by sexually


transmitted agent, Human Papilloma virus (HPV)
which plays an important role in oncogenesis.
Though HPV is considered to be an important
etiological factor, the presence of other risk factors
along with HPV infection are important in deciding
the outcome of the disease i.e. whether HPV infection
will regress or progress to cervical cancers 11 .
291

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Int J Med Res Health Sci. 2015;4(2):287-293

The U.S. Preventive Services Task Force (USPSTF)


has recommended that women aged 21 to 65 years
should undergo cytological screening for every 3
years. If the women (30 to 65 years) want to lengthen
the interval for Pap smear screening, then the
combination of Pap smear test and HPV testing for
every 5 years is recommended. The UPSTF does not
recommend the cervical cancer screening in women
younger than 21 years, for women elder than 65 years
whose previous cytology smears were normal,
women who had undergone hysterectomy with
removal of the cervix without any previous
precancerous lesion or cancers and testing for HPV
alone or along with cytology in women who are
younger than 30 years 12.
Most of the patients who attended the Government
Maternity Hospital, Tirupathi were of low socio
economic group. Low, moderate and high income
groups differ in various aspects like nutritional and
vitamin deficiencies, parity, married life, age at
marriage. Hence socioeconomic group is the index of
all the above factors which share their contribution in
the genesis of cancer cervix.
The incidence of invasive cancer in our study was
2.9% which coincided with the results of JS Misra
(2001) 13. In our study, severe dysplasia and invasive
carcinomas were common after 50 years because of
altered hormonal balance that are usually seen in the
female genital tract. The role of hormonal factors in
the etiology of cervical cancer had been underscored
by recent studies which identified several
independent risk factors like multiple births, early age
at marriage and marital life.
In our study, highest incidence of invasive
carcinomas and dysplasias were found in women who
had more than 30 years of married life. This shows
that there is intimate relationship between married
life and incidence of cancer cervix. Parazzini et al
(1989) suggested that with every pregnancy, women
would have double the risk compared to women
without children and the risk was ten times more than
unmarried women14. Other studies have shown that
the incidence was high in women who marry early
and tend to conceive more number of times as they
are exposed to longer duration in sexual activity.
The cigarette smoking /tobacco chewing was
attributed as one of the risk factors of cervical
neoplasia. In our study out of 29 cases of invasive
carcinoma, cases were found to be associated with

Shanthi et al.,

tobacco chewing and also few cases of dysplasias had


association with tobacco chewing. Cigarette smoking
has been associated with increased risk of cervical
cancer, especially among long term or high intensity
smokers 15. Smoking constituents have been found in
cervical mucous, but the biologic mechanisms
underlying the smoking-cervical cancer relationship
have not been identified.
The use of oral contraceptive pills (OCPs) is also
another risk factor. But because most of the patients
attending outpatient department are low socioeconomic group without formal education, the
number of patients, using OCPs were very few. After
elaborate study it is clearly evident that no single
factor can be named as the cause of cancer cervix.
Many factors may play part and contribute to the
causation of cancer like prolonged sexual life,
multiple sexual partners, parity, low socio-economic
status, the virus infections and genetics.
Immunosuppression has been found to be associated
with dysplastic changes in the cervix. HPV DNA is
detected more often in pregnant women who have
transient depression of cell mediated immunity. More
recently, an increased risk of cervical neoplasia has
been noted in patients infected with HIV 16.
Immunosuppression is considered to inhibit clearance
of papilloma virus and promote their reactivation 17.
Most of the frank invasive carcinomas presented as
growth on cervix or cervix which bleeds on touch
which has also been found to be the same in study by
JS Misra. Many cases of dysplasias presented as
erosion cervix. Other symptoms are leucorrhoea,
dysuria, irregular vaginal bleeding, pain in lower
abdomen and mass per vagina.
For the prevention of cervical carcinoma and
precursor lesions American Cancer Society (ACS)
recommends Human Papilloma virus vaccines for
females aged 11 to 12 years. It also suggests that
females as young as 9 years may receive HPV. For
the females aged 13 to 18 years, HPV vaccination
should be given to catch up missed vaccination or
complete the vaccination series. Vaccination is not
recommended for women over age of 26 years
because ideally the vaccination should be done prior
to genital HPV exposure as the benefit is likely to
diminish with increasing number of lifetime sexual
partners. Even after the vaccination, screening for the
cervical intraepithelial neoplasia and cancer should
continue. Two prophylactic HPV vaccine are
292
Int J Med Res Health Sci. 2015;4(2):287-293

available i,e. Gardasil which protects against HPV


types 6, 11, 16 and 18 (quadrivalent) and Cervarix
which protects against types 16 and 18 (bivalent) 18.

8.

CONCLUSION
Cervical carcinoma is caused not due to single
etiological factor but multiple independent risk
factors like age, age at menarche, age at marriage,
parity, educational and economic status, use of oral
contraceptives, cigarette smoking play role in the
pathogenesis. Due to simplicity, low cost and validity
of the Pap smear screening, it becomes apparent that
this test could be effectively used to detect early
cancer and premalignant changes in cervix uteri.
ACKNOWLEDGEMENT

9.

10.

11.

We are thankful to Dr.Sarela Jothi Bai, professor of


pathology and Dr.Bharathi, professor of Gynecology
for their assistance in completing the project.

12.

Conflict of Interest: Nil.

13.

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DOI: 10.5958/2319-5886.2015.00054.5

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 28 Nov 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 25 Jan 2015
Accepted: 16th Feb 2015

REPARATIVE OSTEOGENESIS DURING TREATMENT OF FRACTURE UNDER TRANSOSSEOUS


OSTEOSYNTHESIS AND INTRAMEDULLARY INSERTION OF WIRES WITH HYDROXYAPATITE
COATING
Iurii M. Irianov1, Arnold V. Popkov1, Nikolay A. Kiryanov2 *, Tatiana Iu. Karaseva1, Evgenii A. Karasev1
1

Russian Ilizarov Scientific Center Restorative Traumatology and Orthopaedics (RISC RTO), Ul'ianova Street, 6.
Kurgan, 640014. Russia,
2
Izhevsk state medical academy, Kommunarov str., 281, Izhevsk, Russia.
*Corresponding author email: kirnik@list.ru
ABSTRACT
Background: The problem of improving medical care for patients with the locomotor system injuries is very
important especially last time. Material and Methods: Canine open comminuted tibial fractures modelled
experimentally, wires with hydroxyapatite coating inserted intramedullary, osteosynthesis performed with the
Ilizarov fixator. Regenerated bones investigated 14-360 days after surgery using the techniques of light
microscopy, scanning and transmission electron microscopy, and X-ray electron probe microanalysis for
histologic sections . Results: It has been found that a zone of active reparative osteo- and angiogenesis forms
around the wires, as well as a bone sheath with the properties of osteogenesis conductor and inductor. Fracture
consolidation occurs early according to the primary type without cartilaginous and connective tissue formation in
bone adhesion. Presented morphological characteristics endovasal angiogenesis. Conclusion: The results of the
study evidence of the positive effect of intramedullary wires with hydroxyapatite coating on the course and
intensity of reparative osteogenesis during fracture healing
Key words: Transosseous osteosynthesis, Intramedullary wires, Hydroxyapatite coating, Fracture healing,
Reparative osteogenesis, Angiogenesis.
INTRODUCTION
The problem of improving medical care for patients
with the locomotor system injuries every year is
becoming increasingly important due to the increase
of injured persons in number, to that of disability and
mortality from injuries not having downward
tendency. However, osteosynthesis real terms remain
to be significant. The technique of directed
stimulation of bone tissue regeneration process is
practiced by using intramedullary wires with calcium
phosphate coating in order to optimize the conditions
for regenerated bone formation, as well as for
treatment period reduction, and complication
prevention [1, 2]. At the same time, the process of
reparative osteogenesis using those or other implants

inserted into the regenerated bone is poorly


understood, as well as both their effectiveness
characterization and mechanism of action are absent.
The purpose of the present work consists in studying
the morphological features of osteogenesis process
for consolidation of long tubular bone fractures under
transosseous osteosynthesis and intramedullary
insertion of wires with hydroxyapatite bioactive
calcium phosphate coating.

Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

MATERIAL AND METHODS


16 mongrel dogs, males and females, at the age from
one to five years with the body weight of 202.9 kg
were used for experiments. The keeping, surgical

294

interventions, and euthanasia of the animals were


made in compliance with European Convention for
the Protection of Vertebrate Animals (Strasbourg,
1986); they were approved by the Ethics Committee
of RISC RTO.
Procedures: The animals underwent intramedullary
reinforcement of right tibia with two wires under
general anesthesia. Wires of titanium alloy were used
with bioactive coating of hydroxyapatite of 20-40-m
thickness and 2-8% porosity; the alloy was obtained
by the technique of anodic oxidation in the arc mode.
The coating presented a multilevel ultraporous system
consisting of macro- and micropores of the diameter
from 50-100 nm to 1-2 m. Osteosynthesis was
performed with the Ilizarov fixator, and an open
comminuted fracture of leg bones was modeled in the
shaft middle third. The Ilizarov fixator dismounting
made after 28 or 35 days of fixation. Radiography
performed in the course of the experiment. The
animals were divided into four groups: 14, 21; 28, 35;
42, 90; 180, 360 days after surgery, four animals in
each group and two ones for each time point.
Clinical observation of the animals carried out
throughout the experiment. Radiography was made
using Premium Vet X-ray machine (Sedecal,
Spain) in direct and lateral views immediately after
surgery and during the experiment. Tibias of three
intact adult dogs were investigated for comparison.
After euthanasia of the animals the shaft portions of
the operated bones were sawed lengthwise, fixed in
2% solution of paraformaldehyde and glutaraldehyde,
embedded in celloidin (after decalcification) and
Araldite (without decalcification). Histotopographic
sections were prepared using Reichert microtome
(Germany) and stained with hematoxylin-eosin, and
with picrofuchsin by Van Gieson. Research and
photomicrography of histological sections were
performed using Stemi 2000-C stereomicroscope
and AxioCam ERc 5s digital camera completed
with Zen blue software (Carl Zeiss MicroImaging
GmbH, Germany). Araldite blocks were smoothed
and investigated with INCA-200 Energy X-ray
electron probe microanalyser (Oxford instruments,
England). Facture zone image was obtained in
characteristic X-ray radiati characterizing the degree
bone tissue maturity was calculated. The index of
compactness was calculated as well (bone tissue/nonmineralized structure content ratio).The blocks are
then sawed ultra thin sections were prepared

prepared on an ultra microtome LKB-8800 (Sweden),


contrasted and examined using a transmission
electron microscope JEM-2010 (Jeol, Japan). Then
Araldite blocks were treated in sodium ethyolate 2%
solution in order to remove the embedding medium,
and they were investigated with scanning electron
microscope JSM-840 (Jeol, Japan). The results of
quantitative studies were processed using standard
methods of variation statistics. The significance of
differences between the values was estimated using
nonparametric Mann-Whitney U-test. Differences
were considered statistically significant for 0.05.

Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

RESULTS
Transverse fractures have been produced in tibial
shaft middle third of all the animals after surgery
(Figure 1, a). The height of diastasis between the
fragments is 0.5-1.0 mm. The signs of periosteal
reaction as cloud-like shadows appear in close
proximity to the fracture line by 8-10 days after
surgery. The formation of new bone cortex is
determined by X-rays 35 days after surgery (Figure 1,
b).

Fig: 1a

Fig: 1b

295

Fig 1: X-rays of canine tibia after fracture


modeling and intramedullary osteosynthesis: a
shaft middle third fracture, immediately after
surgery; b newly formed cortex at the fracture
site 35 days after surgery

other from the periosteal and endosteal surfaces in the


intermediary zone, and they form strata on the ends
of fragments. Primary endosteal-periosteal and
intermediary union is formed. The content of calcium
and phosphorus in the intermediary zone of
regenerated bone is 19 % and 20 %, respectively, and
that of bone tissue 26 % of the values of the shaft
cortex
in
normal
intact
dogs
(Table1)

The regenerated bone is located all over the bone


diameter. Numerous anastomosing trabeculae of
reticulofibrous bone tissue in grow towards each
Table1: Content of calcium, phosphorus, and bone tissue in the intermediary zone of regenerated bone, and
in the cortex of intact shaft (Mm,%)
Measures
Calcium
Phosphorus
Bone tissue
/
Index of compactness

Period of experiment, days


14, 21
28, 35
4.960.31
11.020.65

42, 90
17.271.08

180, 360
23.301.31

25.821.10

2.950.181
5.741.531
1.680.131

6.440.36
53.432.89
1.720.14

9.060.56
80.074.90
1.910.18

11.070.69
94.135.49
2.100.14

11.750.53
96.154.44
2.200.13

0.350.02

1.150.07

4.020.26

16.040.67

Significant changes comparing with the measures of


intact animal shaft cortex.
By 28, 35 days after surgery the ends of fragments
lose clear boundaries due to massive deposits in the
intermediary space of mature lamellar bone tissue.
Periosteal strata of 2.5-3-mm height become
compacted, and they combine the ends of fragments
in fracture zone by the flattened fusiform sleeve.
Ribbon-like spreads are formed in the periosteal area
near fragmental ends as small-looped network of
lamellar-structured bone trabeculae bridging fracture
line.
The regenerated bone in the intermediary zone is
represented by spongy and compact bone tissue
closely adhered with cortex of bone fragments. The
phase of organogenesis and remodeling is observed
evidenced by reorganization of primary trabeculae
into organotypical osteon structures forming cortex
(Figure 2, a, b). Gradual reorganization of the
trabecular structures of coarse-fibered bone tissue
into more mineralized and mature lamellar ones is
also observed in the bone sheath round the wires. The
content of calcium and phosphorus in the
intermediary zone of regenerated bone in this period
increases up to 43-55 %, and that of bone tissue up
to 56-57 % of the measures of the shaft cortex in
normal intact dogs (Table 1).

Cortical layer

24.971.28

Fig: 2b

Fig 2: The newly formed cortex at fracture site 35


days after surgery: a staining according to Van
Gieson. Lens 2.5, eyepiece 10; b the map of
electron probe microanalysis, the image in
characteristic X-ray radiation of calcium,
magnification x15.

296
Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

By 42, 90 days after surgery the ends of fragments in


the intermediary space are connected by narrowlooped network of bone trabeculae, as well as by
osteons of different maturity with compaction signs
all over cortex width, and practically complete
periosteal, intermediary, and endosteal bone union is
revealed. The fracture healing occurs by the type of
primary consolidation due to the fact that osteogenic
cells of Haversian canals forming bone trabecular and
osteons across the fracture line grow into the diastasis
from the ends of fragments along blood vessels. The
bone sheath around the wires is formed by compact
bone of lamellar structure with forming osteons and
spongy bone tissue which spreads not only into the
diastasis but it also fills the medullary cavity of
fragments thereby binding them like a pin. Both
osteogenesis intense process and bone tissue
remodeling is also seen in the periosteal parts of
regenerated bone where numerous osteoblasts and
functionally active osteoclasts are located,
reorganization of the cortex of the fragmental ends is
observed with vascular channel expansion and
extensive stratification on the fragmental ends of the
bone trabeculae surrounded by some layers of large
osteoblasts. Secondary osteons of lamellar bone
tissue are formed in the new cortex at fracture site,
however, the intermediary zone of regenerated bone
still differs significantly from the cortical layer of
animals intact shaft by mineralization degree and
organospecificity (Table 1). The content of calcium in
the intermediary zone of regenerated bone during this
period is 66-67 %, that of phosphorus 76-77 %, and
that of bone tissue 83-84 % of the values of intact
shaft cortex.
By 180, 360 days after surgery the endosteal part of
regenerated bone is rather small being represented by
web-like network of thin lamellar-structured bone
trabeculae in the expanded intertrabecular spaces of
which vascular channels with wide lumens are
located, as well as hematopoietic-and-fatty bone
marrow. The bone sheath around the wires sharply
becomes thinner, and it is fragmented, multiple
functionally active hypertrophied osteoclasts and
resorption lacunae are located on its outer surface.
The content of calcium, phosphorus, and bone tissue
in newly formed cortex at this stage of the experiment
approximates to the measures of the shaft cortex in
intact animals (Table 1).

The investigations of the content of bone tissue and


of the main mineral components in the intermediary
zone of regenerated bone evidence of the fact that as
far as the experiment duration increases, calcium and
phosphorus content in the newly formed bone
increases steadily as well thereby reflecting gradual
prolonged mineralization of the regenerated bone
throughout the experiment. The rise of Ca/P
coefficient with increasing the experiment duration
indicates qualitative changes in the mineral phase of
regenerated bone tissue which are characterized by
gradual decreasing the proportion of soluble calcium
phosphate, as well as by increasing the proportion of
hydroxyapatite and bone tissue maturity degree
thereby approximating for these measures to the shaft
cortex of intact animals. The index of bone tissue
compactness in the newly formed part of regenerated
bone cortex increased gradually as well, reflecting the
rise in its organospecificity degree. At the same time,
the index of bone tissue compactness in the
regenerated bone intermediary zone amounted to
64.243.73 % of the values of intact shaft cortex even
by the end of the experiment thereby evidencing of
incompleteness of remodeling processes.

Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

DISCUSSION
Intramedullary osteosynthesis is known to provide
little-damage fixation of fractures, to allow earlier
weight-bearing of the operated limb, and to be one of
the main standard techniques for treating femoral and
tibial shaft fractures in most countries [3,4]. The main
disadvantage of intramedullary osteosynthesis is
considered the risk of damaging vessels and
circulation system of medullary canal which weakens
the osteogenic and osteoinductive potential of bone
marrow stromal pluripotent cells [5]. Experimental
studies have demonstrated that insertion of even thin
implant into the medullary cavity results in
significant blood supply disorders of the medullary
canal and cortex inside [6]. The possible mechanism of
the stimulating effect of intramedullary wire insertion
is connected with prolonged formation of the local
foci of granulation tissue in the medullary cavity. The
characteristic feature of the granulation tissue is the
expression of endotheliocyte migration phenotype,
and as a consequence angiogenesis activation
evidenced by intense formation of numerous
endothelial sprouts which generate capillary buds and

297

endovasal spreads localizing in vascular lumens


(endovasal angiogenesis).
The creation of such foci provides the increase of
osteoproducing cell population in fracture zone both
endocrinally and paracrinally, as well as it stimulate
regeneration angiogenesis, and thereby contribute to
osteoreparation process activation. The additional
coating of titanium implant surface with
hydroxyapatite nanostructured high-porosity layer
provides high biocompatibility with the tissue
structures
of
regenerated
bone,
increases
osteointegration rate, decreases the output of metal
ions, and prevents the formation of fibrillary
connective tissue and cartilage in the regenerated
bone [6,7]. The zone of active appositional
osteogenesis and angiogenesis is formed around the
wires, as well as the bone sheath with osteogenesis
conductor and inductor properties, which provide
directed growth of bone tissue, prolonged stimulation
of angiogenesis and reparative osteogenesis. Fracture
consolidation occurs by the primary type early
without cartilaginous and connective tissue formation
in bone adhesion.

CONCLUSION
Thus, the results of the study evidence of the
positive effect of intramedullary wires with
hydroxyapatite coating on the course and
intensity of reparative osteogenesis during
fracture healing. The data obtained allow
recommending this relatively little-invasive
method of osteoreparation optimization to be
used in combination with other methods of
conservative and surgical treatment of bone
fractures, especially for sluggish reparative
processes in children, elderly and senile persons,
as well as in debilitated patients.

2.

3.

4.

5.

6.

7.

complications. A review of the prospective


literature. Can J Surg. 2000; 43(4): 256-62.
Griffith LE, Cook DJ, Frulke JP.
Intramedullary reaming of long bones.
Practice of intramedullary locked nails.
Springer Verlag, 2006: 43-57.
John VZ, Alagappan M, Devadoss S,
Devadoss A. A completely shattered tibia. J
Bone Joint Surg. Br. 2005 Nov; 87(11):
1556-59.
Lin CM, Yen SK. Biomimetic growth of
apatite on electrolytic TiO2 coatings in
simulated body fluid.Materials Science
Engineering. 2006; 26: 54-64.
Joseph , Rebello G. B CK. The choice of
intramedullary devices for the femur and the
tibia in osteogenesis imperfecta. J Pediatr
Orthop. 2005 Sep; 14(5): 311-19.
Schemitsch EH, Kowalski MJ, Swiontkowski
MF. Cortical bone blood flow in reamed and
undreamed locked intramedullary nailing: a
fractured tibia model in sheep. J Orthop
Trauma. 1994; 8(5): 373-82.
Liu X, Chu PK, Ding C. Surface
modification of titanium, titanium alloys, and
related materials for biomedical applications.
Materials Science Engineering. 2004; 47: 4921.

ACKNOWLEDGEMENT
We thank the staff of our institutions for their
help in carrying out experiments and supervision
over animals during all stages of work.
Conflict of Interest: Nil
REFERENCES
1. Coles CP, Gross M. Closed tibial shaft
fractures: management and treatment
298
Irianov et al.,

Int J Med Res Health Sci. 2015;4(2):294-298

DOI: 10.5958/2319-5886.2015.00055.7

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
Received: 2nd Dec 2014
Revised: 6th Jan 2015
Research article

Copyright @2014
ISSN: 2319-5886
Accepted: 16th Jan 2015

INFARCTION IN NORMAL AND INTRAUTERINE GROWTH RETARDATION [IUGR] PLACENTA


*Pooja Dhabhai1, Ghanshyam Gupta2
1,2

Department of Anatomy, R.N.T. Medical College, Udaipur, Rajasthan, India

*Corresponding author email: poojadhabhai14@gmail.com


ABSTRACT
Background and Purpose: The purpose of the study is to compare the presence of Infarction in normal placentas
and IUGR placentas. Study design and setting: Research study, Department of Anatomy, R.N.T. Medical
College, Udaipur. Study Sample: 100 control and 100 IUGR Placentas Inclusion criteria: 100 Placentas from
normal control Pregnancies and 100 Placentas from mother who Delivered Intra Uterine Growth Retarded
(IUGR) babies Exclusion Criteria: we refer only uncomplicated Pregnancies without any previous diseases
Results: Chi Square test was used for statistical analysis. Conclusion: Increased incidence of extensive infarction
associated with low fetal weight
Keywords: Infarction, Placenta, Intrauterine Growth Retardation
INTRODUCTION
Fetal growth depends on the proper development and
function of the placenta, which serves to maintain
mater no fetal interference for the exchange of blood
gases, nutrients, and waste [1]. The architecture of the
placenta is altered in many maternal diseases such as
diabetes mellitus[2], hypertension[3], preeclampsia
[PE] [4], and eclampsia[5]., Although the placenta is a
vital organ, its systemic study has been neglected;
however, in recent times, it has evoked great interest,
and much work is being conducted to understand the
unique biological status of this complex organ[6].
Placental examination has clinical value in cases of
PE and intrauterine growth retardation (IUGR), both
of which are associated with high perinatal morbidity
and mortality accompanied with gross pathological
changes in the placenta.
Placental infarcts are usually wedge shaped and
always have a point of contact with the basal plate,
when fresh they are well demarcated, dark red and
moderately firm [7]. Placental infarctions are zone of

ischaemic necrosis of group villi due to complete


interference with their blood supply in the deciduas or
in the local state by thrombosis of a spiral arteriole or
a retroplacental haemorrhage[8]. Small areas of
infarction, involving less than 5% of the parenchyma,
were found in almost a quarter of placentas from
normal pregnancies and are of no clinical
significance. Extensive infarction, that is involving
more than 10% of villous substance is associated with
a high incidence of fetal hypoxia, low birth weight
and fetal death and is virtually confined to placentas
from patients suffering from the hypertensive
complications of pregnancy. Extensive infarction is
[7]
due to occlusion of multiple maternal arterioles . It
was found that extensive infarction in cases of
toxaemia were associated with low birth weight,
[7]
placental weight and increased foetal death
MATERIAL AND METHODS
299

Pooja et al.,

Int J Med Res Heath Sci. 2015;4(2):299 -301

The study of placenta in normal and IUGR cases


was carried out at R.N.T. Medical College &
Hospital, Udaipur. The cases were studied from 1-713 to 1-5-14. The study plan was approved by
institution Ethical Board and consent form was filled
by patients.
The placenta were collected from 200 women
admitted to the labour Rooms of the hospital
(either directly or through the antenatal wards).
All the cases were within the age group of 18-40
years, of average height and weight. Group 1normal pregnancy 100 patients included in this
group, normal Hb and urine analysis, not associated
with any disease.
Group 2-IUGR cases 100 cases of IUGR were
included. After the delivery placenta were collected
for gross studies, washed and surface dried between
blotting papers. Presence of Infarction noted as
Mild(less than 5% of total placental area)
Moderate(more than5% less than 10% of total
placental area) Severe(more than 10% of total
placental area) [7]
Area of infarction on the maternal surface varied
from no Infarcted area to 5-10 % of the total surface
(as calculated from combined area of the infarcts as
seen on the maternal surface.) [7]

Mild(less than 5%
of total placental
area)
Mod(more than5%
less than 10% of
total placental
area)
Severe(more than
10% of total
placental area)

51

20

24

*Highly significant p<0.0001


Table2.Statistical comparison of
present in control and research group
Author

Place

No.
of
case
s

GangaR
Singal
(2013)9
Kotgirwar
(2011)10
PradeepS
Londhe11
Figen Barut12
Gediminas
Mejus13
Nayereh
Ghomian14
Gnyeli 15
Present
Study

Bhavnagar

100

Bhopal

55

nil

1.8

<0.01

Andhra
Pradesh
Turkey
Lithuania

374

5.4

10.6

<0.01

110
120

nil
4.2

92.7
49.2

<0.01
<0.01

Iran

46

8.7

39.1

<0.0001

Turkey
IndiaUdaipur

52
200

4
13

58
96

<0.05
<0.0001

*Highly
significant
p<0.01,p<0.05

RESULTS

Infarction

Infarction
Result
present in % of
cases
Contro Resea
l
rch
5
10
<0.01

p<0.0001,*Significant

DISCUSSION

Area of Infarction

Fig.1 Photograph of maternal surface of placenta


showing area of Infarction
Table 1 Analysis for Infarction
Infarction
type

Normal
pregnancies
group
(n = 100)

IUGR
pregnancies
group
(n = 100)

87

Nil

p value

<0.0001
*

Present study shows that infarction is present in


higher % of cases in IUGR group and the difference
is highly significant in our study. The p value
(<0.0001) is highly significant. The present study is
consistent with Nayereh Ghomian et al 14 also shows
Highly significant values of infarction in research
group.
Among Indian studies the present study is consistent
with study of Ganga R Singal[9], Kotgirwar[10].
Pradeep S Londhe[11] also studied higher percentage
of infarction in research group. The p value (<0.01) is
significant and thus favours the present study. Among
western studies the present study is consistent with
Figen Barut[12], Gediminas Meju[13] ,Gnyeli et
al[15] as they also showed higher occurrence of
infarction in IUGR group. In present study infarction
was seen in 13 cases of normal terms pregnancy but
300

Pooja et al.,

Int J Med Res Heath Sci. 2015;4(2):299 -301

extent of infarction was less than 10% of placental


tissue. It was seen in 96% cases of IUGR , in 24% of
these extent of infarction was more than 10% of
placental tissue on gross examination.

6.

CONCLUSION
Increased incidence of extensive infarction was seen
in cases of IUGR. These cases were associated with
low foetal weight. Every placenta shows many
degenerative features. Presumably these are to an
extent, physiologic sequence of evolution. However,
when they occur in excess, they must be considered
as pathological, particularly when they affect foetal
growth deleteriously.

7.

8.

9.

ACKNOWLEDGEMENT
Conflict of Interest-NIL

10.

REFERENCES
1. Vogel P. The current molecular phylogeny of
Eutherian
mammals
challenges
previous
interpretations of placental evolution. Placenta.
2005; 26:59196.
2. Pardo F, Arroyo P, Salomn C, Westermeier F,
Guzmn-Gutirrez E, Leiva A, Sobrevia L.
Gestational diabetes mellitus and the role of
adenosine in the human placental endothelium
and central nervous system. J Diabetes Metab.
2012; 2:10-11.
3. Barker DJ, Bagby SP, Hanson MA. Mechanisms
of disease: in utero programming in the
pathogenesis of hypertension. Nat Clin Pract
Nephrol. 2006;2:70007.
4. Sankar KD, Bhanu PS, Kiran S, Ramakrishna
BA, Shanthi V. Vasculosyncytial membrane in
relation to syncytial knots complicates the
placenta in preeclampsia: a histomorphometrical
study. Anat Cell Biol. 2012; 45:8691.
5. Akhlaq M, Nagi AH, Yousaf AW. Placental
morphology in pre-eclampsia and eclampsia and

11.

12.

13.

14.
15.

the likely role of NK cells. Indian J Pathol


Microbiol. 2012; 55: 1721.
Murphy VE, Smith R, Giles WB, Clifton VL.
Endocrine regulation of human fetal growth: the
role of the mother, placenta, and fetus. Endocr
Rev. 2006; 27: 14169.
Fox,H.in Post graduate obstetrical and
Gynecological Pathology by Fox,H and
Langley,F.a.1stEd. 1973;409-37,
Zeek PM,Assali NS Vascular changes in the
deciduas associated with eclamptogenic toxaemia
of pregnancy.American Journal of clinical
Pathology,1950;20:1099-09.
Dr.Ganaga R Singal et al
,Placental
Morphometry in Relation to Birth Weight of Full
Term Newborn ; SEAJCRR 2013; 2(5) 334-42
S kotgirwar, M ambiye, S athavale,V gupta, S
trivedi, Study of Gross and Histological features
of placenta in intrauterine growth retardation ;J.
Anat. Soc. India 2011 60(1) 37-40
Londhe, pradeep s.et al Placental morphometry in
relation to birth weight of full term newborn
babies. ,National journal of integrated research in
medicine . 2012; 3( 1): 67-72.
Figen Barut et al;Intrauterine growth restriction
and placental angiogenesis; Diagnostic Pathology
2010,5:24
Gediminas mejus, Influence of placental size
and gross abnormalities on intrauterine growth
retardation in high-risk pregnancies, Acta medica
lituanica. 2005;12 (2)1419
Ghomian, Nayereh et al 2014 Iranian Journal of
Pathology;Winter2014; 9 (1): 9
Gnyeli et al. Placental examination in IUGR and
Stillbirth ; J Turkish-German Gynecol Assoc
2011; 12: 75-9

301
Pooja et al.,

Int J Med Res Heath Sci. 2015;4(2):299 -301

DOI: 10.5958/2319-5886.2015.00056.9

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 7 Dec 2014

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 4 Feb 2015
Accepted: 20th Feb 2015

Research article
COMPARISON OF ENDOSCOPIC SINUS SURGERY AND ANTRAL WASH OUT IN THE
MANAGEMENT OF SUBACUTE AND CHRONIC MAXILLARY SINUSITIS
*MuthuBabuK, Srinivasan MK., Sakthivel M, Kiran kumar C, Arvindh kumar G
Department of ENT, Meenakshi Medical College and Research Institute, Kanchipuram, Tamil Nadu, India
*Corresponding author: MuthuBabu. K ; Email: muthubabu67@gmail.com
ABSTRACT
Introduction: Sub acute and chronic maxillary sinusitis is commonly encountered in day to day ENT practice.
Here we compare the management options available in the treatment of these two conditions. Methodology:
Endoscopic sinus surgery and antral wash out are two well known and authentic procedures used in the
management of maxillary sinusitis. Here we evaluate the effectiveness and advantages of both the procedures in
the management of sub acute and chronic maxillary sinusitis. 40 patients were evaluated. 20 patients underwent
antral lavage and the remaining 20 underwent Endoscopic sinus surgery. Equal number of patients with sub acute
and chronic maxillary sinusits underwent both the procedures. Result: Evaluation was done based on the
symptoms, anterior rhinoscopy finding and radiological finding. Conclusion: Endoscopic sinus surgery is an ideal
management tool for chronic maxillary sinusitis. But sub acute maxillary sinusits can be treated as a day care
procedure by antral washout.
Keywords: Antral wash out, Endoscopic sinus surgery, Maxillary sinusitis.
INTRODUCTION
Sinusitis is classified as acute sinusitis 7days to 4
weeks duration, sub acute sinusitis 4 weeks to 12
weeks duration and chronic sinusitis more than 12
weeks duration, acute exacerbation of chronic
maxillary sinusitis and recurrent sinusitis more than
4 episodes per year [1]. Here we limit our study to sub
acute and chronic maxillary sinusitis. The differential
diagnosis is based upon the duration of symptoms and
sinus endoscpic finding [2]. We compare the
effectiveness of two authentic procedures, antral
washout and endoscopic sinus surgery. Sub acute
maxillary sinusitis usually clears up by repeated sinus
washout [3].
MATERIAL AND METHODS
Patients from the outpatient and inpatient Department
of ENT and head and neck surgery, Meenakshi
Medical College and Research Institute were taken up

for the study after getting the approval. Patients in the


age group of 20 to 45 years of both sexes were taken
up for the study. Only patients who were suffering
from exclusive maxillary sinusitis were evaluated.
Exclusions: Involvement of other paranasal sinuse,
Presence of nasal polyps, Allergic rhinitis, Acute
exacerbations of chronic diseases, Fungal sinusitis,
Presence of any tumours in the nose. Randomized
separation study was done after getting the written
consent from the patients.
40 patients with symptomatic maxillary sinusitis were
evaluated. 20 patients underwent antral wash out.10
patients were suffering from sub acute maxillary
sinusitis and the rest 10 patients were suffering from
the chronic form of the disease. Similarly 20 patients
underwent endoscopic middle meatal antrostomy out
of which 10 were suffering from sub acute maxillary
sinusitis and the other 10 patients with chronic

302
Muthu Babu et al.,

Int J Med Res Health Sci. 2015;4(2):302-304

Disease

Percentage of
patients improved
following antral
wash

Chronic
maxillary
sinusitis
Subacute
maxillary
sinusitis

Percentage of
patients improved
following endoscopic
sinus surgery

20%

90%

90%

90%

RESULTS
9 out of 10 patients who underwent antral wash out
for sub acute maxillary sinusitis were relieved of the
symptoms that they complained off. Anterior
rhinoscopy and nasal endoscopic evaluation also

revealed complete normalcy after the procedure.


Radiological appearance of sinuses also showed
improvement with decrease in the opacification.
Similarly 9 out of 10 patients who underwent
endoscopic surgery with sub acute symptoms showed
similar improvement.
On the other hand 9 out of 10 patients who were
suffering from chronic maxillary sinusits and who
underwent endoscopic sinus surgery showed
improvement based on the symptoms, signs and
radiologic comparisons. But only 2 out of 10 patients
with chronic maxillary sinusits showed symptomatic
improvement following antral wash out (Fig 1).

improved

10

No. of patients

maxillary sinusitis. Evaluation was then done based


on the symptoms like nasal discharge, headache,
anterior rhinoscopic examination, endoscopic
examination of the nose, X-ray of the paranasal
sinuses, CT scan of the paranasal sinuses. The
evaluation of all these parameters was done before
the procedure and after the procedure. In few patients
who had purulent secretions the pus was sent for
culture and sensitivity. Antral lavage: Under local
anaesthesia, 4% xylocaine was used to anaesthetize
the nasal cavity through the inferior meatus[4]. A
Lichtwitz trocar and canula was inserted into the
maxillary antrum through the inferior meatus and the
antrum washed with normal saline. By doing so the
antrum was washed out and the patency of the natural
maxillary sinus ostium was established thus helping
in the treatment of the disease. Endoscopic sinus
surgery: Using 0 degree nasal endoscope, under local
or general anaesthesia the procedure was performed
depending on the ability of the patient to withstand
the procedure [5]. A middle meatal antrostomy and
complete toileting of the maxillary antrum was done.
Pus if present was sent for culture and sensitivity.
Patients were followed up every week for six weeks
and the patients response to treatment was evaluated
depending on the symptoms like headache, nasal
discharge, and nasal obstruction and from the anterior
rhinoscopy and nasal endoscopic findings.
Preoperative and post operative X-ray and CT scan of
the patients were compared to come to a conclusion
regarding the results of both the procedures.
Table1: Showing percentage of patients improved
following antral wash and endoscopic sinus
surgery.

8
6

Subacute

Chronic

2
0
Antral wash

FESS

Fig 1: Comparison of antral wash-out with FESS


for sub acute and chronic diseases.
DISCUSSION
It was Messerklinger who made us understand about
the physiology of the nose and sinuses and also in
recognizing the mucociliary transport mechanism in
the nose and sinus mucosa. The mucociliary transport
of mucous occurs in a definite genetically
predetermined system. The transport is always
towards the natural ostium. In sinusitis the pathology
is not in the major sinuses but secondary to impaired
drainage caused by disease in the ethmoidal
infundibulum blocking the natural ostium in the
middle meatus. This leads to stagnation and impaired
ventilation causing damage to the respiratory
epithelium with consequent inflammation and further
occlusion of the ostium. Functional endoscopic
surgery is aimed in tackling the pathology in the
natural ostium. Antral wash out aims at washing out
the stagnated contents in the antrum through a trochar
and canula inserted through the inferior meatus and is
washed out through the natural ostium. So any
minimal pathology in the ostium may be cleared of in

303
Muthu Babu et al.,

Int J Med Res Health Sci. 2015;4(2):302-304

this procedure itself. Hence we were induced to make


such a comparative study. The predisposing factors
for sinusitis are Upper respiratory tract infections,
anatomic variations, allergic rhinitis, immuno
deficiency diseases, inhalation of irritants etc[2].Dental
infections are also a common cause for maxillary
sinusitis. Here two of our patients had dental
infection. Typical organisms in an odentogenic
sinusitis include anaerobic streptococci, streptococci
sanguis, streptococcus salivarius, streptococcus
mutans, bacteroides, proteus and coliform bacilli [3].
In sub acute cases antral wash out is frequently
carried out as a first line of management. Antral
washouts are also done in some centres at the time of
polypectomy [4].local anesthesia is usually preferred.
We use 4% xylocaine surface anesthesia. In some
centres Propandid as the sole anaesthetic agent for
antral wash out in adult day case is described [5,6].
One of the main benefits of antral wash out in sub
acute cases is that the tap provides material for
culture and sensitivity to guide antibiotic selection
especially in immunocompromised patients in the
intensive care units. The commonest organism being
gram positive organisms responding to amoxicillin
and clavalunic acid [7]. If penicillin group is to be
avoided due to hypersensitivity then cefpodoxime and
cefuroxime can be used [8-11]. In our study no such
limitations were present.
CONCLUSION
From the above study we came to a conclusion that in
the management of sub acute maxillary sinusitis both
antral was out and endoscopic sinus surgery provides
equal relief. Since Antral wash out is a simpler
procedure and doesnt require hospital stay and can
be done as a day case, antral wash out still holds good
in the treatment of sub acute maxillary sinusitis. But
functional endoscopic sinus surgery still remains the
gold standard in the treatment of chronic maxillary
sinusitis.
ACKNOWLEDGMENT

Conflict of interest: Nil


REFERENCES
1. Ian S Mackkay , Valerie J Lund classification
and differential diagnosis of rhinosinusitis,ScottBrowns otorhinolaryngology and head and neck
surgery.7th edition 2008; 1380.
2. A.Masood, Loannis Moumoulidis,Joan Panesar
Predisposing factors for sinusitis. Postgraduate
Medical journal 2007 83(980) 402 08.
3. Legret.KG, Zimmerman,Stierna P Sinusitis of
odontogenic origin. Pathophysiological impli
cations of early treatment. Acta otolaryngol.
2004.124(655) 662 -63.
4. Dowel.M,Pahor AL Antral wash out in nasal
polypectomy The journal of laryngology and
otology 1992,106(8) 695-96.
5. D.L.Scott Propandid as the sole anaesthetic agent
for antral wash out in adult. British journal of
anaesthesia 1970 .42 (10):889 90.
6. Pang YJ,WillatDJ, Do antral wash out have a
place in the current management of chronic
sinusitis.J of Laryngol and otoln 1996:110:92628.
7. Garau .J, DaganR, Accurate diagnosis and
appropriate treatment of acute bacterial rhino
sinusitis: Minimising bacterial resistance Clin
Ther 2003:25 (7):1936-51.
8. Melen I, Lindal L, Andreasson.L, Rundcrantz H
chronic maxillary sinusitis. Definition, diagnosis
and relation to dental infections and nasal
polyposis: Acta otolaryngo 1986. 101(3-4): 3207.
9. G.E.Archer The treatment of subacute maxillary
sinusitis especially in children: Proc.R.Soc.Med.
1947 40(4); 854-58.
10. Mochloulis G, HernJD, Hollis LJ, Tolley NS,
Maxillary antral lavage using inferior meatus
anaesthesia J laryngol otal 1996 110(8) : 763-4.
11. Young JJ, Liw Y, Jil Q, Wang ZY, Sun J, Wang
QP, Liz Q, Xu JG local aneasthesia for functional
endoscopic sinus surgery employing small
volumes of epinephrine containing solutions of
lidocaine produces profound hypertension: Acta
Anaesthesiol Scan 2005: 49(10): 1471-6.

I would like to thank Dr. K.Nithyananthan, M.S.,


DEAN Meenakshi Medical College and Hospital
Research Institute for giving us this opportunity to
conduct this study. I would also like to thank the
medical and paramedical staff of the Dept of ENT for
their assistance.

304
Muthu Babu et al.,

Int J Med Res Health Sci. 2015;4(2):302-304

DOI: 10.5958/2319-5886.2015.00057.0

International Journal of Medical Research


&
Health Sciences

www.ijmrhs.com
Volume 4 Issue 2
nd
Received: 22 Dec 2014
Research article

Coden: IJMRHS
Revised: 5th Jan 2015

Copyright @2014
ISSN: 2319-5886
Accepted: 1stMar 2015

COMPARISON OF THE KNOWLEDGE, ATTITUDE AND PRACTICES OF ESSENTIAL MEDICINES


AMONG MEDICAL PRACTITIONERS OF A MEDICAL COLLEGE VERSUS PRIVATE MEDICAL
GENERAL PRACTITIONERS OF AN URBAN PLACE OF SOUTH INDIA

*Vidyarthi SurendraK1, Nayak RoopaP2, Gupta Sandeep K3, Dandekar Rahul H4


1

Associate Professor, 2Professor and Head, 3Assistant Professor, Department of Pharmacology, Dhanalakshmi
Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu
4
Assistant Professor, Department of Community Medicine, Dhanalakshmi Srinivasan Medical College and
Hospital, Siruvachur, Perambalur, Tamil Nadu
*Corresponding author email: skvmanju9208@yahoo.co.in
ABSTRACT
Background: India is the third largest producer and exporter of medicines to most of the countries. The World
Medicine Situation Report 2011 states that 65% persons in India do not have access to essential medicines. While,
huge unethical prescribing ofdrugs for monetary gains has been a second major cause of rural indebtedness. Aims
and Objectives: The primary objective of the study was to compare the Knowledge, Attitude and Practices of
Essential Medicines among Medical Practitioners of a Medical College and Private Medical General Practitioners
of an urban place, e.g. Perambalur District of South India. Materials and Methods: After ethical approval, the
study was started, in Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Siruvachur-621113,
Perambalur, Tamil Nadu. It was a questionnaire based study. The faculties of the DSMCH and Medical Private
Practitioner of Perambalur district included as participants in the study. We distributed knowledge, attitude and
practice (KAP) based 15multiple choice questions on National Essential Medicine List, 2011 (NEML) to each
healthcare professionals (HCPs) to attempt within 15 minutes. Results: Overall, Knowledge, attitude and
practices regarding NEML 2011 were 57.06%, 38.36%; 51.16%, 51.82%; 21.73%, 28.7% to HCP from DSMCH
and HCP from Perambalur district, respectively. Whereas, 42.2 % HCPs from DSMCH and 44.7 % HCPs from
Perambalur district were prescribed branded and generic drugs both. Conclusion: The results data shows that
regular awareness programmes should be conducted to update knowledge, change attitude and practices regarding
essential medicines to serve the society as best as possible.
Key words: Essential Medicine List (EML), National Essential Medicine List (NEML), Knowledge, Attitude,
Practice, (KAP), Essential medicine.
INTRODUCTION
Access to essential medicines is a fundamental
human right. India is the third largest producer and
exporters of medicines to most of the
countries.[1]Whereas, huge unethical prescribing of
unnecessary drugs for monetary gains by health
service providers has been a second major cause of
rural indebtedness.[1] While, the World Medicine
Situation Report 2011 states that 65% persons in

India do not have access to essential


medicines.[2]Therefore, an earlier attempt of
establishing low cost quality generic medicines,
motivating providers to prescribe generic medicines
and follow standard treatment protocols partially
succeeded and Provision of free medicines to all
patients seeking care in government hospitals has
improved access to health care many folds. The
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Surendra et al.,

Int J Med Res Health Sci. 2015;4(2):305-310

WHO has defined Essential medicines (drugs) those


that satisfy the priority healthcare needs of the
population. They are selected with due regard to
public health relevance, evidence on efficacy and
safety, comparative cost effectiveness and it should
be available at all time, in adequate amounts, in
appropriate dosages forms, with assured quality and
adequate
informations[3]Though,
healthcare
professionals play an important role to prescribing
essential medicines, so question arises what about
their awareness on essential medicines. Thus, the
present survey conducted to compare the Knowledge,
Attitude and Practices regarding Essential medicines
among Medical practitioners of a Medical College
and Private Medical General Practitioners of an urban
place, e.g. Perambalur District of South India.
Aims and objectives: The primary objective of the
study was to compare the Knowledge, Attitude and
Practices of Essential medicines among Medical
practitioners of a Medical College and Private
Medical General Practitioners of an urban place, e.g.
Perambalur District of South India.
MATERIAL and METHODS
After getting approval from the ethics committee, the
present study was conducted in the month of
February 2014, in Dhanalakshmi Srinivasan Medical
College and Hospital (DSMCH), Siruvachur-621113,
Perambalur, Tamil Nadu. The study was
questionnaire based comparison among two groups of
the healthcare professionals. The Professors,
Associate Professor, Assistant Professor, senior and
junior resident (SR, JR), pharmacist, dentist and
casualty medical officer (CMO) of DSMCH included
in group A and they are abbreviated as
A_DSMCH_HCP and Medical General Practitioner
of Perambalur district included in group B and they
are abbreviated as B_Perambalur_GP. We
distributed 5-knowledge, 5-attitude and 5-practice
(KAP) based, i.e. 15 multiple choice questions which
was based on National Essential Medicine List, 2011
(NEML) to each healthcare professionals (HCPs) to
attempt within 15 minutes.
Statistics: After evaluation of each paper, we
analyzed the data by using Epi Info Free available
online/offline software and statistical calculations
done; like percentage, chi-square test, p-values.

RESULTS
We formed two groups, 61 healthcare professionals
from DSMCH in group A (A_DSMCH_HCP) and
in group B (B_Perambalur_GP) 61 general
practitioners from Perambalur District. The
demography of the participated HCPs were the 11professor,
4-associate
professor,
22-assistant
professor, 4-senior resident (SR), 9-junior resident
(JR), 1-casualty medical officer (CMO), 7-pharmacist
and 3-dentist were participated in group A, out of
61 HCPs. While all 61 HCPs of group B were
General practitioners from various medical subjects.
Average age of the included HCPs was 39 years
and45 male, 16 female HCPs were from DSMCH,
while 49 male, 12 female HCPs were from
Perambalur District. We analyzed knowledge,
Attitude and Practices (KAP) about essential
medicines of 61 HCPs of A_DSMCH_HCP and 61
HCP of B_Perambalur_GP; Perambalur District.
Obtained responses data shown in table1, 2 and 3
respectively. Statistics: We used Epi. Info free
available online/offline software to calculate the
obtained responses in percent and applied Chi- square
test and calculated p-value of each questions
response.
Knowledge on National Essential Medicine & its
List2011: Overall, 57.06% HCP from DSMCH and
38.36% HCP from Perambalur district were aware
about EML 2011, while 21.98%, 28.86% HCP were
do not know about EML2011 from DSMCH and
Perambalur district respectively and even 20.98%,
32.82% HCP from DSMCH and Perambalur district
were not sure about knowledge of EML2011
respectively(Table 1).
Attitude about HCP for National Essential
Medicine & its List2011: Overall, 51.16% HCPs
from DSMCH attitude were strongly agree or
strongly like to attend/refer NEML2011, while;
51.82% HCPs from Perambalur district attitude was
strongly agree or strongly like to attend/refer
NEML2011. One side, 44.94% HCPs from DSMCH
were like to refer NEML, whereas 40.62% HCPs
from Perambalur district were like to refer
NEML(See details on Table 2).
Practices about National Essential Medicine & its
List2011 for HCPs:8.2 % HCPs from DSMCH
always prescribed generic drugs, whereas, 14.8%

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Int J Med Res Health Sci. 2015;4(2):305-310

prescribed branded drugs, while 62.3% HCPs


drugs, respectively, while; 20.9 % HCPs from
prescribed branded as well as generic drugs both.
DSMCH and20.9%HCPs from Perambalur district
6.6% HCPs from Perambalur district always
were frequently prescribed old essential drugs,
prescribed generic drugs, whereas, 36.1% prescribed
respectively. Whereas, 42.2% HCPs from DSMCH
branded drugs, while 55.7 % HCPs prescribed
and 44.7% HCPs from Perambalur district were
branded as well as generic drugs both. Overall, 21.73
prescribed branded and generic drugs both (See
% HCPs from DSMCH and 28.7 %HCPs from
details on Table 3)
Perambalur district were always prescribed branded
Table1: Knowledge Based Questions and obtained Responses of Both Group A and B HCPs
Knowledge Based Questions
Know

Indian Essential Medicine list 2011 is


the List of drugs by generic names and
it is required to satisfy the priority
healthcare needs of a population.
Q.2 *NLEM2011 incorporated with twenty
seven sections with 348 drugs.
Q.3
Indian EML2011 formulary has Basic
drug informations like Dose, Generic
name, Clinical indications.
Q.4
Essential medicines selection criteria
are Pattern of prevalent diseases,
Relative efficacy, cost and suitability of
drugs and treatment facilities.
Q.5
WHO revise and publish essential
medicine list in every two years
interval, while Govt. of India, MOHFW
published EML in 1996, 2003, 2011.
Knowledge about NEML2011 (Total
Percentage in Average):

A-DSMCH_HCP
Dont
Not
Know
Sure

B-Perambalur_HCP
Know
Dont
Not Sure
Know

Q.1

39
(63.9%)

7
(11.5%)

15
(24.6%)

34
(55.7%)

30
(49.2%)
40
(65.6%)

20
(32.8%)
8
(13.1%)

11
(18%)
13
(21.3%)

6
(9.8%)
26
(42.6%)

46
(75.4%)

10
(16.4%)

5
(8.2%)

19
(31.2%)

22
(36.1%)

57.06%

21.98%

27 (44.3%)

Chisquared

PValue

10.8

0.005

38
17
(62.3%) (27.9%)
18
17(27.9%)
(29.5%)

22.9

7.3

0.03

32
(52.5%)

12
(19.7%)

17
(27.9%)

9.2

0.01

20
(32.8%)

19
(31.2%)

20
(32.8%)

22
(36.1%)

0.2

0.9

20.98%

38.36%

28.86%

32.82%

Abbreviations: *NLEM= National list of Essential Medicine, MOHFW= Ministry of Health and Family Welfare.

Table 2: Attitude Based Questions and obtained responses of both groups A and BHCPs
Attitude Based Questions

Q.6

Q.7

Have you ever refer essential Strongly


Like to
Medicine list 2011 or your like to refer
refer
Hospital formulary in last three
19 (31.2%) 42(68.9%)
years?
Strongly
Like to
Have you ever read any article
read/
regarding essential medicines or like to read/
attend
attend
attended any seminar,
conferences, symposium, CME,
workshop etc. on it?

Q.8

A-DSMCH_HCP

Do you think prescribing essential


medicines should be made
mandatory?

Q.9

Do you think prescribing Generic


drugs should be made
mandatory?

Q.10

I Strongly like, like, dislike, to


select essential medicines as per
its relative efficacy, cost and
suitability for the treatment.

Attitude for EML2011 (Total Percentage )

B-Perambalur_GP

Dislike to
refer
0

Strongly
like to refer
17 (27.9%)

Like to
refer

Dislike to
refer

41(67.2%) 3(4.9%)

Dislike to
read/
attend

Strongly
like to read/
attend

Like to
read/
Attend

Dislike to
read/
attend

42
(68.9%)

1
(1.6%)

37
(60.7%)

19
(31.1%)

5
(8.2%)

Strongly
agree

Agree

Disagree

Strongly
agree

Agree

Disagree

40(65.6%)

18(29%)

3(4.9%)

37(60.7%)

19(31%)

5(8.2%)

Strongly
agree

Agree

Disagree

Strongly
agree

Agree

Disagree

18
(29.5%)

35(57.4%) 19(31%)
Strongly
Like
like
44
16
(72.1%)
(26.2%)
51.16%

44.94%

7(11.5%)
Dislike
1
(1.6%)
3.9%

25(40.9%) 29(47%)
Strongly
Like
like
42
16
(68.9%)
(26.2%)
51.82%

40.62%

7(11.5%)

Chisquared
3.1

17.9

0.6

PValue

0.2

0.000

0.7

3.8

0.2

1.05

0.6

Dislike
3
(4.9%)
7.54%

Abbreviations:*CME = Continue medical Education , EML2011: Essential Medicine List2011

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Int J Med Res Health Sci. 2015;4(2):305-310

Table3: Practice Based Questions and obtained responses of both groups A and BHCPs
Practice Based
Questions
Q.11. Have you
presented / not
presented numbers
of articles / posters on
Essential Medicine in last
three years?
Q 12. I prescribe/

dont
prescribe Generic /
branded /
both drugs.
Q 13. I always /
frequently / occasionally
prescribe /
dont prescribe essential
drugs.
Q 14. I prescribe/ dont
prescribe New drugs /
Old drugs /
both drugs.
Q15. I prescribe/ dont
prescribe
Zinc supplements
always / frequently
occasionally
to acute diarrhoeal
children.
Practice about EML2011
(Total percentage)

A-DSMCH_HCP

B-Perambalur_GP

Presented

Not Presented

Presented

Not Presented

1
(1.6%)

60
(98.4%)

61
(100%)

Branded
drugs

9
(14.8%)
Always
26
(42.6%)
new drugs
6
(9.8%)

Generic
drugs

Both (Branded
& Generic
drug)

5
38
(8.2%)
(62.3%)
Frequentl
y
Occasionally
30
(49.2%)
old
drugs
2
(3.3%)

Dont
Both
drugs

Branded
drugs

Generic
drugs

9
(14.8%)

22
(36.1%)

4
(6.6%)

Dont both
drugs

Always

3
(4.9%)
Prescribe
both drugs
43
(70.5%)

2
15
(3.3%)
(24.6%)
Dont both
new drugs
drugs
10
0
(16.4%)
Dont
Occasionally prescribe
Always
prescribe
Both
prescribe
drugs

Both (Branded
& Generic
drugs)

1
(1.6%)

Frequently
Prescribe

Occasionally
prescribe

Dont both
drugs

29
(47.5%)

9
(14.8%)

old drugs

both drugs

8
(13.1%)
Dont both
drugs

61
(100%)

Frequently
Prescribe

Occasionally
prescribe

Dont
prescribe
Both
drugs
5
(8.2%)

Freque
ntly

12
(19.7%)

14
(22.9%)

19
(31.2%)

16
(26.2%)

33
(54.1%)

18
(29.5%)

5
(8.2%)

21.73 %

20.9 %

42.2%

15.2%

28.7 %

20.9 %

44.7%

An essential medicines list (EML) is a limited


number of carefully selected medicines by the
authorized committee. For many decades, such lists
have been published as formularies and institutional
lists of medicines that are made available to health
facilities and health workers. These may not be called
EMLs but they serve the same function. EMLs have
been one of the cornerstones of public health delivery
and the basis for efforts to ensure consistent medicine
supply and management.[4] The characteristic
features of Essential medicines (drugs) those that
satisfy the priority healthcare needs of the population,
they are selected with due regard to public health
relevance, evidence on efficacy and safety,
comparative cost effectiveness and it should be
available at all time, in adequate amounts, in
appropriate dosages forms, with assured quality and
adequate information. [5] Thus, EML is an important
strategy in improving access to and use of medicines,
especially for the vulnerable segment of a population.
Furthermore, an EML can be used as an

PValu

12.2

0.007

9.6

0.02

21.1

0.0001

24.2

Dont
both drugs

34
(55.7%)

Always

DISCUSSION

Chisqua
red

5.7%

advocacy tool to help countries spend their limited


resources on the medicines that are most needed and
offer the best value for money. [6] So, on this juncture,
awareness programmes targeting various stakeholders
like doctors, patients, consumer groups, and the
media are needed.[7] The present study compares the
knowledge, attitude and practices about Indian
National essential medicines list 2011among HCPs of
DSMCH as well as Perambalur district. We observed
that, overall, 57.06% HCPs from DSMCH and
38.36% HCPs from Perambalur district had
knowledge in EML 2011, while (55% Hettihewa LM,
2010), though 21.98% HCPs from DSMCH and
28.86% HCPs from Perambalur district were do not
know about EML2011 and even 20.98% HCPs from
DSMCH and 32.82% HCPs from Perambalur district
were not sure about knowledge of EML2011.
Whereas, (54% Hettihewa LM, 2010of his study
group and 29% Hettihewa LM, 2010 MPs had fair
knowledge in EDL and 17 % Hettihewa LM, 2010)
were not aware about EDL in their own study). Thus,
obtained data in the present study indicate that timely
interval evaluation needed to check and update
knowledge regarding EML of HCPs that will help to
308

Surendra et al.,

Int J Med Res Health Sci. 2015;4(2):305-310

improve patients safety and teaching curriculum of


pharmacology. The similar suggestion was also given
by Hettihewa LM, 2010 in his study. Overall, 51.16%
HCPs from DSMCH attitude were strongly agree or
strongly like to attend / refer NEML2011, while;
51.82% HCPs from Perambalur district attitude was
strongly agree or strongly like to attend/refer
NEML2011. Even, 44.94% HCPs from DSMCH
were like to refer NEML, whereas 40.62% HCPs
from Perambalur district were like to refer NEML.
The 65.6%HCPs from DSMCH and 60.7% HCPs
from Perambalur district attitude were prescribing
essential
medicines
should be
mandatory,
respectively. Whereas, the 57.4 % HCPs from
DSMCH and 40.9 % HCPs from Perambalur district
attitude was prescribing generic drugs should be
mandatory, respectively.
The72.1%HCPs from DSMCH and 68.9% HCPs
from Perambalur district attitude was strongly like to
select essential medicines as per its relative efficacy,
cost and suitability for the treatment, respectively.
The 1.6%, i.e., only one out of 61 HCPs from
DSMCH have presented an articles / posters related
to Essential Medicine in last three years. While, no
one HCPs from Perambalur district presented an
article / poster which was related to essential
medicine.
The 14.8 %, 8.2 % and 62.3 % HCPs from DSMCH
were prescribed branded drugs, generic drugs and
branded as well as generic drugs both, respectively,
whereas, 36.1 %, 6.6 % and 55.7 % HCPs from
Perambalur district were prescribed branded drugs,
generic drugs and branded as well as generic drugs
both, respectively. While, Mahajan R, et al, 2010
reported in his study that only 15.1% clinicians wrote
the generic drugs. [8]
The 42.6%, 49.2% and 4.9% HCPs from DSMCH
were prescribed essential drugs always, frequently
and occasionally, respectively, while, 24.6%, 47.5%
and 14.8% HCPs from Perambalur district were
prescribed essential drugs always, frequently and
occasionally, respectively.
The 9.8%, 3.3% and 70.5% HCPs from DSMCH
were prescribed new essential drugs, old essential
drugs and new as well as old both essential drugs,
respectively, while, all 61 HCPs from Perambalur
district, i.e., 100% HCPs were prescribed new as well
as old both essential drugs.

The 19.7%, 22.9% and 31.2% HCPs from DSMCH


were prescribed zinc supplements always, frequently
and occasionally in acute diarrhoeal children,
respectively, though, 54.1%, 29.5% and 8.2% HCPs
from Perambalur district were prescribed zinc
supplements always, frequently and occasionally in
acute diarrhoeal children, respectively.
CONCLUSION
The primary responsibilities of the healthcare
professionals, that many awareness programmes
should be conducted to increase knowledge about
essential drugs, and attitude of the healthcare
professionals should be changed to promote use of
essential medicines as well as generic medicines and
this changed attitudes of healthcare professionals
should be practiced in routine working environment,
then it will be possible to provide medicines to almost
all needy people. Even, it is well known information
that, The enjoyment of the highest attainable
standard of health is one of the fundamental rights of
every human being without distinction of race,
religion, political belief, economic or social
condition.
Limitations: The obtained data in the present study
was based on the responses of the healthcare
professionals from the given questionnaire on
National Essential Medicine List 2011 only.
ACKNOWLEDGEMENT
We acknowledge with gratitude to Chhaya Pachuli;
Mudit Mathur; Ritesh Laddha: Prayas Centre for
health equity, including their entire team
members(Prayas Centre), who allowed to use their
few text lines in this present study. We also
acknowledge heartily to Dr. Hettihewa LM, and Dr.
Mahajan R. including his colleagues who
allowedusing his few texts.
Conflict of Interest: Nil
REFERENCES
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Chhaya Pachauli; Mudit Mathur; Ritesh Laddha;
Prayas Centre for Health Equity, Avinash Kumar;
Oxfam India, S. Srinivasan; All India Drug
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DOI: 10.5958/2319-5886.2015.00058.2

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
rd
Revised: 23 Jan 2015
Accepted: 7th Feb 2015

PHENOTYPIC DETECTION OF MBL, AMPC BETA-LACTAMASE AND CARBAPENEMASES IN


MULTI DRUG RESISTANT ISOLATES OF ACINETOBACTER BAUMANNII
Richa Hans1, *Dakshina Bisht2, Ritu Agarwal3, M.Irfan4
1

MD Student, 2Professor, 3Assistant Professor, 4PhD student, Department of Microbiology, Santosh Medical
College, Ghaziabad, U.P, India
*Corresponding author email: dakshinabisht@hotmail.com
ABSTRACT
Introduction: Acinetobacter baumannii is one of the major pathogens causing nosocomial infections due to
emergence of resistance to various antimicrobial agents. Resistance due to antimicrobial degrading enzymes is
now a worldwide problem and a major reason of concern for the treating physicians. Keeping this in mind, the
present study was designed to isolate Acinetobacter baumannii and study various antimicrobial resistance
mechanisms in them. Materials and methods: A total of 50 A.baumannii isolates from various clinical samples
were screened for meropenem resistance for the detection of Carbapenemase and MBL production.
Carbapenemase production was confirmed by Modified Hodge Test whereas MBL by Disk Potentiation Test.
Cefoxitin resistance was used as a screening test for AmpC beta-lactamase production which was confirmed by
AmpC disk test. Results: Maximum isolation of A.baumannii was found in patients admitted in the Intensive care
unit with respiratory tract infection. Among the 50 A.baumannii strains, Carbapenemase production was observed
in 26.4%, MBL production in 52.9% and AmpC beta lactamase production in 56%. Conclusion: Our study
emphasizes on multi-drug resistant A.baumannii highlighting the antibiotic crisis as a result of emergence of
various bacteria that show resistance to various antibiotics. Acinetobacter epitomises this trend, as it is an
important nosocomial pathogen with a capability of cross-infection particularly in ICUs and a grave limitation of
treatment options, thus, requiring an urgent need to control the spread of MDR strains in the hospitals.
Keywords: Acinetobacter, Modified Hodge Test, Metallo-beta-lactamse, AmpC beta-lactamse
INTRODUCTION
For many years, Acinetobacter species were
considered to be saprophytic in the environment,
found as a major constituent of the flora of soil, water
and sewage and within the hospital environment.
However, due to a number of agents as well as host
factors, they have now emerged as important
nosocomial pathogens predominantly in ICU settings
most commonly affecting immuno-compromised
patients, although they have also been isolated as the
etiological agent of pneumonia in healthy individuals
[1].
Multi drug resistance in A.baumannii is not a new
phenomenon. They are known to be intrinsically

resistant to various antibiotics along with the ability


to acquire genes that encode for resistance
determinants.[2]Production
of
beta-lactamases,
aminoglycoside-modifying enzymes, diminished
expression of outer membrane proteins [OMP] and
up-regulation of efflux pumps play a crucial role in
antibiotic resistance. Newer beta lactamases causing
antimicrobial resistance include Extended-spectrum
beta-lactamases (ESBL), AmpC beta-lactamses and
Metallo-beta-lactamases (MBL). [3]
Beta-lactamases
act
on
many
penicillins,
cephalosporins, carbapenems and monobactams.
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Int J Med Res Health Sci. 2015;4(2):311-316

Metallo-beta-lactamases also referred as Class B


beta-lactamases act on penicillins, cephalosporins and
carbapenems but not on monobactams.[4] MBLs have
zinc as metal ion which is linked to cysteine or
histidine residue and it reacts with the carbonyl group
of the amide bond of penicillins, cephalosporins and
carbapenems.[5]
AmpC beta-lactamases are known to bestow
resistance to cephalosporins in the oxyimino group
and are not affected by available available betalactamase inhibitors. [6] The presence of MBLs and
AmpC beta lactamases in a single isolate confer
resistance to carbapenems which are usually the drug
of choice in Acinetobacter infections.
A. baumannii also possess an intrinsic class D
oxacillinase belonging to the OXA-51-like group of
enzyme. OXA-51-like enzymes are able to hydrolyze
penicillins (benzylpenicillin, ampicillin, ticarcillin
and piperacillin) and carbapenems (imipenem and
meropenem). Accumulation of multiple resistance
mechanism leads to the development of pan-resistant
strains limiting the therapeutic options.
Many multidrug resistant bacteria including
A.baumannii produce combinations of different
enzymes responsible for drug resistance. With the
increasing number of MBL, ESBL and AmpC
producing bacteria along with porin loss and efflux
mechanisms, an increase in carbapenem resistance
has been observed. Carbapenems being the drug of
choice for highly resistant Acinetobacter species, its
increasing resistance pattern limits therapeutic
options. Keeping this in mind, present study was
undertaken to isolate Acinetobacter baumannii and
study various antimicrobial resistance mechanisms
prevalent amongst the isolates in one of the tertiary
care hospitals in North India.

method, as per the guidelines of the Clinical


Laboratory Standards Institute (CLSI).[8]
Susceptibility to the following antibiotics (disc
concentration) were tested: Ofloxacin(5 g); Erythro
mycin(15g);Gentamcin(10g);Cotrimoxazole(1.25+
23.75 g); Doxycycline(30 g); Cefoxitin(30 g);
Ceftazidime(30g); Piperacillin/Tazobactam (100+10
g):Colistin(10g);Tigecycline(15g); Aztreonam(30
g); Imipenem(10 g) and Meropenem(10 g).
Quality control strains used were Escherichia coli
ATCC 25922 and Pseudomonas aeruginosa ATCC
27853. Meropenem resistance was used to screen for
beta-lactamase production and Cefoxitin resistance
for AmpC beta lactamase production.
Detection of Carbapenemase
Modified Hodge Test: It was used to detect
carbapenemase production in meropenem resistant
strains. A culture suspension of Escherichia coli
ATCC 25922 adjusted to 0.5 McFarlands standard
was inoculated on the surface of Muller-Hinton Agar
plate using a sterile cotton swab. After drying, 10g
meropenem disc was placed at the centre of the agar
plate and test strains were streaked from the discs
edge to the periphery of the plate in four different
directions. The plate was then incubated overnight at
37C.
Presence of a clover leaf shaped zone of inhibition
along the growth of test strain was considered as
positive for carbapenemase production. [9] (Figure 1)
Quality control strains used were, K. pneumoniae
ATCC BAA-1705MHT positive, K. pneumoniae
ATCC BAA-1706MHT negative.

MATERIALS AND METHODS


A total of 50 consecutive non-duplicate Acinetobacter
baumannii isolates from various clinical samples and
patients from all age groups and both sexes from
March 2013 till Feb 2014 were included. The
samples comprised of sputum, urine, wound swabs,
tracheal aspirates, blood, pus, bronchial lavage and
endotracheal tubes. A.baumannii strains isolated
were identified by standard microbiological
methods.[7]The anti-microbial susceptibility testing
was performed using antibiotics obtained from HiMedia, Mumbai, by the Kirby Bauer disk diffusion

Fig 1: Modified Hodge Test


Detection of MBL
Disc Potentiation Test: The test organism adjusted to
0.5 McFarlands opacity standards was inoculated on
Muller-Hinton agar plate. Two 10g imipenem discs,
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Int J Med Res Health Sci. 2015;4(2):311-316

100%
80%
60%
40%
20%
0%

ANTIBIOTICS

Cefepime

Of the 50 isolates, 28 (56%) strains were isolated


from the respiratory secretions (sputum, tracheal
secretions, endotracheal tips and BAL), 12 (24%)
from pus (including wound swabs) and 9 (18%) from
blood samples and only 1 (2%) from urine. Intensive
care unit (ICU) had the most isolation rate of 34
(74%) A.baumannii followed by medicine ward 5
(10%), surgery ward 4 (8%), paediatric ward 3 (6%)
and ENT ward 1 (2%).
In our study, all the strains were found to be resistant
to
gentamicin,
erythromycin,
trimethoprimsulphamethaxole,piperacillin/tazobactam,ceftazidime,
cefoxitin and aztreonam. 40 (80%) of the isolates
were resistant to ofloxacin while 34 (68%) to
doxycycline. Colistin and tigecycline showed 50
(100%) sensitivity towards all the strains. Graph 1
depicts the antibiogram of A.baumannii.(Fig 4)

Cefpodoxime

alone was considered as a positive result.[10] (Fig 2)


Fig 2: Disc potentiation test
Detection of AmpC beta-lactamases
The AmpC Disc Test: Cefoxitin resistant strains were
subjected to AmpC disc test for the production of
AmpC beta-lactamase production. A culture
suspension of Escherichia coli ATCC 25922 adjusted
to 0.5 McFarlands standard was lawn cultured on
Muller-Hinton Agar plate. A cefoxitin disc (30g)
was placed on the surface of the agar and a blank disc
moistened with sterile saline and inoculated with few
colonies of test strain was placed besides cefoxtin
disc in such a way that it was almost touching it. The
plate was incubated overnight at 37C. Flattening or
indentation of zone of inhibition around cefoxitin disc
in the vicinity of the disc with the test strain was
considered as positive for the AmpC beta lactamase
production. An undistorted zone was considered as
negative.

RESULTS

Ofloxacin
Imipenem
Meropenem
Gentamycin
Erythromycin
Piperacillin/tazob
Doxycycline
Colistin
Trimethoprim-
Tigecycline
Cefoxitin

one containing 750 g EDTA, obtained from


Himedia, Mumbai were placed on the inoculated
plate and incubated for 24hrs at 37C. The zones of
inhibition around the imipenem disc alone and
imipenem-EDTA disc were recorded. An increase in
the zone of inhibition of at least 7mm around the
imipenem-EDTA disc as compared to imipenem

RESISTANT

INTERMEDIATE
SENSITIVE

Fig 4: Antibiogram of A.baumannii


Of the 50 isolates, 34 (68%) isolates expressed
resistance to meropenem and only 26 (52%) to
imipenem. Of these 34 meropenem resistant strains, 9
(26.4%) were positive for Carbapenemase production
by Modified Hodge test and 16 (52.9%) were positive
for MBL production by EDTA disc potentiation test
(EDTA-DPT). Of the 50 cefoxitin resistant isolates,
28 (56%) were confirmed for AmpC beta lactamase
production by AmpC disc test. Table 1 depicts the
results for MHT, MBL and AmpC production in
A.baumannii isolates.

Fig 3: AmpC Disc test


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Int J Med Res Health Sci. 2015;4(2):311-316

Table 1: Modified Hodge Test, Disc Potentiation Test and AmpC Disc Test
MBL
CARBAPENEMASE
AMPC
Screen Test
(Meropenem
resistance)

Confirmatory
Test (EDTA- disk
potentiating test)

Screen Test Confirmatory


(Meropenem Test (MHT)
resistance)

Screen Test
(Cefoxitin
resistance)

Confirmatory Test
(AmpC disk test)

34 (68%)

16 (47.05%)

34 (68%)

50 (100%)

28 (56%)

9 (26.4%)

Of the 50 A.baumannii isolates, co existence of


Carbapenemase and MBL production was observed
in 8 (16%) isolates. There were 2 isolates which
expressed all three resistance mechanism whereas
only 7 isolates expressed no resistance mechanism.
Fig 5 depicts co-existence of various resistance
mechanisms in MDR A.baumannii.
60.00% 47.05%
50.00%
26%
40.00%
16% 18%
30.00%
10%
20.00%
2%
2%
10.00%
0.00%

56%
26%

RESISTANCE MECHANISMS

Fig 5: Existence of Multi Resistance Mechanisms


in MDR A.baumannii
Of the 50 isolates, 47.05% were found to be MBL
producers, out of which 16% also co-produced
carbapenemase and 18% co-produced AmpC.
However, there were 2% strains which only
expressed
MBL
production.
Carbapenemase
production was found in 26% of the total strains, of
which 10% also co-produced AmpC beta lactamase
and 2% strains were positive only for carbapenemase
production. However, 26% of the isolates were
positive for only AmpC beta lactamase production,
suggesting AmpC beta lactamase being a more
expressed resistance mechanism in our study.
DISCUSSION
A.baumannii is an effective human colonizer in the
hospital. Combination of its environmental flexibility
and presence of multiple resistance determinants
makes it a successful nosocomial pathogen. MDR
A.baumannii infections tend to occur more frequently
in immune-compromised individuals, patients on

broad spectrum antibiotics and with underlying


diseases and those subjected to invasive
procedures.[12]According to Ambler Classification,
Beta lactamases are grouped into 4 major molecular
classes; A, B, C and D. A, C and D are referred as
serine-beta-lactamases, whereas group B beta
lactamases are called MBL. Newer beta lactamases
that
hydrolyse cephamycins, cephalosporins,
monobactams and carbapenems are of increasing
concern as they limit therapeutic options leading to
treatment failures and poor prognosis. [13]
We observed that 56% of the A.baumannii isolates
were from the respiratory secretions which included
sputum samples, endotracheal secretions, bronchioalveolar lavage and endotracheal tips, 24% from pus
samples, 18% from blood and only 2% from urine. In
a study by Muthusamy et al.[11] conducted in
Coimbatore, South India isolation rate was found to
be 73% from respiratory secretions. In yet another
study by Jaggi et al. [14] in Gurgoan, Haryana, 57.4%
of the A.baumannii isolates were from respiratory
secretions, 23.8% from blood, 13.5% from pus and
2.5% from urine, an observation similar to ours,
suggesting thereby that respiratory tract would be the
most common site of isolation in our geographical
area.
It is a well documented fact that a lot of risk factors
associated with Acinetobacter infections exist in the
ICU like potential environment reservoirs,
opportunities for cross transmission, sick, immunecompromised patients who are colonized, patients
with multiple wounds and indwelling devices, heavy
use of broad spectrum antibiotics and frequent
contamination of the hands of health care workers
employed in patient care.
This fact was supported by our results, where 74% of
the A.baumannii isolates were from the ICU followed
by medicine ward (10%), 8% from surgery ward, 6%
from paediatric and 2% from ENT ward. Sinha N et
al. [15] also noted similar findings with maximum
isolation from the ICU of 22.14% followed by
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Int J Med Res Health Sci. 2015;4(2):311-316

paediatrics (20.71%), neurosurgery (15.71%) and


general surgery wards (12.85%).
In our study, high resistance of 68% was observed
against meropenem, which was in contrast to a study
conducted earlier by Sinha N et al.[15] where only
20% resistance was observed. Taneja et al,[16]
observed 18.5% and Dheepa M et al [11] observed
35% resistance. However, in Brazil, the resistance to
carbapenemase was found to be ranging from 71.4%
to 100% in various hospitals of that region. [17]
Thus, the aforementioned observations could only
suggest that Carbapenemase-producing Acinetobacter
spp might be on a rise worldwide which could be due
to indiscriminate carbapenemase usage and selection
pressure in hospitals.
In our study, 26.4% organisms were carbapenemase
producers as evidenced by the Modified Hodge Test.
The prevalence of carbapenemases as reported by
Noyal et al.[9] was 14.3% whereas another study by
Kumar et al.[18] documented a very high prevalence of
71%. A very low prevalence of 2.96% was also
reported by Patwardhan et al.[19]
No established phenotypic methods are available for
detection of specific serine carbapenemases.
However, for zinc based carbapenemases (MBL)
various methods like EDTA-disc potentiation test,
MBL E-test and EDTA based microbiological assay
are available.
In our study, 47.05 % of meropenem resistant strains
were confirmed to be MBL producers, whereas
Dheepa Muthusamy et al [11] detected 10% of the
strains to be MBL producers in her study conducted
in South India and John S et al [20] detected 14.8%.
Noyal MJC et al [9] did a similar study in Pondicherry,
South India and identified 6.5% MBL producers. In a
study done at AIIMS, New Delhi, 48.72% of
A.baumannii strains were ascertained to be MBLenzyme producers by the same method, thus implying
rapid spread of resistance amongst this pathogen. [21]
Although there are no CLSI guidelines for the
detection of AmpC beta lactamase production, but we
followed AmpC disk test to detect AmpC production
and observed 28 (56%) of 50 cefoxitin resistant
isolates of A.baumannii showed production of AmpC
beta-lactamase enzyme. Noyal et at [9] and Sinha et
al[22] also reported 67.4% and 42.9% respectively, in
their studies.
Although carbapenems are the drugs of choice for A.
baumannii infections, such resistance profile limits

therapeutic options to polymyxins and tigecycline,


which showed 100% sensitivity to A.baumannii in
our study. These drugs have their own grave side
effects, limiting their routine usage for patients in
hospitals.
Thus, it is recommended to perform these simple tests
like Modified Hodge Test for carbapenemase, Disc
Potentiation test for MBL and AmpC disk test for
AmpC beta lactamase production in microbiology
laboratories to determine resistance mechanisms and
prevent indiscriminate use of antibiotics.
CONCLUSION
A.baumannii is becoming a global medical challenge
due to the emergence of multi-drug resistance. Newer
beta lactamase are a matter of concern as they are
developing rapidly and lead to treatment failure.
Carbapenems are known to be effective therapeutic
agents for A.baumannii infections and its resistance
limits the use to polymyxins and tigecycline.
Disappointingly, there are limited antibiotics for the
treatment of infections caused by MDR A.baumannii
on the horizon. Several new medicines are still in
research and combination of drug therapy is being
currently used in the hospitals including ours to treat
MDR A.baumannii infections.
Thus, due to such high prevalence of resistance,
antibiotics must be used judiciously by the clinicians
and appropriate infection control measures need to be
implemented to control the spread of infections in
hospitals.
ACKNOWLEDGMENT: None
Conflict of Interest: Nil
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DOI: 10.5958/2319-5886.2015.00059.4

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
rd
Received: 23 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 27 Jan 2015
Accepted: 10th Feb 2015

PREVALENCE OF HEALTH CARE ASSOCIATED INFECTIONS IN A TERTIARY CARE HOSPITAL IN


DAKSHINA KANNADA, KARNATAKA: A HOSPITAL BASED CROSS SECTIONAL STUDY

*Animesh Gupta1, Divya C V1, Diwakar K Singh1, Krutarth B2, Maria N2, Srinivas R1
1

Postgraduate, 2Assistant Professor, Department of Community Medicine, A J Institute of Medical Sciences &
Research Centre, Mangalore, Karnataka, India
*Corresponding author email: animesh245@gmail.com
ABSTRACT
Background: Health Care-Associated Infections (HCAI) affect millions of people each year and raise a great risk
for patients in health care settings, leading to high rates of morbidity and mortality. Objective: To estimate the
prevalence of HCAI and to explore the association between certain socio-demographic factors, invasive
procedures and mean duration of hospital stay with HCAI in a tertiary-care hospital. Materials and Methods:
Data was obtained from the patients who were admitted for more than 48 hours in the general wards and their
records in tertiary-care hospital for duration of 3 months (February 2014 to April 2014). Results: Among 290
patients, the prevalence of HCAI was estimated to be 11.7%. The prevalence of HCAI was proportionately less
among men (10.2%) than in women (14.2%), was more (15.6%) among patients who underwent invasive
procedures after admission and with mean duration of hospital stay of 12.47 days. Conclusion: Health CareAssociated Infections (HCAIs) were found to be significantly associated with increased duration of hospital stay
and invasive procedures done after admission. Prevalence was higher in patients aged more than 40 years.
Keywords: Health Care-Associated Infection, Prevalence
INTRODUCTION
Health Care-Associated Infections (HCAI) are the
infections acquired during hospital care which are not
present or incubating at admission. Infections
occurring more than 48 hours after admission are
usually considered hospital associated. [1]
HCAIs are an important public health problem in
developing as well as in developed countries.
Hospital-wide prevalence of HCAI in low- and
middle-income countries varied from 5.7% to 19.1%
with a pooled prevalence of 10.1% and even as high
as 15.5% in high quality studies.[2] Over 1.4 million
people worldwide suffer from HCAI at any given
time.1 The risk is 2 to 20 times higher in developing
than in developed countries.2

Animesh et al.,

Some of the factors responsible for HCAI are


prolonged and inappropriate use of invasive devices
and antibiotics, high-risk and sophisticated procedure,
immuno-suppression and other severe underlying
patient conditions, insufficient application of standard
and isolation precautions. [3]
The fight against HCAI as a public health priority
was promoted through the World Health
Organization's 'Clean Care is Safer Care' campaign.
HCAIs are multi-factorial, which are related to
healthcare systems and procedures as well as
behavioral practices. [4] At any given time, out of
every 100 hospitalized patients, 7 in developed and
10 in developing countries will acquire at least one
health care-associated infection. [2]
317
Int J Med Res Health Sci. 2015;4(2):317-321

The most common types of HCAIs are urinary tract


infection, surgical tract infection, lower respiratory
tract infection, blood stream infection, skin and soft
tissue infection. Gastroenteritis is the most common
HCAI in children[1].
HCAI is a great risk for patient safety and its impact
can result in prolonged hospital stay, long-term
disability, increased resistance of microorganisms,
and additional financial burden for the health system,
patients and their families, as well as excess deaths.2
It is estimated that 80% of all hospital deaths are
directly or indirectly related to HCAIs[5].
Some of the common determinants of HCAI are
inadequate environmental hygienic conditions, poor
infrastructure, insufficient equipment, understaffing,
overcrowding, inadequate infection control measures,
unsafe injection practices, absence of local and
national guidelines and policies[3]. The main modes of
transmission of HCAI are contact, droplet, air-borne,
common vehicle and vector-borne.
The risk of contracting HCAI is universal and
percolates every health-care facility and system
worldwide, but the true burden remains unknown,
particularly in developing countries [2].
HCAIs usually receive public attention only when
there is epidemic [1].
Although often hidden from public attention, no
institution or country can claim to have solved this
very real ongoing endemic problem, despite many
efforts[2].
Objectives
1. To estimate the prevalence of HCAI.
2. To estimate the association of HCAI with
certain risk factors.
MATERIALS AND METHODS
Study setting: A Hospital based cross-sectional study
was conducted in a tertiary-care hospital in Dakshina
Kannada district of Karnataka, India for duration of 3
months from February 2014 to April 2014. All inpatients admitted in the wards of Medicine, Surgery,
Orthopedics, OBG, and Pediatrics in a tertiary-care
hospital for more than 48 hours were included in the
study irrespective of their age & Sex. Patients who
were critically ill and those admitted in ICUs were
excluded from the study.

Animesh et al.,

Sample size calculation: Taking the prevalence of


26% from a study done by Saleem M et al[6] and with
20% of allowable error, the sample size was
calculated by using the formula n = 4pq/ L. The
sample size was estimated was 290.
Method of data collection
Ethics clearance from the institution was obtained. A
pretested structured proforma was used to collect the
data after obtaining written informed consent from
the patients by interview method. The proforma
included name, age, gender, IP number, name of the
ward, date of admission and discharge, diagnosis,
treatment and procedures done. History and physical
examination were conducted for each patient from the
date of admission until discharge. All the patients in
the study were visited at least once a day. Laboratory
results and medical charts were reviewed. The study
subjects were followed up from the day of admission
till the day of discharge.
Statistics: The data was entered in Microsoft excel
7.0 and analyzed in SPSS Trial Version 16.
Descriptive statistics and tests of significance like
Pearson Chi-square test were used and the statistical
significance level was fixed at p<0.05.
RESULTS
The mean age of study population was found to be
41.8 years (SD-15.4, Range- 4 to 85 years) and the
mean age of patients who developed HCAI was 42.2
years (SD-16.5, Range- 7 to 75 years).
Table 1: Prevalence of HCAI in relation to age
Age
No. of Patients HCAI
group
Examined
No. (%)
(in years)
0-15
11
1 (9.1)
16-30
69
6 (8.7)
31-45
89
14 (15.7)
46-60
90
10 (11.1)
>61
31
3 (9.7)
290
34 (11.7)
Total
Fishers exact test value = 1.986, p value = 0.742
(non significant)
The maximum patients were 31% in the age group
46-60 years followed by 30.7% in the age group 3145 years as shown in Table 1. The prevalence rate of
HCAI was 11.7%, of which thrombophlebitis, urinary
tract infection (UTI) and fever were found to be
5.86%, 4.14% and 1.82%, respectively. Out of the 34
318
Int J Med Res Health Sci. 2015;4(2):317-321

patients who had developed HCAI, 41.2% and 29.4%


corresponds to age groups 31-45 and 46-60 years,
respectively.
200
150

n=177
159 (89.8%)

100

n=113

97 (85.8%)

50
0

18(10.2%)

MALE
HAI

16 (14.2%)

FEMALE
NO INFECTION

Fig1: Prevalence of HCAI in relation to gender


(n=290)
In this study, 61.0% were males, but the prevalence
of HCAI was found to be proportionately higher in
females (14.2%) compared to males (10.2%) as
shown in Figure 1.
Table 2: Association of HCAI in relation to
multiple variables (n=290)
Health
care- Chi
P
Variables
associated infection square value
value
Present Absent
Age
< 40 14
112
0.081
0.776
(in
(11.1%) (88.9%)
years)
> 40 20
144
(12.2%) (87.8%)
Duration < 7 4
135
20.18
0.000*
of stay days (2.9%)
(97.1%)
in
>7
30
121
hospital days (19.9%) (80.1%)
Invasive Yes
21
113
145.16 0.000*
procedur
(15.7%)
(84.3%)
es
No
13
143
(8.3%)
(91.7%)
*significant
Table 2 shows the association of HCAI in relation to
age, duration of stay in hospital and invasive
procedures done. In this study, it was found that the
patients who were more than 40 years had higher
prevalence of HCAI (12.2%) compared to those less
than 40 years (11.1%), though it was not found to be
statistically significant (p>0.05). This finding was
probably due to the higher number of invasive
procedures done among those above 40 years of age
leading to longer duration of stay in the hospital. The

Animesh et al.,

patients who had undergone invasive procedures had


significantly high prevalence of HCAI with 21
(15.6%) compared to those who had not undergone
invasive procedures with 13 (8.3%). The prevalence
of HCAI was higher in patients who stayed in
hospital for more than 7 days compared to less than
or equal to 7 days, which is statistically significant.
The mean duration of hospital stay for the patients
with HCAI was found to be 12.47 days and for those
without HCAI was 7.98 days.
DISCUSSION
Majority of patients in this study were males (61.0%).
Similarly, in a study by Dileep Kumar S et al[7] and
Rahim B et al[8], showed that 53.0% and 53.6% of the
study subjects were males, respectively.
The prevalence of HCAI in this study was 11.7%.
Similar findings were observed in studies conducted
by Malhotra S et al[9] and Razine R et al[10]. The mean
age of patient was high among who developed HCAI
which was similar to the study done by Satpathy et al
[11].

Females had proportionately higher prevalence of


HCAI than males in this study, which was also found
in study done by Dileep Kumar S et al[7] and Saleem
M et al. [6] Prevalence of HAI was insignificantly
high among patients above 40 years of age which was
similar to the findings from the study done by Dileep
Kumar S et al[7].
In this study the prevalence of HCAI was
significantly higher in patients who stayed for more
than 7 days which showed, longer the duration of
hospital stay, more the chances of developing HCAI.
Similar facts were observed in multiple studies
analyzed by World Health Organization were hospital
stay more than 7 days was found to be a risk factor
for the development of an HCAI[2].
The patients who developed HCAI had presented as
thrombophlebitis (5.8%), UTI (4.1%) and fever
(1.8%). Thrombophlebitis was the commonest HCAI.
Askarian M et al12 showed the prevalence of blood
stream infection as 2.5% and UTI as 1.4%, which
concluded that blood stream infection was more
compared to other HCAIs. These findings were
similar to those in this study.
The prevalence of HCAI was significantly higher in
patients who underwent any invasive procedures like
intravenous lines, urinary catheterization and any
319
Int J Med Res Health Sci. 2015;4(2):317-321

surgical procedures. Similar trend was observed in


most of the studies analyzed by World Health
Organization[2].
CONCLUSION
The present study of Health Care-Associated
Infections (HCAIs) in the tertiary care hospital
showed a prevalence rate of 11.7%. HCAI were
found to be significantly associated with increased
duration of hospital stay and invasive procedures
done after admission. The prevalence was higher
among patients aged more than 40 years and
proportionately more among female patients. HCAI
was common in hospital patients in medical and
surgical wards.
Recommendations: In India, however, hospitals
often do not follow infection control practices, and
this leads to the spread of disease. In response to the
growing burden of HCAIs in India, the Global
Antibiotic Resistance Partnership (GARP) is issuing
several key recommendations that aim at reducing the
prevalence of HCAIs, including increased handwashing, use of isolation rooms for infected patients,
increased availability and uptake of diagnostic tests,
reminders to limit catheter use, and use of gloves and
gowns.
The Ministry of Health & Family Welfare Task Force
also recommends that all hospitals create an infection
control plan, committee and team. Surveillance of
antibiotic resistance, combined with tracking
physician prescribing patterns, can be the foundation
of successful infection control programmes in
hospitals. A large proportion of these hospital
infections are easily preventable with increased
hospital infection control, including stepping up
hygiene practices, such as frequent hand-washing.
Limitations: The study was conducted for duration
of 3 months to estimate the prevalence of HCAI,
since the number of study subjects was small, so it is
possible that the prevalence rates may not be
extremely precise.
Acknowledgement: The authors are thankful to Dr.
(Prof) Manohar Rao, Dr. (Prof) Jayaram S, Dr. (Prof.)
P V Kurulkar, Dr. (Prof.) Prasanna K S and Dr.
(Prof.) Hemant Kumar of the Community Medicine
department for their valuable guidance and support.

Animesh et al.,

Conflict of interest: The authors declare no conflict


of interest & not funded by any agency.
REFERENCES
1. Prevention of hospital-acquired infections; A
Practical Guide; 2nd edition, World Health
Organization.[Available at http://www.who.int/
csr/resources/publications/whocdscsreph200212.
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2. World Alliance For Patient Safety. Global Patient
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Safer Care.[Available at http://www.who.int/
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H_FINAL.pdf]
3. World Health Organization. Health careassociated infections Fact Sheet. [Available on
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4. Gignon M, Farcy S, Schmit J L, Ganry O.
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2012;30:69-75
5. Hughes AJ, Ariffin N, Huat TL, Abdul Molok H,
Hashim S etal., Prevalence of nosocomial
infection and antibiotic use at a university
medical center in Malaysia. Infect Control Hosp
Epidemiol 2005; 26:100-4
6. Saleem M, Vaish AK, Idris MZ, Sonkar AA,
Agarwal J, Singh M, etal., Pattern of Nosocomial
Infection among patients admitted in Medical and
Surgical wards of a secondary care hospital in
north India: An epidemiological evaluation.
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24(4): 285-90
7. Dileep Kumar Sharma, Yogendra Kumar Tiwari,
Nitya Vyas and Rakesh Kumar Maheshwaril. An
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infections among the patients admitted in the
intensive care unit of a tertiary care hospital in
Rajasthan, India. International Journal of Current
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428-35
8. Rahim Baghaei, Peyman Mikaili,, Davood
Nourani,
Hamid
Reza
Khalkhali.
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the patients admitted in the intensive care unit of
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9.

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investigation. Annals of Biological Research,


2011; 2 (5) :172-78.
Malhotra S, Sharma S, Hans C. Prevalence of
Hospital Acquired Infections in a tertiary care
hospital in India. Int. J. Med. Med. Sci., 2014;
1(7): 91-94
Razine R, Azzouzi A, Barkat A, et al. Prevalence
of hospital-acquired infections in the university
medical center of Rabat, Morocco. International
Archives of Medicine 2012;5:26
Satpathy. P261: Study of hospital associated
infections (HAI) at tertiary hospital in India;
economic implication for developing countries.
Antimicrobial Resistance and Infection Control
2013, 2 (Suppl 1):P261
Askarian M. Point prevalence and risk factors of
hospital acquired infections in a cluster of
university-affiliated hospitals in Shiraz, Iran.
Journal of infection and public health, 2012;
5:169-16.

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321
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DOI: 10.5958/2319-5886.2015.00060.0

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 24 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 20 Jan 2014
Accepted: 9th Feb 2015

STUDY OF THE BASELINE WIDAL TITRES AMONG HEALTHY INDIVIDUALS OF RURAL


POPULATION IN PUDUCHERRY
*Jeyakumari D1, Jaberlin Sneha AJ2, Gopal R2
1

Department of Microbiology, Tagore Medical College & Hospital, Chennai, Tamil Nadu, India
Department of Microbiology, Sri Manakula Vinayagar Medical College & Hospital, Puducherry, India

*Corresponding author email: karailabscuddalore@yahoo.co.in


ABSTRACT
Background: Enteric fever is endemic in developing countries like India. Widal test in a single serum sample is
often the only test relied upon for laboratory diagnosis. The test is considered positive if the antibody titres are
higher than the cut - off value in a single test or a rising titre in paired sera. But normal baseline titres in healthy
population and cutoff values have not been established in our area. So the aim of our study was to determine the
base line titres of antibodies among apparently healthy populations and to define the significant titres of widal
test. Materials and Methods: Samples were initially screened by Widal slide agglutination test and further
confirmed by the Quantitative tube agglutination test. Results: Among the 500 samples from apparently healthy
individuals, 260 samples were positive for agglutinins. 141 were positive for O agglutinin and 163 were positive
for H agglutinin of Salmonella typhi. Among 141 samples, 30 showed agglutination up to 1in 20 titre, 100 up to
1in 40 and 25 (4.8%) up to 1in 80. Among 163 samples, 18 showed a titre of 1 in 20, 120 showed a titre of 1 in
40 and 21(4.2%) up to 1 in 80. Conclusion: When a single widal titre is used for the diagnosis of enteric fever in
our locality, it will be more appropriate to change the currently used cutoff levels against S.typhi to 1 in 160 for
anti-O and H agglutinins remains the same of 1 in 160.
Keywords: Baseline titer, Widal test, Healthy population
INTRODUCTION
Enteric fever continues to be a global health problem,
especially in tropics and subtropics [1] and enteric
fever is a major endemic health problem in
developing countries like India. The global estimation
of typhoid fever was about 21.6 million in 2000 and
5412,744 illness were due to paratyphoid fever.
These fevers are considered as a major cause of
morbidity and mortality in developing countries with
more than 90% of cases found in Asia only. [2, 3]
Enteric fever is caused by Salmonella enterica
subspecies enterica serotype Typhi and Salmonella
enterica subspecies enteric serotype Paratyphi A and
Paratyphi B. In contrast to other Salmonella
serotypes, these enteric fever serotypes have no

known hosts other than humans. The mode of


transmission is by close contact with the patients or
carriers. Since the clinical presentation of enteric
fever is non-descript, laboratory tests are essential for
diagnosis. The gold standard and definitive diagnosis
is by isolation of Salmonella enterica serotype Typhi,
ParatyphiA and Paratyphi B from blood, bone
marrow, stool or urine etc. which is about 90% in the
first week of illness and decreases to about 50% by
the third week from blood sample. Culture facilities
are not available in the rural set up where Widal
agglutination test has a greater scope for diagnosis of
enteric fever in developing countries. Widal test
though in vogue for more than hundred years is still
322

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Int J Med Res Health Sci. 2015;4(2):322-326

plagued with controversy about its usefulness in


diagnosis of enteric fever. [4] The use of Widal test in
the diagnosis of typhoid fever during the acute phase
of the illness has largely been abandoned in
developed countries. [5] Due to practical difficulties in
the management of a patient the results of a single
test performed at the end of the first week is often the
only test relied upon for laboratory diagnosis. The
significant titres of antibodies to O and H antigens
varies from place to place and with time since
antibodies that react with Salmonella O and H
antigens appear in a variety of other conditions like
malaria, dengue, other gram negative infections and
in healthy persons in endemic areas. [6, 7] In endemic
areas the use and interpretation of single Widal test
depends on result of the baseline titres among the
healthy population. It is therefore necessary to
establish the baseline titres periodically in each
region to define the significant titres of O and H
antibodies for proper interpretation of the results.
Objectives
1. The objective of the present study is to determine
the base line titres of antibodies for each of the
O and H antigens of Salmonella enterica
serotype Typhi, Paratyphi A & ParatyphiB
among apparently healthy blood donors and
patients attending the Microbiology laboratory
for various investigations other than for enteric
fever.
2. To define the significant titres of widal test for
diagnosis of enteric fever in a single serum
sample.
MATERIAL AND METHODS
Type of study: Cross sectional
Subjects: Total samples (n = 500) were collected in
which, Serum samples of Healthy blood donors (n =
300) who voluntarily donated blood to our hospital
blood bank during the study period.
Inclusion criteria: Donors who had no history of any
illness suggestive of enteric fever in the preceding six
months. Negative for all screening tests routinely
done in donors includes Malaria parasite antigen,
HBsAg, and antibodies to HIV 1 and 2, HCV and
Treponema pallidum. No history of typhoid
vaccination in the preceding three years was included.
Serum samples (n=200) received in the Microbiology
laboratory for various serological tests accept widal.
These samples were from the seemingly healthy

individuals who came for Medical checkup and


Antenatal visits.
Only samples of serum with negative results for the
requested serological tests were included in the study.
Patients without fever or gastroenteritis or any illness
suggestive of enteric fever in the preceding six
months and not vaccinated for typhoid in the
preceding three years were included in the study.
Exclusion criteria: Subjects who did not meet the
above criteria were excluded.
Methods: Informed consent was obtained from all
the donors and patients and approval of the
institutional ethics committee was obtained.
Questionnaires were given to evaluate the present and
past clinical conditions. About 5ml of blood was
collected in a clean dry test tube from each of the
subjects and allowed to clot. Serum was separated
and stored in the refrigerator at 2-8 C for no more
than seven days. All samples were initially screened
by rapid slide agglutination test using the standard
colored Salmonella antigen supplied by SPAN
DIAGNOSTICS, Surat, India. Samples showing
agglutination with undiluted serum were retested by
the standard tube agglutination test of Widal for
antibodies against all the four antigens of Salmonella
typhi O and H, Salmonella paratyphi AHand
BH as per the standard procedure. Serial dilutions
of serum were done starting from 1/20 to 1/640 and
one drop of the appropriate antigen suspension was
added. Incubate H agglutinations for 4 hours at
37C in a water bath and read after standing on the
bench for half an hour and O agglutinations for 4
hours at 37C and read after overnight refrigeration at
4C. The highest dilution of serum showing visible
agglutination was taken as the endpoint and titre
expressed as reciprocal of the dilution.[8] For quality
control a known positive and negative control sera
was also included with each run. The results were
analyzed for age, sex and base line titre taken was the
highest titre shown by any of the study samples.
Statistical analysis by using SPSS version 20 was
also carried out. In which one sample T-test was done
to compare the current titre value with the observed
titre values. All samples of blood donors (n=300)
were screened by Immunochromatography strip for
Malaria parasite, HBsAg, antibodies to HIV (Tri dot
ELISA), HCV (Dot ELISA), and Treponema
pallidum (RPR). Samples of donors negative for all
the above cited infections alone were included in the
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Jeyakumari et al.,

Int J Med Res Health Sci. 2015;4(2):322-326

study. In the patients group all serum samples


(n=200) other than those requested for Widal test and
which were negative for the respective tests were
included in the study.
RESULTS

41-50 years

25

Samples were analyzed by using SPSS. Among the


500 samples, 260 samples were positive and 240
were negative for agglutinins to Salmonella serotypes
typhi and paratyphi A & B. In these positive samples,
143 (28.7%) were positive for O agglutinin and 157
(31.5%) were found positive for H agglutinin of
Salmonella typhi. Only 14 (2.8%) and 11 (2.2%)
samples were positive for agglutinins to paratyphi
AH & BH respectively. Amongst 143 samples
positive for O agglutinins, 30 (6%) showed
agglutination up to 1in 20 titre, 93 (18.7%) up to 1in
40 and 18 (3.6%) up to 1in 80 and in 157 samples
positive for H agglutinins, 18 (3.6%) showed a titre
of 1 in 20, 120 (24.1%) showed a titre of 1 in 40 and
15 (3.0%) up to 1 in 80. Among 14 samples (2.8%)
were positive for anti AH in the titre of 1in 20 and 7
(1.4%) were in 1 in 40 whereas among 11 samples
positive for anti BH, 8 (1.6%) were in the titre of 1
in 20 and 3 (0.6%) were in 1 in 40. (Table 2)

Among the total of 500 blood samples, 300 samples


were collected from healthy blood donors who
donated blood to our hospital blood bank and 200
samples from patients who reported to the
Microbiology laboratory for various serological tests
except for Widal. Demographic distribution of
individuals according to age group and sex is given in
the [Table 1]
Table: 1. Demographic distribution of individuals
according to age group and sex.
Total Participants
Frequency
%
500
100
Sex
Male
380
76
Female
120
24
Age
16- 20 years
55
11
groups
21- 30years
270
54
31- 40years
150
30
Table: 2. Number and percentage of samples positive for agglutinins with end titres against different
serotypes of Salmonella enterica.
Serotype

Antibody
type

No and % of
positive
samples

Dilution
(1 in 20)

Dilution
(1 in 40)

Dilution
(1 in 80)

Dilution
(1 in 160)

Dilution
(1 in 320)

S. typhi
Anti- TO
143 (28.7)
30 (6)
93 (18.7)
18 (3.6)
2 (0.4)
NIL
S. typhi
Anti-TH
157 (31.5)
18 (3.6)
120 (24.1) 15 (3.0)
3 (0.6)
1 (0.2)
S. paratyphi A
Anti-AH
14 (2.8)
7 (1.4)
6 (1.2)
NIL
NIL
NIL
S. paratyphi B
Anti-BH
11 (2.2)
7 (1.4)
4 (0.8)
NIL
NIL
NIL
The one sample T test showed that the observed value is different from the present recommended value and it is
statistically significant (P value < 0.01). (Table 3)
Table: 3. one sample T test
Name of the
agglutinins

Salmonella Oab
Salmonella Hab
Salmonella AHab
Salmonella BHab

Mean

Std. Deviation

Sig - ( 2 tailed)
P value

500
500
500
500

11.66
12.72
.76
.60

22.300
20.722
4.926
4.252

< 0.01
< 0.01
< 0.01
< 0.01

DISCUSSION
Bacterial culture remains the gold standard for
definitive diagnosis of enteric fever but lack of the
facility and cost limits its use in the developing
countries. [2] The widal test which detects
agglutinating antibodies to Salmonella enterica

subspecies enteric serotype Typhi O and H


antigens and H antigens of Salmonella enterica
subspecies enteric serotype Paratyphi A and B is
widely used in the developing countries due to the
ease of performing the test, low cost and relatively
rapid results. Widal test is also useful for diagnosis of
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Int J Med Res Health Sci. 2015;4(2):322-326

patients already on antibiotics which may inhibit the


growth in culture.
The present study showed that frequency of
agglutinins to Salmonella typhi O and H is more
than that of Salmonella paratyphi AH and BH. This
indicates that exposure to Salmonella paratyphi A &
B is less than Salmonella typhi among the population
in Puducherry which is similar to that of other regions
in our country. [9, 10]
In the present study the highest dilution of
agglutination against O antigen of S. typhi was
1:160 in two out of 500 samples (0.4%) tested ie) less
than 1% while it was 3.6% at a titre of 1 in 80 which
hitherto has been assumed as the significant titre for
O in this region. The highest titre for Salmonella
typhi H was 1in 320 in 1 out of 500 (0.2%) of the
study population and 3 out of 500 (0.6%) showed a
titre of 1in 160 which is the presumed significant titre
in this region. The study shows that a titre of 1 in
160 for O and Hantibodies of Salmonella typhi
holds good as the percentage of positivity of these
titres is significantly less (<1%) among the
population screened. Nevertheless the majority of the
screened population were having a titre of 1 in 40 (18
24%) for both O and H antibodies of Salmonella
typhi, the titre 1 in 80 should also be considered as
a significant titre with clinical correlations. Also the
highest dilution against AH antigen was 1in 40 in 6
out of 500 samples (1.2%) and 1in 20 in 7 out of 500
samples (1.4%) against BH antigen.
Recent study done by Aruni et al and Sreenath etal
[11,12 ]
showed the significant titres should be greater
than 1: 80 for anti O and greater 1: 160 for anti H
for a presumptive diagnosis of typhoid fever. In the
study done by Senewiratne B etal [13] a titre of 1 in
160 against H and O antigens of Salmonella typhi
was seen in only 1% of patient with non typhoidal
fever. In the study by Frimporg and others at Ghana
[14]
the anti O titre was 1 in 160 in 1% of the 307
healthy food handlers while anti H titre of 1 in
320 for S. typhi was 2.6%. In a study at Jordan by
Shehabi AA,[15] during an outbreak of typhoid fever,
92% of patients with positive blood culture developed
agglutinins against TO and TH in titres of 1 in 80 or
more indicating the utility of a single widal test in the
acute stage of the disease.
In the study by Zailani SB etal, [16] the base line titre
for Salmonella typhi and paratyphi for both O and
H antibodies was 1 in 80 among the healthy

individuals of the community at Ile - Ife, Nigeria. In


the study by
El-Shafie S [17] 10.5% of healthy
individuals in Sudan showed a titre of 1 in 320
against S. typhi O and 4.3% and 5.3% showed a
titre of 1in 160 for S.paratyphi A and B
respectively. In the study by Ibadin MO [18] at Benin
City, Nigeria 1.1% of the healthy school children
tested showed a titre of 1 in 160 for either antigens of
S.typhi.
Studies conducted in various regions of the world at
different periods of time and even within the same
region showed a variable baseline titre. It is therefore
imperative to estimate the baseline titres among the
healthy population in every region at regular intervals
and interpretation of single Widal test result must
take into account of the baseline titres in their
respective areas. In the present study the baseline
titres in the majority was less than 1 in 160 for
Salmonella typhiO (99.6%) and H (99.4%)
antibodies. The significant titre for O and H
antigens of S.typhi could therefore be assumed to be
1 in 160 in this part of the country. None of them
had the baseline titre of 1in 80 (100%) for S.
paratyphi AH and paratyphi BH. The baseline titre
for anti AH was found to be 1 in 40 (1.4%) and for
anti BH was 1in 20(1.6%). Hence the significant
titre could be presumed to be 1in 80 for AH and
1in 40 for BH antibodies of our region.
CONCLUSION
More than fifty percent of healthy participants (52%)
were positive to agglutinins for serotypes of
Salmonella. This indicates that enteric fever is
strongly endemic in our region which would be the
sanitation index of a country. Our study disclosed
that periodic evaluation of baseline titres of
Salmonella serotypes agglutinins, particularly in
endemic areas is necessary to avoid false positive
results. Based on the results of our study it is
recommended to change the currently used cut - off
value, that is 1 in 80 for O agglutinins of
Salmonella typhi to 1 in 160. The significant titre
for H agglutinins of Salmonella typhi remains the
same, which is 1 in 160. The significant titre for
AH of Salmonella paratyphi A is considered to be
of 1in 80 and for Paratyphi B is 1in 40. The
baseline titre for TO is same in most of the regions
while the titres against TH is variable in the
different studies.
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Int J Med Res Health Sci. 2015;4(2):322-326

ACKNOWLEDGEMENT
We would like to acknowledge and thank the Indian
council of Medical Research for sanctioning this
project (ICMR STS project 2012) to MS. Jaberlin
Sneha JA.

10.

11.

Conflict of Interest: Nil


REFERENCES
1. Abdul Razak SH, Abbas Abood AD, Adawia
Fadil A. The distribution of anti salmonella
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2. Deepak P, Komal Raj R, Bimala S, Suresh Raj K,
Bishnu Raj T. baseline titre and diagnostic cut off
value for widal test: A comparative study in
healthy blood donors and clinically suspected of
enteric fever. JHAS 2012; 2:22-26.
3. Crump JA, Luby Sp, Minz ED. The global
burden of typhoid fever. Bulletin world health
organization 2004; 82:346-53.
4. Lateef AO, Aprileona LK. Widal agglutination
test-100 years later: Still plagued by controversy.
Postgrad Med J 2000; 76: 80-84.
5. Cammie F, Lesser SI Miller. Salmonellosis. In:
Dennis LK, Eugene B, Anthony SF, Stephen LH,
Dan LL etal., eds, Harrisons Principles of
Internal Medicine. 16th edn. Newyork: McGraw
Hill, Medical Publishing division, 2006; 897-02.
6. Bharat M P, Rajendra K, Shyam KM, Janak K.
Distribution of antibody titer against Salmonella
enterica among healthy individuals in Nepal.
Annals of Clinical Microbiology and Antimicrobials 2009; 8: 1-7.
7. Collee JG, Fraser AG, Marmion BP, Simmons A.
Mackie and Mc Cartney Practical Medical
Microboiology. 1996; 14th ed, New York,
Churchill Livingston; 38.
8. Kok TW, Worswick D, Gowans E. Some
serological techniques for microbial and viral
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BP, Simmons A, eds, Mackie & McCartney
Practical Medical Microbiology. 14th edn. Delhi:
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9. Punia JN, Joshi RM, Gupta V, Arora RK.
Determination of Baseline widal titres from

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Chandigarh. Indian J Med Microbiol 2003;


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Patil AM, Kulkarni ML, Kulkarni AM. Baseline
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Aruni I.S, Prabakaran P, Kumaran J. Study of
baseline widal titre against Salmonella species
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Sreenath K, Sujeesh S, Deepa R. Detection of
baseline widal titres among the blood donors: A
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Senewiratne B, Senewirante K. Reassessment of
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DOI: 10.5958/2319-5886.2015.00061.2

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2 Coden: IJMRHS
Copyright @2015
th
th
Received: 9 Jan 2015
Revised: 6 Feb 2015
Research article

ISSN: 2319-5886
Accepted: 12th Feb 2015

COMPARISON OF POTENCY OF ANTIFUNGAL ACTION OF DANDRUFF SHAMPOOS AND


DIFFERENT PLANT EXTRACTS
*Naga Padma P, Anuradha K, Divya K
Dept of Microbiology, BVB, Bhavans Vivekananda College, Secunderabad, Telangana, India
*Corresponding author: Naga Padma; Email: naga_padmathota@yahoo.com
ABSTRACT
Context: Dandruff a very common scalp disorder with high prevalence in population is caused by numerous host
factors in conjunction with Malassezia furfur. Most of the commercially available anti-dandruff hair shampoos
contain some form of antifungal agent(s) that appear to reduce the incidence of the disease. There are no good
scientific studies done to prove the antifungal activity of commercially available hair shampoos. Aim: In this
study commercially available shampoos were assessed for antifungal activity against a human dandruff isolate of
M. furfur. The shampoos were Head & Shoulders, Clinic All Clear, and Pantene etc. The results demonstrated that
all six of the assayed hair shampoos have some antifungal effect on growth of M. furfur. These products have
poor efficacies, more side effects and give scope for recurrence of symptoms. Methods and Materials: Therefore
different plant extracts that possess various active compounds which have antifungal activity could help to
overcome the incidence of the disease and also avoid the emergence of resistance in the pathogen. The plant
extracts were tested in different concentrations like 1:5, 1:10, 1:20 and they were hibiscus, neem, soap nut, etc.
The inhibitory action was studied using agar well assay and disc diffusion method and the results indicated in
percentage of inhibition. Conclusion: The study was significant as not only efficient known plant products with
anti-dandruff activity could be compared with commercially available shampoos but also their better efficacies at
minimum concentrations could be identified. This can help make a polyherbal mixture that could be incorporated
in hair oil or shampoos for better anti-dandruff activity.
Keywords: Malassezia furfur, Dandruff, plant extracts, anti-dandruff hair shampoos
INTRODUCTION
Malassezia species formerly known as Pityrosporum
is a lipophilic, dimorphic opportunistic yeast causing
skin and hair infections like Pityriasis versicolar,
seborrheic dermatitis and dandruff, etc[1][2] . Dandruff
medically described as Pityriasis capitis is caused by
Malassezia species like M.furfur, M.globosa,
M.restricta [3]. It is a common scalp disorder and also
a major cosmetic problem as it causes hair fall [4]. It
has been investigated and reported that there was no
complete cure for this disease. This disease is of
global prevalence and needs effective therapeutic

remedy. There are natural effective remedies to


control dandruff in Ayurveda [5] but presently people
are depending on commercial shampoos containing
some antifungal compounds like miconazole,
ketoconazole, selenium sulphide etc. Plant products
contain various compounds like alkaloids, flavanoids,
tannins, terpenoids etc which have efficient
antifungal activity [6] [7]. These compounds can be
used in combination as polyherbal mixtures for
controlling dandruff. The present work was a
comparative study of the effect of commercial anti
327

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Int J Med Res Health Sci. 2015;4(2):327-331

dandruff shampoos and natural plant products to


evaluate their anti fungal efficacy. There are no
reports of such comparative study and this study
gives significant information about the higher
antifungal efficiency of natural products at low
concentration which can be exploited for commercial
poly herbal preparations.
Aim: The present study was undertaken to find the
comparison of efficacy of different types of plant
extracts verses chemical shampoos.

by using gelatin hydrolysis test, litmus milk reaction,


fermentation of carbohydrates like dextrose, xylose,
rhamnose, raffinose and mannitol and the results were
recorded [11].
Inoculum preparation:
The inoculum of
Malassezia furfur was prepared by inoculating in 5ml
of Sabourauds broth and incubated at 300C such that
there are 106 cell/ ml[12].
Dilution of shampoos: The commercially available
shampoos as mentioned in (Table 1) along with their
active ingredient were diluted with sterile distilled
MATERIALS AND METHODS
water to get 10 fold, 20 fold dilution. These were
used for antifungal assays.
Isolation of culture: In the clinical study the
Table 1: Active ingredients in different
organism was isolated from scalp of person suffering
commercially available shampoos
from Dandruff and maintained on Sabourauds
[8]
Active antidandruff
Shampoos
media (which is a defined selective media for
ingredients
medically significant fungi and inhibits growth of
Zinc Pyrithione
Head and shoulders,
normal flora) slants and stored in refrigerator at 40C
Pantene, Garnier, Loreal
for one month.
Selinium
sulphide
Head and Shoulders,
Growth and Identification: The isolate was
Nuetrogena
screened by plating the scalp swab on Sabourauds
Ketoconazole
Nizoral , Vivel Ultra Pro
media enriched with 2 % lipid source like olive oil.
Preparation of plant extracts: The different plant
The organism was identified based on cultural,
sources tested are mentioned in (Table 2) along with
microscopic and biochemical methods.
their generic names, appropriate plant part used and
Cultural: Growth pattern and colony morphology
[7]
was observed on Sabourauds media enriched with a
dosage . The plant part was collected from the plant
[9]
source washed thoroughly, cut into smaller pieces and
lipid source like olive oil/ butter .
ground into fine paste. The fine paste was made into a
Microscopic: Gram stained smear of the culture was
[10]
solution with sterile distilled water, centrifuged at
observed under microscope for cell morphology ..
5000 rpm and the supernatant was used as sample for
Biochemical: The organism was biochemically tested
anti fungal assays.
Table 2: Different plant extracts used and their common names[7]
Scientific name

Plant part used for extraction


of active compound

Part used

Extracted
i.e. Alcohol/ aqua

Dose
used
for
antifungal activity

Azadirachta indica
Piper betle
Ocimum tenuiflorum
Murraya koenigii
Hibiscus rosasinensis
Aloe vera
Coriandrum sativum
Mentha asiatica
Phyllanthus emblica
Citrus limon
Sapindus mukorossi
Alpinia galangal
Lawsonia inermis
Hibiscus rosasinensis

Neem
Betel leaf
Tulsi
Curry leaf
Hibiscus flowers
Aloevera
Coriander
Mint
Amla
Lemon
Soapnut
Dumparashtram
Henna
Hibiscus leaves

Leaf
Leaf
Leaf
Leaf
Flower
Leaf
Leaf
Leaf
Fruit
Fruit
Fruit
Root
Leaf
Leaf

Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water
Water

1:10
1:5
1:5
1:5
1:5
1:20
1:5
1:5
1:20
1:20
1:20
1:5
1:10
1:5
328

Naga Padma et al.,

Int J Med Res Health Sci. 2015;4(2):327-331

zone of inhibition. The highest was for Vivel


followed by Head and Shoulders and Dove (Fig3).

Zone of Inhibition Using Different


Shampoos

Fig 1: Microscopic observation of Malssezia furfur


Effect of lipid source on the growth of M. furfur:
Among the fatty substances tested, M. furfur grew
well in Sabouraud's dextrose broth and agar medium
containing olive oil followed by butter, coconut oil
etc (Fig 2 A and B) .

Fig 2 A and B: Growth of Malassezia furfur on


Olive oil (A) and butter (B)
Antifungal Assay: Among the Antidandruff
shampoos tested every shampoo showed a very good

10

Dove

Zone of
inhibition (1:40)

Nizoral

Vivel

Zone of
inhibition (1:20)
Pantene

Head

Malassezia furfur grew as white to tan cream colored


colony
with smooth pasty consistency on
Sabourauds media and the cells appeared bottling
shaped when observed microscopically (Fig 1). The
Biochemical studies indicated that fermentation of
dextrose and xylose produced acid but no gas.
Maltose, lactose, rhamnose, raffinose and mannitol
were not fermented by M. furfur. Liquefaction of
gelatin was observed and there was acidification of
litmus milk.

Inhibition zones in cm

RESULTS

Clear

Antifungal Assays: The antifungal activity of


antifungal shampoos and plant extracts was tested by
[13]
disc diffusion method and agar well assay .

Shampoo

Fig 3: Anti fungal activity of different shampoos,


represented by zone of inhibition (in cm)
The zones of inhibition of different plant extracts
indicated significant antifungal activity on
Malassezia furfur (Fig 4).

Fig 4: Plates showing zone of inhibition for


different plant extracts

Fig 5: Anti fungal activity of different plant


extracts, represented by zone of inhibition (in cm)
on Malassezia furfur
329

Naga Padma et al.,

Int J Med Res Health Sci. 2015;4(2):327-331

Among the plant extracts tested Lemon showed the


highest zone followed by Soap nut, Henna, Aloevera
and Neem (Fig 5). Comparatively the plant extracts
shampoos showed a high zone of inhibition than the
shampoos. The inhibition zones of antidandruff
shampoos at low concentrations almost matched with
those of plant extracts.
DISCUSSION
Dandruff is a common disease caused by Malassezia
species especially Malassezia furfur. The lipolytic
activity of these organisms induces hydrolysis of
human sebum tri-glycerides in to free fatty acids that
cause both hair loss and scalp [14]. Medically
significant fungi are known to grow on Sabourauds
agar medium. The present isolate being lipolytic grew
well on olive oil and Butter enriched medium this is
in accordance with other reports on growth of
Malassezia [15].
All the antidandruff shampoos had good antifungal
activity but there is considerable variation in the
potency of their antifungal activity depending on the
active compound and its concentration. In the present
study the best antidandruff shampoo was Vivel Ultra
Pro as it contains Ketokanozole which is reported to
be anti-malassezial agent [16]. This was followed by
Dove and Head and Shoulders as they contain
antifungal compounds like Zinc Pyrithione. Most of
the plant extracts were showing good antifungal
activity almost equivalent to that of commercially
available shampoos. Lemon, Henna, Soap nut, Amla
had more antifungal activity and this could be
because of their active compounds like Citric acid in
Lemon and Amla and Saponins in Soap nut [17]. As
there are no reports of such comparative aspect the
present study gives significant information about the
higher antifungal activity of natural products at low
concentration which can be exploited for commercial
poly herbal preparations. Use of natural plant
products is not only cost effective but also negligible
side effects. [18] [19].
CONCLUSION
The present study was significant as not only efficient
known plant products with anti-dandruff activity
could be compared with commercially available
shampoos but also their better efficacies at minimum

concentrations could be identified. Further this


research work can help make a polyherbal mixture
that could be incorporated in hair oil or shampoos for
better anti-dandruff activity.
ACKNOWLEDGMENTS
The authors (P. Naga Padma , K.Divya and
K.Anuradha) are grateful to the management of BVB
Bhavans Vivekananda College for encouraging to
carry out this work.
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1. Gupta AK, Batra R, Bluhm R, Boekhout T,
Dawson TL. Skin diseases associated with
Malassezia species. J Am Acad Dermatol. 2004;
51 (5): 785-98.
2. Vijayakumar R, Muthukumar C, Kumar T,
Saravanamuthu
R.
Characterization
of
Malassezia Furfur and its control by using plant
extracts. Indian J Dermatol. 2006; 51:145-8.
3. Shuster S. The aetiology of dandruff and the
mode of action of therapeutic agents. Br J
Dermatol. 1984; 111: 235-42
4. Ravichandran G, Shivaram,Kolhapur SA.
Evaluation of the clinical efficacy and safety of
Antidandruff Shampoo in treatment of
Dandruff. The Antiseptic.2004; 201(1): 5-8
5. Sonica Krishnan. Effective home remedies for
fungal
infections,
Available
from:
http://completewellbeing.com/article/naturecures/andhttp://www.herboveda.co.in/2011/7/14/
ayurveda-cure-for-fungal- infections-combat-thefungus-naturally/. 2011.
6. Agrawal DP. Medicinal properties of Neem: New
Findings, Available from: http://www.infinity
foundation.com/mandala/t_es/t_es_agraw_neem.
htm. 2001.
7. Saneesh Kumar. Analysis on the Natural
Remedies to Cure Dandruff/Skin Disease-causing
Fungus - Malassezia furfur. Adv Bio Tech.
2013;12 (07) : 01-05
8. Sabouraud R. Contribution a l'etude de la
trichophytie
humaine.
Etude
clinique,
microscopique et bacterioloqique sur la pluralite
des trichophytons de l'homme (French). Ann.
Dermatol. Syphil. 3:1061-1087.
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9. Kaw Bing Chau, I-Ly Chau, I-Ee Chau, Kwai


Hoe Chong and Kerk Hsiang Chau. A modified
mycological medium for isolation and culture of
Malassezia furfur. Malaysian J Pathol 2005.
27(2) : 99 105.
10. Kindo A.J, Sophia S.K.C, Kalyani J and Anandan
S. A identification of Malassezia species. Ind J.
Medical Microbiol. 2004;22(3):179-181.
11. Nakabayashi A, Sei Y, and Guillot J.
Identification of Malassezia species isolated from
patients with seborrhoeic dermatitis, atopic
dermatitis, pityriasis versicolor and normal
subjects. Med. Mycol. 2000; 38: 337-41
12. Nakamura Y, Kano R, Murai T, Watanabe S, and
Hasegawa A.
Susceptibility
Testing
of Malassezia Species Using the Urea Broth
Microdilution Method. Antimicrob. Agents
Chemother. 2000; 44 (8):2185-86
13. Finn RK. Theory of agar diffusion methods

19. Krishnamoorthy J, Ranganathan S. Gokul


Shankar S and Ranjith M.S. Dano: A herbal
solution for dandruff. Afr J Biotechnol.
2006.5(10):960-62.

for bioassay. Anal Chem1959: 31: 975-7


14. Yvonne M, De Angelis, Christina M. Gemmer,
Joseph R. Kaczvinsky, Dianna C. Kenneally,
James R. etal.,
Three Etiologic Facets of
Dandruff and Seborrheic Dermatitis: Malassezia
Fungi, Sebaceous Lipids, and Individual
Sensitivity. J Investig Dermatol Symp Proc.
2005; 10: 295 297.
15. Vijayakumar R, Muthukumar V, Kumar T, and
Saravanamuthu
R.
Characterization
of
Malassezia furfur and its Control by Using Plant
Extracts. Indian J Dermatol. 2006:51(2):145-8.
16. Nikam SR, Khanvilkar VV, Jagdale DM, Jadhav
AP, More SH and Kadam VJ. Evaluation of
antibacterial and antifungal activities of marketed
anti-dandruff shampoos. Indo Am J Pharm Res
2013:3(10):8097-100.
17. Prabha Manju M, Gokul Shankar S, Navin
Kumar Sharma, Babu K and Chiranjeevi A.
Antifungal activity of selected plant extracts
against Malassezia globosa. Int. J of Scientific
and technical research. 2012:5(2): 162-168.
18. Krishnamoorthy J, Ranganathan S. Anti
Pityrosporum ovale activity of a herbal drug
combination of Wrightia tinctoria and Hibiscus
rosasinensis. Indian J. Dermatol .2000:45 (3): 2128.

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DOI: 10.5958/2319-5886.2015.00062.4

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 25 Dec 2014
Research article

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 27 Jan 2015
Accepted: 22nd Feb 2015

ASSESSMENT OF AWARENESS AND BELIEFS REGARDING INTRA UTERINE DEVICE


AMONGST ITS FORMER USERS ATTENDING TERTIARY CARE CENTRE IN GUJARAT
*Jogiya Priyanka D1, Lodhiya Kaushik K2, Chavada Paras3
Department of Obstetrics & Gynaecology, Pandit Deendayal Upadhyay Govt. Medical College, Rajkot, Gujarat
*Corresponding author email: drpjogia@gmail.com
ABSTRACT
Background: Only 1.8% of married women of reproductive age in India use IUDs despite its advantages over
Hormonal pills or permanent methods. The present study was done to study the awareness of the mothers about
IUD which affects its utilisation. Method: This was a descriptive cross sectional analytical study was carried out
at obstetrics and gynecology department of PDU Government medical college and civil hospital, Rajkot, Gujarat,
from January 2014 to June 2014. Post natal mothers who had delivered in the hospital, who had previously used
intrauterine contraceptive device (IUCD) for a period of more than one month & who agreed to be a part of the
study were included in the study. Results: A total of 110 women who agreed to be a part of the study, were
interviewed. The mean age of study participants was 29.23.3 years & over half of them resided in urban areas
(56.36%) & were housewives (74.54%). Over 90% of the participants were aware of barrier or hormonal methods
of contraception & 25 to 50 % of them had also used them in the past. Mean duration of IUD use amongst the
study participants was 36.9 18.9 months. While over three fourth of the participants reported to have been
provided some sort of counselling before IUD insertion only 64% of them agreed that their pelvic examination
was done simultaneously. Awareness about IUD was significantly higher among graduate & working women
while there was no significant association of knowledge with other independent variables. Conclusion: There was
lack of knowledge amongst participants regarding IUDs as well as many myths which needs to be addressed in
order to improve its utilisation by the community.
Key words: Adverse events, Attitude, Awareness, Beliefs, Intra Uterine device, Knowledge
INTRODUCTION
According to the Population Reference Bureau1,
about 17% (100 million) of all married women in less
developed countries (LDCS) would prefer to avoid a
pregnancy but are not using a contraceptive method.
In Africa, 22 countries have levels of unmet need of
20 percent or higher, and in Latin America and Asia,
most countries have levels of unmet need of 10
percent of women or higher.[1]
Worldwide, 61% of women aged 1549 years who
were married or in a consensual union (635 million
women) used some form of contraception in 2003. In
Priyanka et al.,

developed countries, women relied mostly on oral


contraceptives (16%), female or male sterilization
(15%) and condoms (13%); only 9% of women used
long-acting reversible contraceptive (LARC)
methods. The respective percentages in developing
countries were 6, 25, 3 and 18% (United Nations,
2003).[2]
Indias population, which crossed one billion in 2000,
is projected to reach 1.53 billion by 2050, making it
the most populous country in the world. Women of
reproductive age group (15-49 years) make up
332
Int J Med Res Health Sci. 2015;4(2):332-338

approximately 248 million. As per NFHS 3, the


contraceptive prevalence rate in India is 56.3 %,
which varies widely among different states and the
unmet need for family planning is high at 13% (6%
for spacing).[3]
Although oral contraceptives can be very effective in
preventing unintended pregnancies, they have been
associated with poor compliance which often results
in contraceptive failure.
In contrast, female
sterilization does not depend on users adherence, is
highly effective, but it has a permanent contraceptive
effect. Notably, LARC methods combine reversibility
with particularly high effectiveness, which does not
rely (or relies at a small degree only) on users
compliance or correct use.[2, 4-7]
Intrauterine contraception is the most widely used
amongst the long-acting reversible contraceptives
(LARC) in the world today, especially in developing
countries. The majority of devices used are copper
intrauterine devices (Cu-IUDs) with 1 150 million
women users.[8]
The evolution of the intrauterine device (IUD) has led
to a safe and effective contraceptive choice for many
women. The efficacy in pregnancy prevention far
surpasses other daily and scheduled methods such as
pills, patches, and contraceptive rings.[9,10]
Satisfaction rates rank high among IUD users in the
United States (US) compared to other methods, and
complication rates have been shown to be low.[11]
Since the mechanism of action of IUDs is localized to
the uterus and cervix, with little if any systemic
effect,[12] they are an optimal method for women with
multiple medications or medical co-morbidities. In
addition to its high efficacy over other contraceptives,
additional advantage of its use in women with
contraindications to other systemic contraceptives[13]
makes IUDs a standout among contraceptive choices.
IUCD services are offered free of cost by the
government in India. Yet despite this favourable
profile, only 1.8% of married women of reproductive
age in India use IUDs.[3] So the present study was
carried out with the objective to assess the knowledge
& beliefs of post natal mothers about IUD & their
attitude towards the use of the same.
MATERIAL AND METHODS
Type of study: This was a descriptive cross sectional
analytical
Priyanka et al.,

Place of research: Study was carried out at obstetrics


and gynecology department of PDU Government
medical college and civil hospital, Rajkot, Gujarat.
Inclusion criteria: Post natal mothers who had
delivered in the hospital, who had previously used
intrauterine contraceptive device (IUCD) for a period
of more than one month & who agreed to be a part of
the study were included in the study. The present
study was conducted over a period of 6 months from
January 2014 to June 2014.
Sampling Method: The subjects were selected by
convenient sampling method based on availability of
mothers (N=110). The consent of all the subjects was
taken prior to the study. Permission from the ethical
committee of the institution was sought before the
starting of the study.
Method: Data on socio-demographic profile,
awareness & use of different contraceptives, their
preference for IUCD, their attitude & beliefs
regarding IUCD was collected using a pretested,
semi-structured questionnaire. Independent variables
were Age, education, occupation & obstetric profile
of the woman. Dependent variables were awareness
& beliefs of women regarding IUCD use.
For each of the ten knowledge based questions about
IUD asked to participants, each correct response was
given a score of one. Their performance was
classified as Good, average or poor if their score was
8-10, 5-7 & 0-4 respectively.
Statistics: Data entry and analysis was done using
MS-Excel 2007. Chi-square test was used to find the
association
between
knowledge
scores
&
demographic variables for an alpha error of 5%.
RESULTS
Depending on the inclusion criteria & consent given
by mothers, interview of a total of 110 post-natal
mothers was taken. The mean age of study
participants was 29.23.3 years & over half of them
resided in urban areas (56.36%) & belonged to joint
families (54.64%). Majority of the participants
belonged to Hindu religion (76.36%) & were
housewives by occupation (74.54%). Although none
of the participants were illiterate only 20% of the
participants had graduated. The mean parity of the
participants was 2.40.6.
Over 90% of the participants were aware of barrier or
hormonal methods of contraception & 25 to 50 % of
333
Int J Med Res Health Sci. 2015;4(2):332-338

them had also used them in the past. Mean duration


of IUD use amongst the study participants was
36.918.9 months. While over three fourth of the
participants reported to have been provided some sort
of counselling before IUD insertion only 64% of
them agreed that their pelvic examination was done
simultaneously. This highlights the laps in duty on
the part of service providers & could lead to flare up
of cervical infection have it been present at the time
of insertion of IUD. (Table 1)
The proportion of mothers giving correct responses to
each of the ten knowledge based questions about IUD
is shown in table 2. Majority (93.6) of the participants
were aware of at least other methods of
contraception. Over three fourth of them knew the
type of IUD used & its duration of effectiveness.
Around one third of the mothers were aware of at
least two of the adverse events as well as changes in
menstrual bleeding pattern following its insertion.
Nearly half of the participants did not know the
importance of regularly feeling the thread of IUD or
its follow up criteria following IUD insertion. Very
few of the mothers knew of newer IUDs available or
that IUD can also be used in a nulligravida. These
findings highlight serious gaps in the knowledge of
the participants about IUDs. (Table 2)
In the present study, the major reasons for preference
of IUD over other methods as per the participants
were minimum user interference (46%) & its long
lasting contraceptive efficacy (40%). Other reasons
were its ability to be discontinued at any time when
needed, less cost, easily controlled by women, no
consuming drugs & fewer side effects. (Table 3)
The main side effect reported by participants was
abdominal pain/cramps after insertion in around 40%
cases. The other were Leucorrhea (25%),
Dysmenorrhea (21%), changes in bleeding pattern
during menstruation (14%), expulsion of IUD (8%),
infection (3%). About 17% of the participants
reported no occurrence of any adverse events. (Table
4) The mothers who were interviewed also had many
myths & beliefs about IUD as can be seen in table 5.
Participants above thirty years of age had higher
levels of knowledge than those under thirty. However
this difference was not statistically significant.
Residents from urban areas had significantly higher
knowledge scores than their counterparts in rural
areas. Participants belonging to Hindu religion had

higher scores which showed borderline significance


as compared to other religions. This difference could
be attributed to the difference in level of education of
the participants belonging to other religions. The
knowledge scores of participants who had used IUD
for more than three years did not differ significantly
than those who had used IUD for less than three
years. Participants who were educated up to
secondary level or higher & those who were
employed had higher level of knowledge about IUD
than those who were educated up to primary
standards or those who were unemployed. This
difference was highly significant. There was no
significant association between increasing parity of
participants or participants with past history of
abortion & their level of knowledge about IUCD.
(Table 6)
Table 1: Profile of IUD use amongst study subjects
Response
N= 110

Variable

Main source of information about IUCD*


Mass media (TV, Newspaper)
Friend, Relative
Health care personnel

15
99
73

13.6
90
66.36

65
13
16
15

59.0
11.8
14.5
13.6

104
108
20
52

94.5
98.1
18.1
47.2

27
49
00

24.5
44.5
0

84

76.3

60

64.5

Decision making for IUD use


Couple
Husband
Herself
Mother-in-Law
Method
IUCD*

aware

other

than

Condom
OCP
Injectable method
Permanent methods
Utilisation of other methods in
past*
OC Pills
Barrier method
Others
Counselling provided before
IUD insertion
Pelvic examination done before
IUD insertion
Mean duration of IUD use

36.95
months

18.89

*multiple answers
334

Priyanka et al.,

Int J Med Res Health Sci. 2015;4(2):332-338

Table 2: The knowledge of participants about


various aspects of IUCD
Knowledge regarding

Total
N = 110

At least two other methods of


temporary contraception
Type of IUCD used

103

93.64

83

75.45

Duration of effectiveness of
IUCD
Side effects of IUCD (at least 2)

85

77.27

76

69.09

Changes in menstrual bleeding


pattern
At least two advantages of IUD
over other methods of temporary
contraception
Necessity to feel thread
Ideal follow-up criteria

68

61.82

64

58.18

55
52

50.00
47.27

Knows about newer IUCD


Use of IUD for family planning
of a newly married childless
couple

25
10

22.73
9.09

Minimum user interference


Long lasting
Can be stopped any time when
pregnancy is wanted
Less cost
Controlled by women
Others (less side effects, no
taking regular drugs)

*multiple responses

Adverse events*

Encountered
by participants

Abdominal
pain/cramp
after insertion
Leucorrhea
Dysmenorrhea
Bleeding pattern changes
during MC
Expulsion
Fever with infection
No side effect

43

39.09

28
24
16

25.54
21.81
14.54

09
03
19

8.18
2.72
17.2

*Participants may have more than one adverse event

Table 3: Preference for IUCD over other methods


amongst the participants
Advantages of IUCD

Table 4: Frequency distribution of adverse events


due to IUD use amongst the participants (multiple
responses)

Yes
N=110*
51
44
36

28
28
24

25.54
25.54
21.81

46.36
40
32.72

Table 5: Beliefs regarding IUCD amongst users


(multiple responses)
Belief (N=110)
Yes
%
Rest period needed after
prolonged use
Perforate uterus
Discomfort during sex
Causes infection in uterus
Decrease capacity to do
physical work
Causes cancer
Acts by causing abortion
Birth defect
Ectopic pregnancy
Infertility
Moves to heart /brain
Infection to foetus
Weight gain
Cause preterm labour in case
of accidental pregnancy

88

80

60
55
36
33

54.5
50
32.7
30

31
23
17
17
15
13
05
07
03

28.1
20.9
15.4
15.4
13.6
11.8
4.5
6.3
2.7

*multiple responses

Table 6: Association of knowledge scores of the participants to various demographic variables


Demographic variables
Good
Average
Poor
Chi-square test
(8-10)
(5-7)
(1-4)
Age in Years
<30, N=77
16
37
24
Chi = 2.913,
p = 0.233
>30, N=33
11
16
6
Residence
Rural, N=48
5
27
16
Chi = 7.491
p = 0.023
Urban, N=62
20
28
14
Religion
Hindu N=84
24
36
24
Chi = 5.772
p = 0.055
Others N=26
2
17
7
Education
Up to primary N=37
1
17
19
Chi = 21.478
p = 0.00002
Secondary & above N=73
26
35
12
Occupation
House-wife N=81
9
48
24
Chi = 24.135
p = 0.000005
Employed N=29
16
7
6
Parity
Two para N=74
20
36
18
Chi = 1.298
p = 0.522
More than two para N=36
7
17
12
Abortion
No abortion N= 60
12
29
19
Chi = 1.308
p = 0.519
Past history of abortion N= 50
14
24
12
Duration of use < 3 years N = 73
17
36
20
Chi = 0.052
p =0.974
>3 years N = 37
8
19
10
335
Priyanka et al.,

Int J Med Res Health Sci. 2015;4(2):332-338

Table 7: Attitude of subjects regarding IUCD


Attitude of subjects about Yes
%
IUCD use
(N= 110)
Feels satisfied with IUCD 84
76.36
use
Will encourage a friend to 101
91.81
use IUCD
Willing to use it again if 54
49.09
needed
Willing to check the thread 69
62.72
of inserted IUD regularly
after every menstruation
DISCUSSION
The major source of information about IUCD was a
friend or a relative in 90% of the participants with
secondary role of health care personnel & minimal
information through mass media. (Table 1) This
highlights the failure of mass media in creating
awareness about IUDs. Reddy et al in 2003[14] stated
that the major source of knowledge among men about
Family Planning methods was magazines (64%)
followed by personal relations i.e. spouse, friends and
relatives (62%), mass media (54%) and health
personnel (34%). The role of health care providers in
providing contraception knowledge should be
prioritised as its a two way communication process
& will provide correct & complete information as
compared to friends or mass media.
Although in 60% of cases the decision for IUD use
was by the couple themselves, in about 25% of the
cases the decision for IUD use was dominated by
husband or mother-in-law hampering the decision
making ability of the women. (Table 1) Prachi R et al
in 2008[15] mentioned that in 41.6% of the women the
choice of contraceptive methods used was decided by
their husband which is higher than that in present
study. The difference was due to difference in the
literacy rate of women & settings in which the study
was done.
In a comparative study on attitude of contraceptive
methods users by Ehsanpour et al (2010), desirable
attitude amongst users towards IUD in comparison
with other methods was due to high efficacy, ease of
use, lack of interference with sexual relationship and
no need for daily remembrance.[16] This finding was
very similar to the present study. (Table 7)
Patients must also be counselled regarding expected
adverse events after IUD insertion & tips to manage

them. Thorough counselling about expected changes


in bleeding patterns before IUD insertion correlates
with satisfaction rates and continuation rates.[17,18] It
must be stressed upon that the occurrence of side
effects experienced by the mothers will decrease
over a period of few months.[18] This will ensure
greater compliance among the mothers towards use of
IUD.(Table 4)
In the present study, 80% of the participants
mentioned that a break from continuous usage of IUD
is needed, while there is no such literature supporting
this view point, discontinuation of IUD would also
increase the risk of unintended pregnancy. Table 5
highlights many myths & beliefs about IUD amongst
its former users. Around half of the mothers believed
that IUD will perforate the uterus & over one third of
them believed that it would lead to infection.
Infection following IUCD insertion is less than 1%.
This minimal risk is highest during the first 20 days
after IUCD insertion, especially if aseptic precautions
have not been taken, rather than due to IUCD itself.[3]
World Health Organization found that the risk of
development of pelvic inflammatory disease (PID) in
women with IUD is same as or less than the risk of
PID in women without IUDs.[19, 20, 21]
The attitude of a woman about the use of IUD is
based on her existing knowledge, her beliefs about
IUD & counselling provided by the service provider.
Although over three fourth of the participants were
satisfied about IUD use still there remained a quarter
of them who for various reasons were not satisfied
with IUD. Only half of the participants were willing
to use IUD again for contraception which is a matter
of concern. As many as 40% of the participants were
not motivated to check the thread of IUD after
menstruation. These findings pose a serious threat to
the continuation of use of IUD in future. The
concerns of these women need to be immediately
attended to prevent discontinuation of IUD use in
them. (Table 7)
CONCLUSION
The mothers in the present study were unaware about
the basic knowledge regarding IUD. Age of the
participants, Religion, parity status, history of
abortion or duration of use of IUDs did not
significantly affect the knowledge scores of the
participants regarding IUD. However there was

336
Priyanka et al.,

Int J Med Res Health Sci. 2015;4(2):332-338

strong association between education & working


status of participants to their awareness about IUD.
The findings of the present study showed that many
former users of IUDs still have false beliefs, concerns
& unfavourable attitudes about IUDs. This may result
in discontinuing their IUD use as well as propagate
false beliefs amongst their peer groups. IUDs are
safe and effective in women of any reproductive age.
They offer superior contraceptive efficacy, plus noncontraceptive benefits that can improve quality of life
in many women. Patient lack of knowledge about
IUDs coupled with practitioner apathy for sufficient
counselling, all continue to be barriers to IUD use.
Recommendation: The dispersion of accurate
information addressing their beliefs & concerns is
crucial to the continued use and growing acceptance
of this beneficial method.

7.

8.

9.

10.

Conflict of Interest: Nil


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1. Ashford, Lori. Unmet need for family

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4.

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Mavranezouli I. The cost-effectiveness of
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Institute for Health and Clinical Excellence
(NICE) clinical practice guideline.Hum
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IUCD Reference Manual for Medical
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Rosenberg
MJ,
Waugh
MS.
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contraceptive discontinuation: a prospective
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Ingelhammar E, Moller A, Svanberg B,
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Bianchi-Demicheli F, Perrin E, Bianchi PG,
Dumont P, Ludicke F, Campana A.
Contraceptive practice before and after

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dArcangues C. Worldwide use of
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Yoost J. Understanding benefits and
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Reddy RS, Premarajan KC, Narayan KA,
Mishra A. Rapid appraisal of knowledge,
attitude and practices related to family
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Renjhen P, Gupta SD, Barua A, Jaju S, Khati
B. A study of knowledge, attitude and
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Ehsanpour S, Mohammadifard M, Shahidi S,
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DOI: 10.5958/2319-5886.2015.00063.6

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
st
Received:31 Dec 2014
Research article
BIOFILM
FORMATION
UROPATHOGENS

AND

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 27 Jan 2015
Accepted: 20th Feb 2015
ANTIMICROBIAL

RESISTANCE

PATTERN AMONG

*DardiCharanKaurG1, MaralSanjivani.S2
1

Department of Microbiology, Maharashtra Institute of Medical Education & Research (MIMER), Talegaon
Dabhade, Pune, Maharashtra, India
2
Assistant Professor Symbiosis Institute of Health Sciences, Pune Maharashtra, India
*Corresponding author email: charan13@rediffmail.com
ABSTRACT
Background: Bacterial biofilms play an important role in urinary tract infections and is responsible for
persistence infections and also the higher antimicrobial resistance is seen in biofilm forming uropathogen as
compared to free floating bacteria. So the present study was undertaken with the aim to know the prevalence of
biofilm formation and antimicrobial resistant pattern of biofilm producer and non-biofilm producing
uropathogens. Materials & Methods: A total of 146 Gram negative bacilli and 62 S. aureus isolated from
patients suspected UTIs were tested for biofilm formation and antimicrobial susceptibility testing by Kirby-Bauer
disc diffusion method on Mueller Hinton agar as per CLSI guidelines. Result: Out of 208 isolates from urine,
Biofilm formation was noted in 122(58.66%) and no biofilm formation in 86(41.35%).[Strong Biofilm formation
in 76(36.54%) and weak biofilm formation in 46(22.12%).In our study, we noted biofilm and non-biofilm
forming microorganism showed mark difference in antimicrobial resistance pattern. In Staphylococcus aureus
striking difference was noted to ciprofloxacin (100% versus 33.33%) and azithromycin (96%versus 41.67%).
Isolates showed no resistance to linezolid. Whereas isolates of Pseudomonas aeruginosa to netilin (100% versus
42.86%).And in other Gram negative bacilli difference was noted to gentamicin (87.93% versus 13.43%) and
norfloxacin (84.48% versus 37.31%) Conclusion: Biofilm forming isolates showed higher antimicrobial
resistance as compared to non-biofilm producer. Thus, Uropathogen should be routinely screened for biofilm
formation.
Keywords: Uropathogen, Biofilm formation, Antimicrobial resistance pattern
INTRODUCTION
Urinary tract infections (UTIs) are the important
causes of morbidity affecting 150 million people
globally each year and also continue to be the most
common causes of infections in hospitalized
patients. [1, 2] It is the most common bacterial
infections in humans both in the community and
hospital settings, and in all age groups, and usually
requires urgent treatment. Malnutrition, poor hygiene,
low socio-economic status is associated with urinary

tract infections and these factors are rife in rural


settings.[3]Microorganism associated with UTI has a
property to form biofilm and this biofilm can be
formed by one or many bacteria which show
antimicrobial tolerance. Host factors like age,
diabetes, long term hospitalization and catheterization
are the predisposing conditions.[4]According to the
NIH, urology is one of the main areas of concern
where biofilm can become a serious problem and
339

Charan et al.,

Int J Med Res Health Sci. 2015;4(2):339-344

Biofilm are found in the urothelium, prostate stones,


and implanted foreign bodies. [5]
The population of bacteria growing on the biotic and
biotic surfaces is the biofilms. The bacteria embed
themselves in a self-produced extracellular matrix of
exopolysaccharide (EPS), proteins and some micro
molecules such as DNA. This matrix accounts for
about 90% biomass. [6]The extracellular matrix of
exopolysaccharide protects the bacteria from host
defenses and impedes delivery of antibiotics.[7]Infact
higher antimicrobial resistance is seen in biofilm
forming uropathogenas compared to free floating
bacteria. Bacterial biofilm is responsible for
persistence urinary tract infections and the multidrug
resistance so the present study was undertaken with
the aim
To know the prevalence of biofilm formation in
uropathogens
To know the antimicrobial resistant pattern of
biofilm producer and non- biofilm producing
uropathogens
MATERIAL AND METHODS
The Prospective study was carried out in the
department of Microbiology of a tertiary care rural
hospital from the period of July 2012 to December
2013. Urine specimen from patients suspected of
UTIs was collected. The sample was processed and
identification of uropathogen was done by standard
microbiological techniques. [8]A total of 146 Gram
negative bacilli and 62 S. aureus isolated from
patients suspected of UTI were randomly
selected.The isolates were tested for biofilm
formation by Tube method as described by
Christensen et al.[9]
1. The tube containing TSBglu (10mL) were
inoculated with culture of uropathogen and
incubated at 37 degree C for overnight.
2. The tubes were decanted and washed with PBS
(pH 7.3) and dried.
3. Dried tubes were than stained with 0.1% crystal
violet.
4. Excess stain was removed and tubes were washed
with deionized water.
5. Tubes were then placed in inverted position to dry
6. Tubes were finally observed for biofilm formation
Assays were performed in triplicate at three different
times.

The Isolates were tested for antimicrobial


susceptibility testing by Kirby-Bauer disc diffusion
method on Mueller Hinton agar as per CLSI
guidelines.[10] The following antimicrobial agents
were tested for Staphylococcus aureus: amikacin(Ak)
(30g), ampiclox(ACX) 20g, azithromycin(AZ)
15g, calithromycin (CLR)15 g, cefoperazone
(CFP)30g,cefotaxime(CF)30g,cefuroxime(CR)30
g,ciprofloxacin (CIP)5g, cotrimoxazole (Cot)5g,
gentamicin (30g), linezolid (30g), sparfloxacin
(SF)5g.
The antimicrobial agents tested for Pseudomonas
aeruginosaare: amikacin(Ak) 30g, cefepime(CPM)
30g, cefoperazone (CFP)75g ,ceftazidime(CAZ)
30g,
ciprofloxacin(CIP)
5g,
gentamicin
(GEN)10g,levofloxacin(Le) 5g, meropenem(MRP)
10g, netilin(NET) 30g, Piperacillin(Pi)100g,
ticarcillin(Ti)75g, tobramycin(TOB)10g
The antimicrobial agents tested for Gram negative
bacilli were amikacin (An) 30g, cefaclor (CFC)
30g, cefadroxil (CD) 30g, ceftriaxone (CTX) 30g,
ciprofloxacin (CIP)5g, gentamicin (G)10g, netilin
(NET) 30g, nitrofurantoin (NF) 300g, norfloxacin
(NR) 10g, ofloxacin (ox) 5g,
The Antimicrobial disc was obtained from Hi-media
Laboratories Pvt. Ltd, Mumbai, India.
RESULTS
Out of 208 isolates from urine, Strong Biofilm
formation was noted in 76(36.54%) and Weak
Biofilm formation in 46(22.12%) and no biofilm
formation in 86(41.35%). (Table No 1).Higher
Biofilm formation was seen in females 140(67.31%)
as compared to males 68(32.69%),
Table 1: Biofilm producers in uropathogens
Isolates

No of
Samples

E .coli

93

Staphylococcus
aureus
Pseudomonas
sps

62
21

Strong
Biofilm
formation

Weak
Biofilm
formation

Negative
Biofilm
formation

27(29.03)

16(17.20)

50(53.76)

32(51.61)

18(29.03)

12(19.35)

8(38.09)

6(28.57)

7(33.33)

Klebsiellasps

13

5(38.46)

3(23.07)

5(38.46)

Citrobactersps

13

4(30.77

3(23.07)

6(4615)

Proteus sps

Morganellamor
ganii
Serratiamarcesc
ens
Total

1
1
208

76(36.54%)

46(22.12%)

86(41.35%)

340
Charan et al.,

Int J Med Res Health Sci. 2015;4(2):339-344

Overall strong biofilm formation was 36.54%, weak


in 22.12% and 41.35%were Negative for Biofilm.
Strong biofilm formation and weak biofilm formation
was significantly less for E.coli. (Chi2test =5.99;
P0.05). As against that Strong biofilm formation
was significantly more in Staphylococcus aureus
(Chi2test =12.44; P0.05). Outcome of P. aeruginosa
was comparable to the overall outcome. The above
table depicts highest Biofilm producers were
Staphylococcus aureus 50/62 (80.65%) followed by
P. aeruginosa 14/21(66.67%)

antimicrobial agent tested and on Y axis is the


percentage of resistance shown by the isolates.
Biofilm formation and antimicrobial resistance
pattern of Gram negative bacilli

100
80

Biofilm formation (N=58)%


Non-Biofilm formation (N=67)%

60
40
20
0

Biofilm formation and antimicrobial resistance


pattern of Staphylococcus aureus

Sparfloxa

linezolid

Gentamy

Cotrimox

Ciproflox

Cefuroxi

Cefotaxi

Calithro

Cefopera

Ampiclox

Amikacin

120
100
80
60
40
20
0

Azithrom

Biofilm formation (No=50)%


Non-Biofilm formation(N=12) %

Fig 1: Biofilm formation and antimicrobial


resistance pattern of Staphylococcus aureus
The above chart depicts Biofilm formation and nonBiofilm producer showed mark difference in
antimicrobial resistance pattern to ciprofloxacin and
azithromycin. Isolated showed no resistance to
linezolid. On the X axis are the antimicrobial agent
tested and on Y axis is the percentage of resistance
shown by the isolate
Biofilm formation and antimicrobial resistance
pattern of Ps. aeruginosa

Tobram

Ticarcillin

Piperaci

Netilin

Merope

Levoflo

Gentam

Ciprofl

Ceftazi

Cefoper

Cefepime

Biofilm formation(N=14)%
Non-Biofilm formation (N=7) %

Amikacin

120
100
80
60
40
20
0

Fig 2: Biofilm formation and antimicrobial


resistance pattern of Ps. aeruginosa
In the above table it is observed Biofilm formation
and non-Biofilm producer Pseudomonas aeruginosa
showed significant difference in antimicrobial
resistance pattern to netilin. On the X axis are the

Fig 3: Biofilm formation and antimicrobial


resistance pattern of Gram negative bacilli
In the above table it is depicted that Gram negative
bacilli (Biofilm formation and non-Biofilm producer),
showed significant difference in antimicrobial
resistance pattern to gentamicin and norfloxacin. On
the X axis are the antimicrobial agent tested and on Y
axis is the percentage of resistance shown by the
isolates.
DISCUSSION
Biofilms are estimated to be responsible for over 65%
of nosocomial infections and 80% of all
microbial infections as stated by U. Rmling.[11] E
.coli, Staphylococcus aureus, Pseudomonas sps
Klebsiellasps,
Citrobactersps,
Proteus
sps,
Morganellamorganii, Serratiamarcescens are the
pathogen isolated from urine similar were the
findings of Sara M. Soto. [12]In our study E.coli was
the predominant organism agent from urinary tract
infections whereas in a study by Lucchetti et al P.
aeruginosa. According to epidemiologic data, 35.0%
to all acquired nosocomial infections are urinary and
80.0% are related to catheter use. [13]
In our study higher prevalence of UTI was seen in
females as compared to the males 68 (32.69%), thus
showing a female predominance. Our study is similar
to the findings of Syed M A,Devanand P et al. [14,15]
Kamat US et al in their study noted females are more
prone to develop UTIs, probably due to their
anatomical physiological changes like short urethra,
its proximity to the anus, dilatation of the urethra and
the stasis urine during pregnancy. [2]
341

Charan et al.,

Int J Med Res Health Sci. 2015;4(2):339-344

In our study we observed for Biofilm formation


among the uropathogen. We noted highest Biofilm
producers were Staphylococcus aureus 50/62
(80.65%) followed by P. aeruginosa 14/21(66.67%)
and E.coli 43/93(46.24%).
The bacteria from the bowelmove to the bladder and
adhere to the uroepithelium and form biofilm which
can invade the renal tissue causing pyelonephritis.
The clinical spectrum of complicated UTIs may range
from cystitis to urosepsis with septic shock and
relapse is due to the biofilm forming capacity of the
microorganism.[16, 17]
Alicia ValriaZaranzain their study showed biofilm
production by the Congo Red Agar method in 52.0%
& biofilm formation by 86% on polystyrene
microplates. Among them strong biofilm formation
was found in 22.1%, moderate in 47.7% and weak in
30.2%. Carlos J et al reported biofilm formation in P.
aeruginosa in 83% of clinical strains & that biofilm
formation was higher in MDR isolates. [18,19]
The components of the EPS involved in the formation
of P. aeruginosa biofilm are encoded mainly by
different genes located in three independent operons:
algU, psl, and pel andin S. aureus by gene
icaABDC.[20, 21]
The persistent cells shows reduced metabolism
leading to higher antimicrobial resistance. Biofilm are
difficult to eradicate so combined therapy is
recommended for the treatment of biofilm-associated
infections.
In our study, we noted Biofilm and non-Biofilm
forming Staphylococcus aureus isolates showed mark
difference in antimicrobial resistance pattern to
ciprofloxacin
(100%
versus
33.33%)and
azithromycin (96% versus 41.67%). Isolates showed
no resistance to linezolid. Pseudomonas aeruginosa
isolates showed significant difference to netilin
(100% versus 42.86%). In the Gram negative bacilli
(Biofilm formation and non-Biofilm producer),
significant difference in antimicrobial resistance
pattern was observed to gentamicin (87.93% versus
13.43%) and norfloxacin (84.48% versus 37.31%).
(Chart 1-3) Fatima Khan et al found ciprofloxacin
was effective against biofilm producers and Zheng Z
et al noted rifampicin has putative antibiofilm
properties, to penetrate StaphylococcalBiofilm. [22, 23]
Donlan R.M., et al in their study on Biofilms
Survival mechanisms of clinically relevant
microorganisms observed the age of the biofilm also

affects the susceptibility to antibiotics. In their study


they highlighted 10-day-old biofilms are more
resistant than 2-day-old biofilms. This emphasizes the
need for prompt diagnosis and treatment.[24]
Sara M. Soto in the review article analyzed some
workers observed Macrolides (erythromycin,
clarithromycin, and azithromycin) present high "in
vitro" and "in vivo" activity, against biofilm-forming
organism P.
aeruginosa,
other Gram-negative
bacteria, and Staphylococcus spp. Other workers
reported macrolides enhances biofilm formation in
Gram-positive bacteria with the explanation that there
is increase in the expression of biofilm-related genes
(icaAatlE fruA, pyrR, sarA, and sigB). [12]
In our study we found higher antimicrobial resistance
in biofilm producers as compared to thenegative
biofilm producers. Similar were the findings of other
workers Fatima Khan et al, BijayiniBehera et al[22,25]
Sara M. Soto in study, noted higher antimicrobial
resistance by biofilm may be due to the some
antimicrobial agents are not able to diffuse through
the matrix or sometimes the time taken to diffuse
through is longer than the duration of treatment or the
antibiotic lifetime. Or an antimicrobial agent that
diffuses can be inactivated by the pH inside
biofilm.[12]
CONCLUSION

Biofilm forming isolates showed higher antimicrobial


resistance as compared to non-Biofilm producer. This
is due to metabolically inactive persister cells.
Antimicrobial resistance is a global issue, so
uropathogen should be routinely screened for biofilm
formation and antimicrobial resistance before
initiating the treatment.
Conflict of Interest: Nil
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Elsevier; 2007:842-55
9. Gordon D. Christensen,W. Andrew Simpson,
Alan L. Bisno, And Edwin H.
Beachey.
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Performance standards for antimicrobial disc
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32(3):100-21.
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infections, their resilience to therapy and
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Internal Medicine. 2012; 272(6):54161.
12. Sara M. Soto. Importance of Biofilms in Urinary
Tract Infections: New Therapeutic Approaches.
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13. G. Lucchetti, A. J. Silva, S. M. Y. Ueda, M. C. D.
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DOI: 10.5958/2319-5886.2015.00064.8

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
th
Received: 8 Jan 2015
Revised: 10th Feb 2015
Research article

Copyright @2015
ISSN: 2319-5886
Accepted: 17th Feb 2015

HEPATITIS B VIRUS (HBV) AND SYPHILIS CO-INFECTIONS AMONG THE PEOPLE OF EKITI,
SOUTH-WEST, NIGERIA
*Akinbolaji Thompson J1, Odeyemi Festus A2, Adegeye Festus O3, Ojo Olalekan I4, Akinseye Funmilayo J5.
1

Haematology and Blood Transfusion Unit, Ekiti State University Hospital, Ado-Ekiti, Ekiti State, Nigeria
Kidney Clinics Nigeria, Kemta Housing Estate, Idi-Aba, Abeokuta, Ogun State, Nigeria
3
Clina-Lancet Laboratory 3, Jose Babatunde Ademola Adetokunbo Area, Victoria Island, Lagos
4
Primary Health Centre, Saki East Local Gvt, Oyo State
5
Medical Laboratory Services, State Specialist Hospital, Akure, Ondo State, Nigeria
2

*Corresponding author email: akinbolajithompson@gmail.com


ABSTRACT
This study was carried out to know the prevalence of hepatitis B, syphilis and co-infection of both among the
people of Ekiti, South-West, Nigeria. Individuals and patients who visited the Haematology and Blood
Transfusion Unit of Ekiti State University Teaching Hospital, Ado-Ekiti to screen themselves for HBV and
Syphilis infections between January to November, 2014 were recruited for this study having obtained their
consent. 4ml of blood sample was collected from each subject into a plain bottle and was allowed to stand for
1hour for clotting and clot retraction to take place. Sera were separated into khan tubes labeled appropriately and
were screened for the presence of antibodies to HVB and syphilis using One-Stage Rapid Test Kits (DiaSpot
Diagnostics) and were later confirmed using enzyme linked immune sorbent assay (ELISA) (Stat Fax Awareness,
England). One Thousand Six Hundred and Thirty-Nine subjects were recruited for this study, out of which Seven
Hundred and Seventy-Four were males while Eight Hundred and Sixty-Five were females. 101(6.16%) were
positive to HBV, 51(0.92%) positive to syphilis and 5(0.31%) were co-infected with both infections. The results
of this study showed higher prevalence of hepatitis B infection than syphilis infection with the highest prevalence
found within the age group 31-40 years and 21-30 years indicating that most of the infected people got the
infection through sexual intercourse.
Keywords: Prevalence, Hepatitis B, Syphilis, Co-infection, Ekiti people
INTRODUCTION
Syphilis is an infection caused by bacterium,
Treponema pallidum, and it remains a serious public
health problem in sub-Sahara Africa. It is spread
through sexual intercourse, transfusion of blood
and/or blood products, vertical transmission [1].
According to some researchers, prevalence of active
syphilis infection among African countries has been
reported to be 12.8% in Tanzania [2], and 3.8% in
Kenya [3]. In 1995, a study was conducted to know
the prevalence of HIV, syphilis and HBV infections

among blood donors in Ethopia and it was reported


that HIV has sero-prevalence of 16.7%, syphilis has
12.8% while HBV has 14.4% [4]. Infection with
syphilis can take up to 3 months for symptoms to
show and some people may never have noticeable
symptoms of this infection, people infected with the
infection can transmit it to other persons even if they
show no sign or symptoms of the infection [5].
The globally important health problems are viral
hepatitis infections [6, 7, 8]. Chronic hepatitis B has
345

Akinbolaji et al.,

Int J Med Res Health Sci. 2015;4(2):345-349

been reported to be the leading cause of chronic liver


disease and a leading cause of death worldwide [6].
Chronic hepatitis B, which can be referred to as
persistence of hepatitis B surface antigen (HBsAg)
for a period more than 6 months, has differing
epidemiology in regions of high versus low
endemicity. Usually people successfully manage to
get rid of the infection within a few months by
developing an immunity that lasts a lifetime.
Evidence of this immunity may be shown by blood
tests but there will be no signs of active infection,
while some dont get rid of the infection and such
people are considered carriers. Sero-prevalence of
HBV and syphilis infections are well recognized
worldwide but has been reported to be more common
in developing countries in Africa and Asia [9].
Aim: This study was embarked upon to actually
know how prevalent are hepatitis B virus (HBV),
syphilis and their co-infections in this part of the
country because there is no documented or published
report on such.
MATERIAL AND METHODS

Nine Patients and individuals (males and females)


who visited the Haematology and Blood Transfusion
Unit of Ekiti State University Teaching Hospital,
Ado-Ekiti, to screen themselves for HBV and
Syphilis infections were recruited into this study
having obtained the consent of those 18years and
above and those below 18years gotten from their
parents. The maximum age of the subjects was
70years. Ethical approval was obtained for this study
from ethical and research committee.
Methodology: 4ml of blood was aseptically collected
from each subject into plain bottles. Each blood
sample was allowed to stand for one hour at room
temperature (25) for clotting and clot retraction to
take place. It was spun and sera separated into plain
khan tubes labeled appropriately and the sera were
screened for the presence of antibody to HBV and
Syphilis using One-Stage Rapid Test kit (DiaSpot
Diagnostics, USA) which were later confirmed using
enzyme linked immuno sorbent assay (ELISA) (Stat
Fax Awareness, England). The manufacturers
instructions were strictly followed.
RESULTS

Type of study: This work is a case study research


Study Area: This study was conducted at the
Haematology and Blood Transfusion Unit of Ekiti
State University Teaching Hospital, Ado-Ekiti,
between January to November, 2014. Ekiti State
University Teaching Hospital is located in Ado-Ekiti
in Ado Local Government Area of Ekiti State and
Ado-Ekiti is the capital city of Ekiti State, situated in
the tropical rain forest belt of Southwest of Nigeria. It
is about 450km from Abuja (the capital city of
Nigeria). People from different parts of the state visit
the Teaching Hospital for Healthcare Services.
Subjects: One Thousand Six Hundred and Thirty-

Out of the One Thousand Six Hundred and ThirtyNine subjects screened for the presence of antibodies
to HBV and T. pallidum (syphilis), One Hundred and
One were positive to HBV giving rise to 6.16%,
Fifteen positive to syphilis infection amounting to
0.92% while only Five of the subjects were coinfected with both HBV and syphilis infections which
is 0.31%. the highest prevalence to HBV, syphilis and
co-infections were found in the age group 31-40 years
followed by 21-30 years as shown in the (table 1)
below

Table 1: Sero-prevalence of HBV and syphilis co-infection in different age groups among Ekiti people
HBV
Syphilis
Co-infection(HBV/syph)
Age-Groups
(years)
No. Exam.
No. Pos. %Pos.
No. Pos. %Pos.
No. Pos.
% Pos
10
53
11-20
154
06
3.90
01
0.65
21-30
709
44
6.21
05
0.71
02
0.28
31-40
410
40
9.75
08
1.95
03
0.73
41-50
178
09
5.06
01
0.56
51
135
02
1.48
Total
1639
101
6.16
15
0.92
05
0.31
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Akinbolaji et al.,

Int J Med Res Health Sci. 2015;4(2):345-349

Key; No. Exam.-------------Number Examined,No.


49(6.33%), 09(1.16%) and 02(0.26%) out of the 774
Pos.----------------Number Positive, % Pos.------------males were positive to HBV, syphilis and
-----Percentage Positive.
coinfections
respectively
while
52(6.01%),
In the table 2 below, One Thousand Six Hundred and
06(0.69%) and 03(0.35%) out of the 865 females
Thirty-Nine subjects were recruited, out of which
were positive to HBV, syphilis and co-infection
Seven Hundred and Seventy-Four were males while
respectively
Eight Hundred and Sixty-Five were females.
Table 2: Sero-prevalence of HBV and syphilis co-infection among males and females in Ekiti
HBV
Syphilis
Co-infection(HBV/syph)
Gender No. Exam. No. Pos. %Pos.
No. Pos. %Pos.
No. Pos.
%Pos.
Male
Female
Total

774
865
1639

49
52
101

6.33
6.01
6.16

DISCUSSION
Hepatitis B virus (HBV) is important and has several
implications among the blood-borne viruses
transmissible through the parenteral route, by blood
transfusion, as well as by sexual intercourse. It does
not only establish asymptomatic persistent infection
but also cause significant morbidity and mortality
when transmitted through transfusion of blood and
blood products [10]. Prevalence of HBV has been
reported to vary between 2% in developed countries
where the prevalence is low to about 8% in
developing countries where infection is endemic with
sex, age and socioeconomic status as important risk
factors for infection [11, 12, 13]. In 2006, Centers for
Disease Control and Prevention (CDC) reported more
than 36,000 cases of syphilis in the United States, and
the rate of syphilis among homosexual men has been
rising consistently since 2000 [14].
The results of this study showed a higher prevalence
of hepatitis B infection (6.16%) than that of syphilis
infection (0.92%). The higher prevalence of hepatitis
B infection than syphilis infection in this study
correlates with reports of [15, 16, 17, 18] who all reported
the prevalence of hepatitis B infection to be higher
than that of syphilis infection in their various
researches, but it is against the reports of [19] who
reported higher prevalence for syphilis than hepatitis
B infection.
The prevalence of hepatitis B infection (6.16%) in
this study is a little higher than the reports of [18, 20, 21,
22]
who reported prevalence of hepatitis B infection to
be 4.7%, 5.9%, 5.3% and 4.9% respectively, and
much higher than the reports of [19, 23] who reported

09
06
15

1.16
0.69
0.92

02
03
05

0.26
0.35
0.31

2.9% and 3.0% respectively, but it is lesser than the


prevalence reported by [24, 25].
The prevalence of syphilis infection (0.92%)
according to this study is considerably low among the
people of Ekiti when compared to the prevalence
reported by [15, 18, 19, 21] but is also higher than the
reports of [16, 17, 26]. The prevalence of people coinfected with both hepatitis B and syphilis infections
was 0.31% which is against the reports of [16, 18] who
both reported no co-infection between hepatitis B and
syphilis infections. And this study also showed that
both hepatitis B and syphilis infections are more
common in males than females which correlates with
the reports of [25], and the highest prevalence is found
within the age group 31-40 years followed by 21-30
years which is line with the reports of [27, 28].
CONCLUSION
Based on the results of this study, the prevalence of
hepatitis B infection is higher than that of syphilis
and it can be said that hepatitis B infection is
considerably high among the people of Ekiti with the
highest prevalence found within the age groups 31-40
years and 21-30 years which indicates that most of
the infected people would have got infected through
sexual intercourse because the age groups within
which the infections are mostly found is referred to as
the sexually active age group.
ACKNOWLEDGEMENT
We want to appreciate the most-high God who made
this study a reality and we also extend our profound
gratitude to all individuals who contributed their
347

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Int J Med Res Health Sci. 2015;4(2):345-349

quota towards the success of this study. We thank you


all.
10.
Conflict of Interest: Nil
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S, Savasi V, Semenenko I, Stelmah A, Tibaldi
C,Thorne C. Hepatitis B or hepatitis C
coinfection in HIV-infected pregnant women in
Europe. HIV Med. 2008; 9(7):526-34.
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Wahab AA, Akinyosoye LS, Adelowo TO.
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Int J Med Res Health Sci. 2015;4(2):345-349

DOI: 10.5958/2319-5886.2015.00065.X

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 9 Jan 2015
Research article

Coden: IJMRHS
Revised: 6th Feb 2015

Copyright @2015
ISSN: 2319-5886
Accepted: 12th Feb 2015

CLINICO PATHOLOGICAL CORRELATION OF LEPROSY: A 4 YEARS RETROSPECTIVE STUDY


FROM A TERTIARY REFERRAL CENTRE IN NORTH INDIA
*Shirazi Nadia1, Jindal Rashmi2, Ahmad Sohaib3, Rawat SDS2, Selvi Thamarai N1, Harsh Meena1
1

Department of Pathology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India
Dermatology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India
3
Internal Medicine, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India
2

*Corresponding author email: shirazinadia@gmail.com


ABSTRACT
Introduction: Leprosy is a chronic infectious disease caused by Mycobacterium leprae that primarily affects the
skin and nerves. The histopathological findings in leprosy are related to the immunological status of the patient.
Aim: To tabulate the incidence of different clinical and pathological patterns of leprosy and establish their
correlation. Materials and Methods: A total of 118 consecutive skin biopsies of leprosy patients were studied in
the Department of Pathology over 4 year duration (2010 2014). A Ridley-Jopling criterion was used for the
diagnosis and classification of the disease. All biopsies were stained with H&E and Fite Faraco. Clinicohistopathological correlation was calculated using percentage values. Results: A total of 118 cases of leprosy
were studied out of which 76 were males. The age of the patients ranged from 8 years to 76 years. Majority were
in the 31-40 year age group ( n= 52.44%). Both clinically (n=55, 46.6%) and histologically (n=41, 34.7%), the
maximum patients were in the BT category. Histopathologically LL (21.2%) and BB (16.1%) were the other
common groups. The overall concordance between clinical and histopathological classification was 61.8%.
Maximum concordance was seen in LL (79.2%) & TT (72.7%). The concordance was lower in borderline groups
and least in BL (18.7%). Fite Faraco stain demonstrated acid fast bacilli in 28 cases (23.7%). Conclusion: The
clinicohistopathological correlation is best at the polar ends of spectrum as compared to borderline cases.
Histopathology remains the most powerful indicator of shift in patients immune status.
Keywords: Leprosy, Clinico histopathological correlation
INTRODUCTION
Leprosy is an infectious disease which was
considered a curse to mankind since times
immemorial. The earliest possible account for leprosy
has been found in ancient Egyptian Papyrus
documents as early as 600 B.C. It was Hansens
discovery of causative organism: Mycobacterium
leprae in1873 which proved that leprosy was a
bacterial disease and not a curse or sin. It occurs more
commonly among those living in poverty or
overcrowded areas and is transmitted by respiratory

Nadia et al.,

droplets. Entry into susceptible host is by respiratory


route or broken skin. The disease has a slow
incubation period ranging from few weeks to as long
as 30 years (average being 3-5 years). India alone
reports over 50% of worlds leprosy cases.[1]
Skin lesions (macules, papules, nodules), sensory loss
and thickened nerves are the reliable signs of leprosy.
Positive skin smear for Acid Fast lepra bacilli are
considered
diagnostic.
The
WHO
system
subclassifies leprosy as paucibacillary or
350
Int J Med Res Health Sci. 2015;4(2):350-354

multibacillary based on the number of bacteria


present. These two types are clinically distinguished
by the number of hypopigmented, numb skin patches
with paucibacillary having five or less such lesions
while multibacillary having more than five.[ 2]. The
ICD-10 however uses Ridley-Jopling classification
and also adds an indeterminate or I category .
Access to information, diagnosis and treatment with
Multidrug therapy (MDT) remain the cardinal points
in eliminating the disease.
Since 1995 WHO provides free (MDT) to all
patients.[3]. Prior to starting MDT for particular type
of leprosy, the clinical findings should be correlated
and confirmed with histopathological examination
and bacteriological index of skin biopsy
Aims: To tabulate the incidence of different clinical
and histopathological forms of leprosy and to
establish their correlation.
MATERIALS AND METHODS
Type of study: Retrospective study
Study place & Duration: Carried out in the
Department of Pathology during a 4 year period
(2010-2014).
Inclusion Criteria: Cases where histopathological
diagnosis of leprosy was made or considered in the
differential diagnosis irrespective of age and sex of
the patient or nature of the lesion were selected for
the study.
Exclusion criteria: Those cases where leprosy was
suspected clinically but not confirmed on biopsy were
not included. Lepra reactions were excluded.
Ethical Clearance: The present study was approved
by the Institutional Ethics Committee.
Methodology: The requisition form accompanying
the biopsy specimen as well as the copy of issued
histopathology report that were preserved in the
Department of Pathology were routinely used to
obtain data pertaining to age, sex, clinical information
and histopathology findings. The Ridley Jopling
criteria was used to diagnose and classify leprosy
clinically and histopathologically into the following
subgroups: [4]
Tuberculoid (TT): shows epithelioid granulomas
with Langhans giant cells surrounded by dense
lymphocytic infiltrate. Nerve infiltration is usually
seen. AFB is negative.

Nadia et al.,

Borderline
Tuberculoid
(BT):
Epithelioid
granulomas with peripheral lymphocytes and
Langhans giant cells. Clear subepidermal zone, nerve
infiltration present. AFB may or may not be seen.
Borderline(BB): Epithelioid granulomas with
diffusely spread lymphocytes, presence of
subepidermal clear zone. AFB usually seen.
Borderline Leprosy (BL): Loose granulomas
composed of histiocytic cells with dense lymphocytic
infiltrate. AFB usually seen but large globi are not
present.
Lepromatous Leprosy (LL): Histiocytes and foam
cells are abundant. Lymphocytes are scanty, if
present they are diffusely spread. Nerves are without
cellular infiltrate or cuffing. Grenz zone is present.
AFB are numerous.
Indeterminate (I): Lymphocytes and histiocytes are
localized around skin structures. AFB are very
scanty.
Histoid Leprosy (HLL): Nodular form of leprosy.
Microscopy shows circumscribed histoid lepromas
characterized by predominance of histiocytes. AFB is
numerous.
All the biopsies were fixed in 10% formalin. Serial
sections of 5 thickness were cut and stained with
Haematoxylin and Eosin (H&E) along with Fite
Faraco to demonstrate Acid Fast Bacilli.
Histopathology findings described in detail epidermal
atrophy, subepidermal clear zone, distribution and
nature of epithelioid granulomas, density of
lymphocytes and nerve involvement along with
presence of acid fast bacilli.
RESULTS
A total of 118 cases of leprosy were studied over a
duration of 4 years (July 2010- July2014). There were
76 males and 42 females. The age of the patients
ranged from 8 years to 72 years. Majority of cases
(n=52, 44%) were in the 31-40 year age group
followed by 23.7 % in the 21-30 year age bracket.
The most common presenting complain was hypopigmented patch with loss of sensations (n=67,
56.7%) followed by erythematous macules
(n=27,22.8%), nodules (n=14,11.8%) and thickened
nerves (n=11,9.3%). (Figures 1,2). All the skin
biopsies were taken from the edge of the lesion.
Nerve biopsy was not performed in any case.

351
Int J Med Res Health Sci. 2015;4(2):350-354

Fig.1 : Lepromatous leprosy

Concordance was 80% for histoid leprosy. (Table 2)


(Fig 5). Epidermal changes varied from atrophic
(64.8%) to unremarkable to acanthotic. Lymphocytes
were most numerous in BB and most scanty in LL.
Fite Faraco stain demonstrated Acid Fast Bacilli
(AFB) in 28 cases (23.7%). The AFB were mostly
seen in LL and HLL forms and only 2 cases in BT
type while none in TT type showed AFB positivity.
(Fig 6).
Table
2:
Correlation
of
clinical
and
histopathological diagnosis in leprosy cases
(n=118)
Clinical Clinically TT
Type diagnosed

TT
BT
BB
BL
LL
IL
Histoid

Fig 2: Histoid leprosy


Both clinically (n=55, 46.6%) and histologically
(n=41,34.7%), the maximum patients were in the BT
category. Histopathologically LL (21.2%) and BB
(16.1%) were the other common groups. (Table 1)
(Fig 3,4).
Table 1: Clinical and histopathological spectrum
of leprosy using Ridley-Jopling classification
(n=118)
Clinical No.
%
HPE
No.
%
Type
type
TT
11
9.3
TT
17
14.4
BT
55
46.6 BT
41
34.7
BB
06
5.1
BB
19
16.1
BL
16
13.5 BL
07
5.9
LL
24
20.3 LL
25
21.2
IL
01
0.8
IL
05
4.2
Histoid 05
4.2
Histoid 04
3.4
Total
118
100 Total
118
100
The overall concordance between clinical and
histopathological
classification
was
61.8%.
Maximum concordance was seen in LL (79.2%) &
TT (72.7%). The concordance was lower in
borderline groups and least in BL (18.7%).

Nadia et al.,

11
55
06
16
24
01
05

8
3
6
-

BT BB BL

2
36
2
1
-

9
3
3
3
1
-

2
1
3
1
-

LL

1
4
19
01

IL Histoid Concord
ance
(%)

1
4
-

72.7
65.4
50.0
18.7
79.2
0
80.0

Fig 3: Numerous epithelioid granulomas in BT


Hansens (10x10X:H&E:)

Fig 4: Foamy macrophages in LL Hansens(20x10X


H&E)
352
Int J Med Res Health Sci. 2015;4(2):350-354

is supposed to be better at stable poles LL and TT


probably because of clinical and histological stability
of the disease. Maximum discordance was seen in
midborderline cases as was also noted by Singhi et al,
Sharma et al, Manandhar et al, Mitra et al, Moorthy et
al [11,12,13,14,15] (Table 3).
Table 3: Comparative study of Clinicopathological correlation of Hansens disease by
different authors
Study

Fig 5: Histoid Hansens disease(20x10X H&E)

Fig 6: Fite Faraco: Acid Fast Bacilli seen in LL


Hansens(100x10X)
DISCUSSION
Leprosy is a chronic infectious disease caused by
Mycobacterium leprae and is present in a wide
variety of clinical and histopathological forms
depending on the immune status of the host. The
clinicopathologic correlation studies have provided
further insights into the disease, its manifestations
and complications[5]. Ridley-Jopling classification is
based upon clinical, histopathological and
immunological features and is widely accepted by
pathologists and dermatologists. The clinicopathological discordance is noted because clinical
diagnosis is based on Ridley-Jopling classification
even when biopsy has not been done[5]. Since biopsy
findings may be influenced by biopsy site, age of the
lesion, morphology of the lesion, immunological and
treatment status of the patient; these may also
contribute to discordance between clinical and
pathological findings. The best correlation in our
study was found with histoid (80%), LL (79.2%) and
TT (72.7%). This is similar to study by Bhatia et al,
Kalla et al, Kar et al, Jerath et al [6,7,8,9]. Nandkarni et
al found 98% correlation in LL form[10]. Correlation
Nadia et al.,

No. of cases
studied

%
correlation

Present study (2014)


118
61.8
ManandharU et al (2013)[13]
75
45.33
Vargas- Ocampo et al 6000
42.9
(2004)[16]
Mitra K et al(2001)[14]
92
57.16
Moorthy BN et al(2001) [15]
372
62.6
[7]
Kalla G et al (2000)
736
64.7
[10]
Nandkarni NSet al(1999)
2640
81.8
Kar PK et al (1994)[8]
120
70
[6]
Bhatia AS et al (1993)
1272
69
Jerath VP et al (1982)[9]
130
68.5
[18]
Sehgal VN et al (1977)
95
33
In the present study 5 cases (4.2 %) were diagnosed
as Indeterminate leprosy as compared to only 1 case
clinically. Indeterminate lesions cannot be classified
within Ridley-Jopling spectrum due to lack of
distinguishing features like not finding granulomas
and this happens more often histologically. All 5
cases in our study diagnosed as IL were clinically TT
or BT types. A large study of 6000 cases in Mexico
by Vargas-Ocampo encountered LL as the most
common form of leprosy[16]. They also found cases of
diffuse lepromatosis (Lucio phenomenon) which was
not seen in any study done in India. The
predominance of LL cases as well as diffuse
lepromatosis indicate that a high percentage of
population in Mexico has a very low degree of
resistance to lepra bacilli as compared to those in
Indian subcontinent. In a study by Bal et al , out of
303 leprosy cases , 206 were BT and only 27 were
TT. Out of 206 BT cases only 6 were positive for
lepra bacilli while none of TT were positive[17]. This
was similar to our study where none of TT cases
showed AFB positivity. Most previous authors have
recorded a higher frequency rate in children (<14
years) and that LL is infrequently seen in this age
group[18,19].In our study only 4.2% cases were seen in
children and all the cases were of TT+BT subtype.

353
Int J Med Res Health Sci. 2015;4(2):350-354

Though definite diagnosis can be made on


histopathological examination, size of specimen, site
of biopsy, nature and depth of biopsy, quality of
sections, immune status, treatment history and interobserver variation (both clinically and histologically)
should be kept in mind which may lead to
clinicopathological discordance[20]
CONCLUSION
Histopathology is the confirmatory test for early
diagnosis and proper labelling of all cases of leprosy.
It also gives indication of progression or regression of
disease
under
treatment.
Clinicopathological
correlation of the disease is maximum in polar groups
because they are stable and showed a uniform
pathology. Maximum disparity is seen in borderline
cases because they may have different histopathology
in different sites and in different lesions.
Conflict of interest: Nil
REFERENCES
1. World Health Organization. Epidemiology of
leprosy in relation to control. Report of a WHO
study group. World Health Organ Tech Rep Ser
(Geneva: World Health Organization). 1985; 716:160. ISBN 92-7-120716-7.OCLC 12095109
2. Suzuki K, Akama T, KawashimaA, Yoshihara A,
Yotsu RR, Ishii n. Current status of leprosy:
epidemiology, basic science and clinical
perspectives. The Journal of Dermatology.
2012;39(2): 121-9.
3. WHO Action Programme for the elimination of
Leprosy. A guide to eliminating leprosy as a public
health
problem.
Geneva,
World
Health
Organization, 1995 (Unpublished document
WHO/LEP/95.1; available on request from Action
Programme for the Elimination of Leprosy, World
Health Organization,1211 Geneva 27, Switzerland)
4. What is leprosy? The Medical News and Research
from Around the World. http://www.newsmedical.net/health/what-is-leprosy
5. Ridley DS, Jopling WH. Classification of leprosy
according to immunity. A five group system. Int J
Lepr Other Mycobact Dis 1966; 34: 255-73
6. Bhatia AS, Katoch K, Narayanan RB. Clinical and
histopathological correlation in the classification of
leprosy. Int J Lepr 1993;61: 433-38

Nadia et al.,

7. Kalla G, Salodkar A, Kachhawa D. Clinical and


histopathological correlation in leprosy. Int J Lepr
2000; 68: 184-85
8. Kar PK, Arora PN. Clinicopathological study of
macular lesions in leprosy. Indian J Lepr 1994; 66:
435-41
9. Jerath VP, Desai SR. Diversities in clinical and
histopathological classification of leprosy. Lepr
India 1982; 54: 130-34
10. Nandkarni NS, Rege VL. Significance of
histopathological classification in leprosy. Ind J
Lepr 1999; 71(3): 325-32
11. Singhi MK, Kachhawa D, Ghiya BC. A
retrospective study of clinic-histological correlation
in leprosy. Ind J Pathol Microbiol 2003; 46: 47-8
12. Sharma A, Sharma RK, Goswami KC, Bardwaj S.
Clinico-histopathological correlation in leprosy. JK
Science 2008; 10(3): 120-23
13. Manandhar U, Adhikari RC, Sayami G.
Clinicohistopathological correlation of skin biopsies
in leprosy. Journal of Pathology of Nepal 2013; 3:
452-58
14. Mitra K, Biswas S, Saha B, Dasgupta A.
Correlation between clinical and Histopathological
criteria for the classification of Leprosy. Ind J
Dermatol 46(3): 135-7
15. Moorthy B, Kumar P, Chatura KR, Chandrashekhar
HR, Basavaraja PK. Histopathological correlation
of skin biopsies in leprosy. Ind J Dermatol Venereol
Leprol 2001; 67 (6): 299-31
16. Vargas-Ocampo. Analysis of 6000 skin biopsies of
the National Leprosy Control Programme In
Mexico. Int J Lepr. Other Mycobact Dis 1966; (34):
255-73
17. Bal A, Mohan H, Dhani GP. Infectious
granulomatous dermatitis: A clinico-pathological
study. Ind J Dermatol 2006; 51: 217-20
18. Sehgal VN, Srivastava G. Leprosy in children. Int J
Dermatol 1987; (26): 557-66
19. Kumar B, Kaur I. Childhood leprosy in Chandigarh:
Clinico-histopathological correlation. Int J Lepr.
Other Mycobact Dis 2000; (68): 330-31
20. Chacko CJG. Role of histopathology in the early
diagnosis of leprosy. Ind J Lepr 1993; 65: 23-27

354
Int J Med Res Health Sci. 2015;4(2):350-354

DOI: 10.5958/2319-5886.2015.00066.1

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 10 Jan 2014
Research article

Coden: IJMRHS
Revised: 5thFeb 2015

Copyright @2015
ISSN: 2319-5886
Accepted: 12th Feb 2015

ASSOCIATION BETWEEN REFRACTIVE ERRORS AND SENILE CATARACT IN RURAL AREA OF


WESTERN MAHARASHTRA
*Chaudhari SagarV1, Shelke SanjayT2, BangalSurekha V3, Bhandari Akshay J4, Kulkarni AmeyaA1
1

Post graduate student, 2Associate Professor, 3Professor, 4Assistant Professor, Department of Ophthalmology,
Rural Medical College, Loni, Ahmednagar, Maharashtra, India
*Corresponding author email:sagar2986@rediffmail.com
ABSTRACT
Purpose: To study the association between refractive errors and senile cataract in rural area of western
MaharashtraMaterials & Methods: It is a prospective cross sectional study carried out on 420 eyes of 210
patients with senile cataract was included in the study. The age and sex of the patient, grade and the refractive
status of the cataract of the eyes were recorded. The grade of the cataract was recorded by the LOCS III (Lens
Opacities Classification System, version III). Refractive status was measured subjectively using retinoscope and
refractive error for each eye was converted into spherical equivalent units. Results: The age variation in the study
was between 60-85 years.The maximum number of patients was in the age group of 60-65 years.The spherical
equivalent ranged between -3.0 D to +4.25D.45.95% of the study population had a spherical equivalent between 2 to -1.73.81 % of the study population had a myopic refraction.20% had a hypermetropic refraction. Percentage
of patients with a score of nuclear opalescence and colour between 1.0-2.0 was 41.90%, between 2.1-3.0 was
26.67% and above 3.0 was 31.43%.Percentage of patients with a score of cortical cataract between 0.1-1.0 was
69.76% and with a grade between 2.1-3.0 was 26.91 %. Percentage of patients with a score of posterior
subcapsular cataract between 0.1-1.0 was 53.57% and with a grade between 2.1-3.0 was 39.05%. Conclusion:
The myopic refraction was associated with nuclear, cortical and posterior subcapsular cataract and this refractive
error was stastically significant with nuclear, cortical and posterior subcapsular cataract.
Keywords: Cataract, Refraction.
INTRODUCTION
Cataract is defined as opacity within the clear lens
inside the eye that reduces the amount of incoming
light and results in deterioration of vision. Natural
lens is a crystalline substance and a precise structure
of water and protein to create a clear passage for
light.
Cataract is one amongst the major cause blindness in
India accounting for nearly 50-80% of blindness in
both eyes in the country[1]. There are several known
risk factors for cataract formation. These include
individual factors like age, smoking, systemic factors
like diabetes mellitus, environmental factors like
Chaudhari et al.,

ultraviolet light exposure, trauma, dehydration and


drugs like steroids[2]. An additional hurdle arises from
the fact that different types of cataracts may have
different etiologies and risk factors which are difficult
to measure.Cataract is often described as being
similar to looking through a waterfall or waxed
paper.[3].
Refractive errors are frequently associated with age
related cataract. Myopia has been associated with
cataract[4]. It is a well known fact that nuclear cataract
can cause myopic shift in some cases which accounts
for the second sight in the elderly that provides
355
Int J Med Res Health Sci. 2015;4(2):355-359

normal reading ability without glasses but distant


vision worsens. The effect of posterior subcapsular
cataract and cortical cataract on refractive error is less
clear.
The present study evaluates the association between
refractive status and senile cataract.
MATERIAL AND METHODS
Study was conducted at Department of
Ophthalmology, in a tertiary care teaching hospital
located in rural area of western Maharashtra. The
study was carried out over a period of two years,
from September 2012 to August 2014. Total 210
patients with 420 eyes fulfilling the inclusion and
exclusion criteria were enrolled in the study.

Fig 1: LOCS III Classification

Inclusion criteria: Patients above the age of 60 years


with diminished vision. Patients of either sex.
Patients ready to give informed consent.
Exclusion criteria:History of intraocular surgery,
ocular trauma, Corneal scar or opacity, Known case
of dry eye syndrome, Lens induced glaucoma.Patients
with the following risk factors for cataract: uveitis,
glaucoma and steroid medications. Patients with the
following conditions which are likely to affect the
refractive status of the eye: keratoconus, trauma,
orbital mass, pterygium and eyelid mass such as
chalazion. Cases where refraction cannot be carried
out due to extreme media opacity will also be
excluded. Patients with the chronic systemic illness.

Fig 2: Nuclear Cataract

Each patient documenting as per proforma:


1. Sociodemographic information.
2. Clinical findings like Vision, anterior segment
examination, fundus examination.
Age, sex, grade of the cataract, the refractive status of
the eye was recorded. The grade of the cataract was
then be recorded by the LOCS III (Lens Opacities
Classification System, version III)[5] (Fig-1)and
categorized as nuclear(Fig-2) and cortical(Fig-3) and
posterior subcapsular type(fig-4).
After recording visual acuity, pupil will be dilated
and funduscopy done by direct ophthalmoscope or
78D or 90D. The refractive status of the patient was
evaluated by performing retinoscopy on dilated
pupils. Pupillary dilatation was achieved by putting
Phenylephrine or Tropicamide eye drops. Refractive
status was measured objectively by trial and error
method[6].

Fig3: Cortical Cataract

Fig4: Posterior subcapsular Cataract


356
Chaudhari et al.,

Int J Med Res Health Sci. 2015;4(2):355-359

RESULTS
Table 1: Age and sex wise distribution of cases
studied

Out of the 420 eyes of 210 patients studied 225


patients (53.57%) had Posterior subcapsular cataract
between 0.1-1.0, 31 patients (7.38%)between 1.1-2.0
and 164 patients (39.05%) had PSC above 2.1.(Fig
no-5)

Males

Females

Total

60-65

No. (%)
59(63.44%)

No. (%)
83(70.94%)

No. (%)
142(67.62%)

66-70

19(20.43%)

26(22.22%)

45(21.43%)

250

71-75

13(13.98%)

2(1.71%)

15(7.14%)

200

76-80

6(5.13%)

6(2.86%)

81-85

2(2.15%)

2(0.95%)

Total

93(44.29%)

117(55.71%)

210(100%)

In the present study the age variation was from 60 to


85 years. Highest number of 142 patients were found
in the age group of 60-65 years. (Table no.1)
There were 93 male and 117 female patients in the
study group comprising of 44.29% and 55.71 % of
the study population respectively.
Table 2: Nuclear Colour & Opalescence of cases
studied
Nuclear Colour

Total no eyes

Percentage

&Opalescence

No.

(%)

12

176

41.90%

2.13.0

112

26.67%

> 3.0

132

31.43%

Total

420

100%

Mean SD

1.74 0.47

Out of the 420 eyes of 210 patients studied 176


patients (41.90%) had nuclear colour (NC)&
(NO)between 1.0-2.0, 112 patients (26.67%) had
NC& (NO) between 2.1-3.0 and 132 patients
(31.43%) had (NC) & (NO) above 3.0. (Table -2)
Out of the 420 eyes of 210 patients studied 293
patients (69.76%) had cortical cataract between 0.11.0, 14 patients (3.33%) had cataract between 1.1-2.0
and 113 patients (29.91%) had cortical cataract above
2.1. (Table 3)
Table 3: Cortical Cataract of cases studied

225
164

150

No of eyes

Age in
years

100

31

50
0

0.1-1.0
1.1-2.0
2.1-3.0
Posterior subcapsular cataract

Fig 5: Posterior subcapsular cataract of cases


studied
The pre-op refraction was expressed in terms of
spherical equivalent. Spherical equivalent was
calculated using the formula sphere (D) + cylinder
(D). The spherical equivalent ranged between 3.0 to
+ 4.25 D. About 45.95 % of the study population had
a spherical equivalent of -2 to -1 followed by 21.90%
with a spherical equivalent of -1 to -0.5D.(Table 4)
Table 4: Spherical equivalent of cases studied
Total eyes Percentage
Spherical equivalent
No.
(%)
-3 to -2
25
5.95%
-2 to -1
193
45.95%
-1 to -0.5
92
21.90%
-0.5 to 0.5
26
6.20%
0.5 to 1
48
11.43%
1 to 2
19
4.52%
2 to 3
9
2.15%
3 to 4
4
0.95%
>4
4
0.95%
Total
420
100%
Mean SD
-1.040.027
Definition:

Total eyes

Percentage

No.

(%)

Emmetropia: -0.5 TO +0.5 D

0.1-1.0

293

69.76%

Myopia : LESS THAN -0.5D

1.1-2.0

14

3.33%

Hypermetropia: MORE THAN +0.5D

2.1-3.0

113

26.91%

Total

420

100

Mean SD

0.940.03

Cortical cataract

73.81 % of the study population had a myopic


refraction while only 20% had a hypermetropic
refraction
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Int J Med Res Health Sci. 2015;4(2):355-359

26

84

Less than -0.5

310

-0.5 to 0.5

More than 0.5

Fig 6:Spherical equivalent as per definition of


cases studied
Association of Grading LOCS and Spherical
Equivalence of patients studied
Statistically significant association was found for
nuclear, cortical and posterior subcapsular cataract.
Table 5:Association of Grading LOCS and
Spherical Equivalence of patients studied
LOCS

No. of
patients

Nuclear opalescence
1.0 2.0
176
2.1 3.0
112
> 3.0
132
Nuclear colour
1.0 2.0

176

2.1 3.0
112
> 3.0
132
Cortical cataract
0.1 1.0
293
1.1 2.0
2.1 - 3.0

14
113

Mean SD,
Spherical
equivalence

P value

-1.230.05
-1.030.08
-1.420.09

= 16.13,
p<0.05

-1.230.05
-1.030.08
-1.420.09

= 16.13,
p<0.05

-1.340.06
-1.560.09
-1.070.07

Posterior subcapsular cataract


0.1 1.0
225
-1.260.01
1.1 2.0
31
-1.310.05
2.1 - 3.0
164
-1.560.07

= 24.128,
p<0.05

= 26.415,
p<0.05

DISCUSSION
ASSOCIATION BETWEEN CATARACT AND
SPHERICAL EQUIVALENT:
For nuclear cataract:In my study, 193 eyes had
spherical equivalent between -2 to -1 and 92 eyes had
spherical equivalent of -1 to -0.5. The mean spherical
equivalent of -1.230.05D was found in the group
with a score between 1.0-2.0 while the group with a
score of more than 3.0 had-1.420.09D and mean
spherical equivalent of -1.030.08was found in the
group between 2.1 to 3. Myopic refraction being

associated with nuclear cataract. This correlation was


statistically significant.
In the study by Kubo et al[7] mean spherical
equivalent of 0.33 4.06 D was found in the group
with a score between 1.0-2.0 while the group with a
score 4.0-5.0 had a spherical equivalent of 3.96
5.8D.In the Tanjong Pagar survey[8] nuclear cataract
was associated with a myopic refraction. Nuclear
cataract was associated with myopia (-1.25 D vs -0.11
D, p<0.001)
In the Beaver Dam Eye study[9], myopia was related
to prevalent nuclear but not cortical and posterior
subcapsular cataracts.In Singapore Malay study[10],
myopia (spherical equivalent less than 0.5D) was
associated with increased prevalence of nuclear
cataract. In blue mountain eye study [11], myopia
subject who had worn distance glasses were more
likely to have nuclear cataract. High myopia was
associated with late nuclear cataract.In Tehran eye
study[12], myopia was significantly higher with
nuclear cataract. High myopia seen in higher grade of
nuclear cataract. For cortical cataract: In my

study, 193 eyes had spherical equivalent -2 to -1


and 92eyes had spherical equivalent -1 to -0.5.
The mean spherical equivalent of -1.070.07D
was found in the group with a score 2.1-3.0 and
the group with a score of 1.1-2.0 has a spherical
equivalent of-1.560.09D and mean spherical
equivalent of -1.340.06 was found in the group
with score 0.1 to 1.0. Myopic association was
found in cortical cataract and this correlation was
statistically significant.
In the study by Kubo et al[7], spherical equivalent of
1.96 5.07 D was found in the group with a score
of 1.0-2.0. The group with score 3.0-5.0 had a
spherical equivalent of 0.97 4.44 D. Thus myopic
refraction was associated with cortical cataract in this
study. In the Tanjong Pagarsurvey[8] no refractive
association was seen in cortical cataract. In the
Beaver Dam Eye study9, cortical cataracts were
possibly related to hyperopia.In blue mountain eye
study[11], high myopia was associated with cortical
cataract.In Singapore Malay study[10],myopia
(spherical equivalent less than 0.5D) was not
associated with cortical cataract.In Tehran eye
study[12], high percentage of hyperopia was
significant in patient with cortical cataract.For

posterior subcapsular cataract: In my study,


358

Chaudhari et al.,

Int J Med Res Health Sci. 2015;4(2):355-359

193 eyes had spherical equivalent between -2 to 1and 92 eyes had spherical equivalent to -1 to 0.5. The mean spherical equivalent of -1.560.07
was found in the group with a score of 2.1-3.0
and the mean spherical equivalent of 1.260.01D was found in the group with a score
of 0.1-1.0 and mean spherical equivalent of 1.310.05D was found in the group with the
score of 1.1 to 2. Myopic refraction was
associated with posterior subcapsular cataract in
this study. However there was statically
significant correlation found.
In the study by Kubo et al[7], mean spherical
equivalent of 1.85 5.09D was found in the group
with score 3-5 and the mean spherical equivalent of
0.97 4.39 D was found in the group with a score
1.0-2.0.In the Tanjong Pagar survey [8],posterior
subcapsular cataract correlated with myopic
refraction. Posterior subcapsular cataract was
associated with myopia,deeper anterior chamber,
thinner lens, and longer vitreous chamber.In the
Beaver Dam Eye study[9],no refractive association
was found with posterior subcapsular cataract. In
Singapore Malay study[10]. Myopia (spherical
equivalent less than 0.5D) was associated with
increased prevalence of posterior subcapsular
cataract.In blue mountain eye study, was supported
by the finding of an association between current
myopic refraction and PSC cataract (OR 2.5 ; CI 1.64.1). PSC was inversely associated with hyperopia.
High myopia was associated with PSC.In Tehran eye
study12, PSC shows a significantly higher prevalence
of myopia.

Limitations of the study:.


1. Prior refractive status of the patient could not be
studied as many patients were presenting for the
first time with the cataract.
2. Patients with early cataract could not be followed
up to study the refractive changes as the cataract
develops.
CONCLUSION
The myopic refraction was associated with nuclear,
cortical and posterior subcapsular cataract and this
refractive error (spherical equivalent) was statically
significant with nuclear, cortical and posterior
subcapsular cataract.

Acknowledgement: We thank Professor and HOD


Dr. Mrs.Neeta Misra Department of ophthalmology,
RMC, Loni for permission to carry out the study.
Conflict of Interest: Nil
REFERENCES
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6. Abrams D. Duke-Elders Practice of Refraction.
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1993
7. Kubo E, Kumamoto Y, Tsuzuki S, Akagi Y. Axial
Length, Myopia, and the Severity of Lens Opacity
at the Time of Cataract Surgery. Arch Ophthalmol.
2006;124: 1586-90
8. Wong TY, Foster PJ, Johnson GJ, Seah SK.
Refractive errors, axial ocular dimensions, and
agerelated cataracts: The TanjongPagar Survey.
Invest Ophthalmol Vis Sci 2003;44:147985.
9. Lee KE, Klein BE, Klein R, Wong TY. Changes in
refraction over 10 years in an adult population: the
Beaver Dam Eye study. Invest Ophthalmol Vis Sci.
2002:2566-71.
10. Pan CW, Boey PY, Cheng CY. Myopia, axial
length, and age related cataract: the Singapore
Malay Eye Study. Invest Ophthalmol Vis Sci.
2013;54:449802.
11. Pan CW, Boey PY, Cheng CY, et al. Myopia, axial
length, and age Related cataract: the Singapore
Malay Eye Study. Invest Ophthalmol Vis Sci.
2013;54:449802.
12. Hashemi H, Khabazkhoob M, Miraftab M,
Mohammad K, Fotouhi A. The association between
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DOI: 10.5958/2319-5886.2015.00067.3

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 14 Jan 2014
Research article

Coden: IJMRHS
Revised: 10th Jan 2015

Copyright @2015
ISSN: 2319-5886
Accepted: 27th Feb 2015

COMPARATIVE STUDY FOR EVALUATING T SPOT-TB IN ANALYSIS BETWEEN LOW AND


HIGH RISK SUBJECTS - A PILOT STUDY
*Gupta V1, Athavale A.U2, Natraj G3
1

Registrar, 2Professor and Head, Department of Pulmonary Medicine, 3Professor, Department of Microbiology,
Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai
*Corresponding author email: drvishalgupta1985@gmail.com
ABSTRACT
Latent tuberculosis infection (LTBI) is a non- communicable asymptomatic condition, which might develop into
active tuberculosis. Health care workers in contact with active TB cases are at high risk. Impact of exposure in
high TB endemic population remains to be studied. Objective: To study the prevalence of IGRA positivity in
high risk health care worker and comparing with clinical and radiological data. Methods: From a tertiary care
institute, 40 subjects of which low risk subjects (16), high risk subjects / health care workers (24) were recruited
randomly. TSPOT TB spot counting was done and correlation with the clinical data and radiology was analysed.
Results: Out of 18 positive results, 16 were HCWs (66.67%), 2 were of low risk group (12.5%). Among the
HCWs, doctors had the maximum percentage of the positive results (71.42%). Administration related workers all
had negative results. Correlation was established between different antigens used. 8 subjects with normal chest x
ray also had TSPOT positive result. Conclusion: HCWs especially those proximally exposed are at greater risk
of having positive T SPOT assay. Chest X ray may not be an adequate screening tool. The exact significance and
clinical implication need study even in high endemic population.
Keywords: IGRAS, Interferon-, Health Care workers, Latent Tuberculosis
INTRODUCTION
Latent tuberculosis infection (LTBI) is a noncommunicable asymptomatic condition, which can
develop into active tuberculosis months or years later
[1]
. There are two principle approaches for tests used
in clinical practice to detect latent infection with M.
tuberculosis. These are, the in vivo tuberculin skin
test (TST), which uses a mixture of antigens obtained
as a protein precipitate from the liquid cultures of M.
tuberculosis, and the ex vivo interferon- release
assays (IGRAs), which are designed to identify a
memory of an adaptive immune response against
mycobacterial antigens [2].IGRAS most popularly
available includes the T SPOT TBTM and the
Quantiferon Gold (QFT-GTM). T SPOT-TBTM
measures release of IFN- from sensitized

lymphocytes in vitro. Although TST and IFN- assay


use different antigen combinations, these tests had
comparable prevalence estimates (41% and 40%,
respectively) and a high level of agreement [3]. TSPOT. TB is intended for use for detection of M.
tuberculosis infection in conjunction with risk
assessment, radiography and other medical and
diagnostic evaluation [4]. The use of the Tuberculin
skin test in diagnosing active infection is limited to
the category of people who have high levels of
exposure to tubercular antigens like the health care
worker [5,6].
A community based tuberculosis elimination strategy
will require a reduction in the prevalence of infection
with M. tuberculosis through identification of latent
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Int J Med Res Health Sci. 2015;4(2):360-365

TB infection (in future possibly treatment) that may


later develop into active tuberculosis disease [7], thus
possible early diagnosis of active disease. An Indian
study by Mahomed et al. showed that there was poor
agreement between TST and QFT tests, and also
between the different generations of QFT tests (K =
0.12-0.50). Of the subset with TST indurations >15
mm, 30- 56% had negative QFT test [8]. A study
conducted by Pai et al.[9] on health workers in India
demonstrated a high prevalence of LTBI in Indian
health care workers as has been in studies from
around the world[10]. Increasing age and years in the
health profession were risk factors for both IFN-
assay and TST positivity, and the risk factor
associations were fairly similar for both tests [3,10].
Aims and Objectives: To determine the clinical
utility and prevalence of significant result of TSPOT.TBTM in health care workers. To determine the
extent of correlation of A and B antigen wells of
TSPOT test.
MATERIAL AND METHODS
Research Design: Prospective observational study
Sample size: A total of forty subjects were included
of which 16 were categorized as low risk subjects
(group 1) and 24 as high risk subjects / health care
workers (group 2).
Sampling Method: Purposive sampling; non randommised.
Inclusion criteria: Health Care workers between the
ages of 18-60 years and consenting for the study. In
order to rule out disease in the subjects, history,
clinical examination, chest radiography, blood counts
and sputum evaluation was done.
Exclusion criteria: History of past or current
treatment with anti-tuberculosis drugs or any other
active disease state. Low risk subject: Subject not
involved in active patient care, thus unlikely to be
having exposure to tubercle bacillus more than
baseline population.
High risk subject: Subject involved in the active
patient care having high likelihood of contact
with tubercle bacillus.
Study period: 2 years from obtaining the ethical
committee approval. (June 2012).
Procedure: The subjects (male and female) working
in all departments in a tertiary care hospital were
recruited for the study after consenting as per the
institutional ethical committee requirements. They

were grouped into high and low risk categories (CDC


2010 criteria) [4] based on their risk of exposure to
sputum AFB positive cases in the hospital. After
detailed history and examination, the blood sample
was drawn and the T SPOT TBTM test was done on
the heparinised sample within an average time span
of 6 hours. The T SPOT TBTM test was performed as
per the kit literature provided with PANEL A
representing the ESAT -6 and PANEL B representing
the CFP-10 (TB specific antigens). (as per kit
literature for TSPOT TBTM )
The results of the TSPOT TBTM of the serum sample
obtained from both groups one and two were tallied
and analysed using chi square test of analysis on the
SPSS data analysis software. p<0.05 was considered
significant.
RESULTS
Of the total 40 subjects tested (Table1), a positive T
SPOT TB result was detected in 16 subjects (66.67%)
of the high risk group and 2 (12.5 %) in the low risk
group.
Table1: Risk v/s Result of T SPOT TBTM
RISK
RESULT OF T SPOT TB TM
Total
Positive
Negative
High
16 (66.6%)
8(33.33%)
24
2(12.5%)
14(87.5 %) 16
Low
18
22
40
Total
The difference was found to be statistically
significant. (p=0.002) (Table2)
Table 2: Chi-square test for the statistical analysis
of the study
Asymp. Exact Exact
Sig.
Sig.
Sig.
Value Df (2-sided) (2-sided) (1-sided)
9.82a 1
.002

Pearson
Chi-Square
Continuity
7.88 1
.005
Correction
Likelihood
10.73 1
.001
Ratio
Fisher's
.003 .002
Exact Test
Linear-by9.57 1
.002
Linear
Association
No. of Valid 40
Cases
a. 0 cells (.0%) have expected count less than 5. The
minimum expected count is 6.80.
b. Computed only for a 2x2 table

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Comparing the cadre of work with the results of the T


SPOTB TM test (Table 3), it was observed that doctors
had the maximum percentage of positive results
(71.42%) followed by the labour class workers
(61.53%) whereas the administrative workers who
had minimal exposure to active TB cases, had no
positive results. The labour class workers who were
directly exposed to the patients in ward activities
were found to be all positive for TSPOT TBTM.
Table 3: Comparing the result and the cadre of
work
cadre of work
Doctor
Staff nurse
Class Four Worker
Ward work
Administrative work
Administration
Total

Result of T SPOT TB
Positive
Negative
5 (71.42%) 2 (28.6%)
5 (50%)
5 (50%)

Total
7
10
13

8 (61.53%)
0 (0 %)
0 (0%)
5 (38.47%)
0 (0)%
10 (100%)
18
22

10
40

Comparing the findings of Chest X ray abnormalities


and the TSPOT TB (Table4), the one subject with the
upper zone opacities had a strongly positive TSPOT
TBTM. There were 8 subjects who had no symptoms
and had normal chest x-ray, but still had positive T
SPOT TB results.
Table 4: CXR findings v/s Result of T SPOT TBTM
Result of T SPOT
TB
CXR findings
Positive Negative Total
CXR not available
9
7
16
Minimal UZ infiltrates 1
0
1
Normal
8
14
22
Opacities
0
1
1
Total
18
22
40
Comparing the results of the individual antigen
panels A and B (TABLE 5), it was observed that
there was good correlation between the two panel
antigen tests as a majority (11 subjects) had both
titres positive ( >10 spots).
Table 5: Panel A and B assays as compared with
the results of the test
PANEL A spots

<6
6 to 10
>10

PANEL B spots
<6

6-10

>10

22
0
0

0
4
0

2
1
11

NEGATIVE RESULT
POSITIVE RESULT
Gupta et al.,

However, one subject had low PANEL B titre while 2


subjects had low PANEL A titres. Thus, a low cut off
value at 6 is likely to optimise the sensitivity while
maintaining the specificity of the test. Likely a lower
cut off value will be helpful in a high incidence
setting. Correlation between the titres and the
magnitude of the exposure will need further study.
Further evaluation of the utility of the test to detect
the latent TB cases in the high risk population
especially doctors, staff nurses and the labour class
workers will be needed
DISCUSSION
T SPOT-TBTM measures release of IFN- from
sensitized lymphocytes in vitro. These tests have
enhanced specificity because they selectively detect
responses to CFP-10 and ESAT- 6, antigens secreted
by M. tuberculosis that are not present in BCG, hence
diminishing false positives seen in TST due to prior
BCG vaccination and NTM[11]. Therefore, in
countries with adequate resources, QFT-GTM or T
SPOT-TBTM may ultimately replace skin testing in
the diagnosis of latent TB infection while also serving
as an adjunct in the diagnosis of active TB by
conducting risk assessment, radiography and other
medical and diagnostic evaluations [4]. In light of the
above, it was worthwhile considering the specific
tests like IGRAS in the evaluation of high risk
candidates (health care workers) and comparing its
titres with the low risk population.
For IGRAs, the reported sensitivity of T-SPOT was
highest, reaching a pooled value of 87.5% while
pooled sensitivity from the QFT-IT studies was 81%.
This figure is remarkably different from the pooled
sensitivity of 70% based on the six QFT-IT studies
referenced by Pai et al [12]. Because most of the TSPOT studies with respect to sensitivity were also
performed in developed countries, the pooled
sensitivity estimate for QFT-IT increases to 84.5%
(and 88.5% for T-SPOT) in developing countries [13].
In the current study, it was shown that the probability
of the subject having the low risk and the negative
result (specificity) was about 87.5% which was close
to the figure projected by the study by Pai et al.[9] The
sensitivity (positive TSPOT TB test in high risk
candidates) is likely to be low, in this case is about
66.6 % from the total population considered. The
significantly lower sensitivity of the IGRAS observed
in this study and few other studies from resource
362
Int J Med Res Health Sci. 2015;4(2):360-365

limited settings needs further evaluation and should


be addressed in upcoming studies with larger sample
size [14]. Studies with patients have attributed this to
the immunologic status of patients in such settings
i.e., HIV co infection, advanced disease, or
malnutrition) and to logistic requirements of the
studies [14]. QFT-IT cut off is drawn to achieve
maximum specificity, whereas the commonly used
European T-Spot cut off of 6 spots appears to
maximize sensitivity [13]. No such cut off values have
been set for high burden, high endemic countries.
Thus, the current study has also used the cutoff of
TSPOT-TBTM test as per the European standards. The
results of the same have been satisfactory but need
confirmation in larger trials.
CDC USA guidelines [4] suggest that QFT-G can be
used in place of the TST for infection control
surveillance, and conversion (i.e. new infection) has
been defined as change from a negative to a positive
result. The UK National Institute for Health and
Clinical Excellence (NICE) TB guidelines were
published in March 2006 [15]. This guideline
recommends a two-step (hybrid) strategy for LTBI
diagnosis: initial screen with TST and those who are
positive (or in whom TST may be unreliable) should
then be considered for IGRA testing, if available, to
confirm positive TST results. There are no consensus
guidelines in India for the IGRAS but for serial
testing of health care workers, the IFN- assay will be
appropriate [16]. It will eliminate the need for repeat
visits, avoid boosting, and minimize interpretational
difficulties. [7,17]. However; the limited evidence on
the use of IGRAs in serial testing of healthcare
workers suggests that the diagnostic threshold for
conversion does not take into account the possibility
of misclassifying nonspecific IFN- changes as true
conversions [3,18].
Several studies have shown that working in
healthcare is a well-known risk factor for TB
infection [9, 10, 19, 20, 16, 5, 6]. However, older studies did
not test for LTBI [3, 18]. Positive result from the current
study 66.67 % of high risk subjects being positive
against the 12.5 % of low risk subjects. TST and the
IGRAS conversion may have significance in
detecting active cases but IGRAS yield fewer false
positives in the BCG vaccinated HCWs.[12,20]
In the current study, the subject with upper zone
opacity on chest X ray was found to have a positive T
SPOT test while those with normal chest X ray had a

significantly positive result in 8 of 22 subjects


(36.36%). This is likely to represent the load of latent
TB infection in this population. The prevalence of the
TSPOT TB positive result in our study is 45 %
(TABLE1). Which correlates with the study by Pai et
al. [9] might be an underestimate because of the varied
people involved in the health care and the differing
degree of exposure to TB bacilli. Although age and
years in health care reflect cumulative exposure to M.
tuberculosis, variability of risk across job categories
as both these studies may reflect variations in
exposure frequency and intensity. Lalvani et.al [21]
showed the prevalence of LTBI to be 80% in healthy
adults (affluent corporate executives) in Bombay who
were Enzyme-Linked Immuno Spot positive to either
ESAT-6 or CFP-10. In contrast, only 55.8% of our
high-risk cohort was positive by IFN- assay. The
epidemiological estimate for LTBI in India is 41%
TST positivity [21].
The limitations to the TPSOT TB testing in general
have been:
Cost of testing is extremely high.
Skilled lab technicians and laboratory setup are
needed. Not all the laboratory reagents and reading
equipment are included by the manufacturer. Inter
observer variability is high.
There is no true way of differentiating the latent and
the active TB infection i.e. lack of a gold standard.
TST has higher sensitivity according to many studies
as compared to the IGRAS. But some newer trials
have suggested that the true positives may in fact be
higher for the QFTG-IT and the TSPOT TB tests for
variable reasons. [3, 19] Thus, while TST conversion
remains as an indication for treatment, the same
cannot be reliably stated for TSPOT TB. Association
between the conversion and benefit of therapy still
remain to be proven. Thus, more studies are needed
to evaluate the transmission of the TB bacillus in the
nosocomial setting.
Cut off titres for TSPOT TB and definition of
conversion in high TB prevalent population are yet to
be confirmed.
Guidelines from low income and high prevalence
countries are needed for the screening and initiation
of treatment of LTBI. The value of these tests in
follow up of patients has an added value in TB
management. Cost-effectiveness of the IGRAS in
various settings (low and high risk populations) will
need to be studied.
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Int J Med Res Health Sci. 2015;4(2):360-365

Overall, our findings highlight the need to study


tuberculosis among Indian health care workers. The
safety and well-being of health care workers is
important for the continued expansion of the TB
program.
The current study consisted of health care workers in
a high prevalence country. Although this may limit
our ability to generalize the results to settings with
different baseline prevalence, we believe our data will
be helpful in understanding the performance of
IGRAS in high-burden settings for which data are
scarce. The results and the available evidence suggest
that the test has its advantages and limitations and, as
of this time, it may have a useful role, depending on
factors unique to each setting.[3] Subjects from the
high risk group who had a positive result later
developed constitutional features and radiological
manifestation of disease activity and responded to
ATT.
CONCLUSION
The study highlights the high prevalence of latent TB
infection especially in high risk groups such as health
care workers ( 66.5 % positive in the health care
workers as compared to 12.5 % in low risk
population). Since the low risk group had most
negatives, the test is likely to have a high specificity.
Even though there is sparse data to allow broad
application, the correlation between positive and
negative results is significant and should prompt
physicians to evaluate such individuals to be
evaluated for active / latent disease with sputum and
radiography.

1.

2.

3.

4.

5.

6.

7.

8.

ACKNOWLEDGEMENT
I am extremely grateful to the staff, fellow residents
and administration for their valuable support in the
study. I am also grateful to the ICMR ( Indian
Council Of Medical Research ) and the Diamond
Jubilee Research Trust, KEM Hospital and RNTCP
(DOTS) programme for the support with funding of
this project. Special mention to Dr. Rupali
Suryavanshi ( Asst. Professor, Microbiology ) and Dr.
Jairaj Nair ( Asst. Professor, Pulmonary Medicine )
for their valuable help and technical expertise from
time to time.

9.

Conflict of Interest: Nil

12.

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10.

11.

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DOI: 10.5958/2319-5886.2015.00068.5

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
st
Received: 21 Jan 2015
Revised: 10th Feb 2015
Research article

Copyright @2015
ISSN: 2319-5886
Accepted: 6th Mar 2015

STUDY OF PRIOR PREPAREDNESS AND AWARENESS REGARDING THE MBBS COURSE


AMONGST FIRST YEAR STUDENTS ADMITTED AT RURAL MEDICAL COLLEGE, OF PIMS-DU,
LONI
*Padmanabhan P1, Kunkulol R2, Jangle SN3
1

Associate Professor, 3Prof and Head, Department of Biochemistry, 2Professor, Department of Pharmacology
Rural Medical College, Pravara Institute of Medical Sciences-Deemed University, Loni, Ahmednagar,
Maharashtra, India
*Corresponding author email: preetipadmanabhan@gmail.com
ABSTRACT
Background: Adolescents in India choose career in medicine under the influence and pressure from parents,
family members, peers and external sources. There are no measures taken to study whether these medical students
understand the demands and priorities of a career in medicine once they decide to choose it. Hence the study was
undertaken at PIMS-DU with Ist year MBBS students as participants. Aims: 1) Assess the factors influencing the
choice of MBBS. 2) Analyze the prior knowledge and awareness of medical students regarding the course. 3)
Their career trend in future. Material and Methods: All newly admitted students present at the orientation
programme in September 2014 at PIMS DU were included as participants. Their written responses to a 14 point
questionnaire were entered into a Microsoft Excel Spreadsheet and descriptive analysis was done. Results: A
majority of students had their parents and family members in medical profession indicating prior idea amongst the
students regarding the course, even when the choice was made at an early stage of academics or without
appearing for aptitude tests due to unawareness. Appearance for entrance exams to kept their options wide open
but caused unnecessary stress, anxiety and economic burden to parents. However, these participants had limited
knowledge about medical curriculum but had decisive ideas regarding future trend in career. Conclusions: Family
being strong motivator for career choice for medical students; should encourage students to undertake aptitude
tests, career guidance courses and investigate about future prospects to create a strong foundation as MBBS
students.
Keywords: Career, Medical students, Awareness, Medical curriculum.
INTRODUCTION
The personnels opting for medical profession must
have the right approach, aptitude, attitude, selfless
service motto and ability to work relentlessly for the
patients. Other attributes are ability to overcome
sleep, preparedness for a kaleidoscope of emotions,
service over economics and empathy [1].
To enable the medical students to make the right
choice of professional career, aptitude tests are
developed by trained expert psychologists to prevent

frustrations in future in case of failures.


Consequently, educational authorities have realized
the need for institutions to have career guidance
counselors who enable the students to select
appropriate career in co-ordination with their
intellectual abilities and virtues [2].
In some cases students are forced to choose a
professional course such as MBBS at an early stage
in student life and persist in their choices until their

Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

366

early academic goals are completed [3,4].At this


juncture of selection, their choice is influenced by
parents, relatives, peers and other external sources as
well as their own perceptions [5] .
After the decision of choosing MBBS as a course of
study, there are some requirements which the medical
student should possess, such as comprehension of
English language, competence in communication,
empathy, independent thinking and decision making,
integrity, dedication to lifelong learning, as well as
ability to cope with stress [6].
However, several studies indicated that stress due to
the profession is dominating problem amongst the
current medical practitioners suggesting the choice
regarding the career is replaced by pessimism and
cynicism [7, 8].
It has been noted that students in India opt for a
career in medicine because of influence and pressure
from parents, even they lack self motivation. It should
be kept in mind that in our country the majority of
children taking this decision are very young (17-18
years old) and have a protected life with plenty of
parental guidance in nuclear family with not much
career counseling. Nothing much has been done to
know whether they really understand the high
demands and rigours of a career in medicine once
they decide to choose it [9].
At the Pravara Institute of Medical Sciences-Deemed
University the MBBS course has tenure of 5 years,
which is inclusive of one year of internship. As soon
as they get admission in the First year, subjects like
Anatomy, Physiology, Biochemistry and Community
Medicine are taught for two terms. In the Second year
for 3 terms Pharmacology, Microbiology, Pathology,
Forensic Medicine and Community Medicine are
taught along with clinical posting. In Final MBBS
Part I of 2 terms cover the subjects Community
Medicine, Ophthalmology and Oto-rhino laryngology
and Final MBBS Part II of 2 terms includes the
subjects Medicine, Surgery including Orthopedics,
Obstetrics and Gynaecology and Pediatrics.
Internship lasts for a period of one year which is as
per MCI guidelines.
The objectives of the present study were to:
1) Assess the factors influencing the choice of MBBS
as a course of study.
2) Analyze the prior knowledge and awareness of
newly admitted medical students regarding the
MBBS course and

3) Their career trend in future.

Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

MATERIAL AND METHODS


All newly admitted medical students (n= 91) of first
year MBBS course admitted in an observational study
in September 2014, at Pravara Institute of Medical
Sciences- Deemed University were included as
volunteers in the 2 month study. On the first day of
orientation programme of the newly recruited
students who were present and the questionnaire with
14 point questions were distributed amongst the
students. The modified questionnaire [10] was
anonymous and self administered. Further data
confidentiality was ensured over and above the
anonymity.
The primary outcome measures were the number of
attempts taken by students for admission and the
people who motivated them for a profession in
medicine. The secondary outcome measures were
number and type of career preparation activities
pursued prior to admission and the extent of prior
knowledge and awareness about the various aspects
of medical curriculum.
Ethics: After approval from the Institutional Ethical
Committee, Registration No: PIMS/RMC/2014/86.
Statistics: Responses were entered into a Microsoft
Excel Spreadsheet and descriptive analysis was done.
RESULTS
Table 1: Distribution of characteristics and
responses of newly admitted first year MBBS
students according to gender.
Student Age
Boys (%)
Girls (%)
17 yrs
20 (45.45)
24 (51.06)
18 yrs
14 (31.82)
11 (23.40)
19 yrs
06 (13.64)
11 (23.40)
20 yrs
04 (9.09)
01 (2.12)
Total
44
47
Figure 1: Age and Genderwise distribution of Ist
year MBBS students.

60

50

Percentage

40
Boys(%)
Girls (%)

30
51.06
20

31.82
23.4

10

45.45
2.12

23.4
13.64

0
17 yrs

18 yrs

9.09
20 yrs

19 yrs

Age in years

367

Fig: Age and Gender wise distribution of 1st year


MBBS students
Table 1: Distribution of characteristics and
responses of newly admitted first year MBBS
students according to gender.
Parameter
Boys (%)
Girls (%)
Number of attempts in entrance exam for MBBS course
First attempt
28 (63.64)
36 (76.60)
Second attempt
16 (36.36)
10(21.28)
> two attempts
00 (0.00)
01 (2.13)
Decision to choose MBBS course
Before 10th Std
25 (56.82)
30 (63.83)
During Junior College
17 (38.64)
17 (36.17)
Not disclosed
02 (4.55)
00 (0.00)
Reason for selecting MBBS course
Answered and explained
34 (77.27)
45 (95.74)
Unanswered
10 (22.72)
03 (4.25)
Consideration of other option if not admitted to MBBS
BDS
14 (31.81)
07 (14.89)
BPT

12 (27.27)

20 (42.55)

B .Pharm
00 (00.00)
Biotech
03 (6.82)
B.Sc
03 (6.82)
BAMS
02 (4.55)
Engineering
01 (2.27)
Any other
01 (2.27)
Not disclosed
08(18.18)
Awareness that ragging is prohibited
Yes
42 (95.45)
No
02 (4.55)

05 (10.64)
01 (2.13)
00 (0.00)
01 (2.13)
03 (6.82)
02 (4.26)
08 (17.02)
47 (100)
00 (0.00)

Parameter
Boys (%) Girls (%)
Any other member of the family in medical
profession
Mother
11 (25.00) 20 (42.55)
Father
09 (20.45) 07 (14.89)
Maternal uncle
08 (18.18) 11 (23.40)
Paternal uncle
07 (15.90) 03 (6.38)
Grandparents
05 (11.36) 03 (6.38)
Sister
03 (6.82)
03 (6.38)
None
01 (2.27)
00 (0.00)
Profession of family
Nursing
10 (22.73) 23 (48.94)
Hospital
12 (27.27) 08 (17.02)
administration
Pharmaceutical
08 (18.18) 08 (17.02)
Business
08 (18.18) 03 (6.38)
Bank
04 (9.09)
02 (4.26)
Education
01 (2.27)
02 (4.26)
Not disclosed
01 (2.27)
01 (2.13)

Table 2: Guidance availed before admission to


MBBS course.
Boys (%)
Girls (%)
Decision to choose MBBS encouraged by
Mother
06 (13.64)
10 (21.28)
Father
06 (13.64)
06 (12.77)
Maternal uncle
03 (6.18)
06 (12.77)
Paternal uncle
07 (15.91)
05 (10.64)
Teacher
07 (15.91)
09 (19.15)
Friend
08 (18.18)
07 (14.89)
Grandmother
00(0.00)
01 (2.13)
Inner voice
01 (2.27)
01 (2.13)
Not disclosed
06 (13.64)
02 (4.25)
Taken prior Aptitude test
Yes
12 (27.27)
22 (46.80)
No
19 (43.18)
18 (38.30)
Was not aware
06 (13.64)
04 (8.51)
Not disclosed
07 (15.91)
03 (6.38)
Common entrance test for admission to MBBS other than test
conducted by PIMS-DU
One
05 (11.36)
01 (2.13)
Two
08(18.18)
06 (12.77)
Three
05 (11.36)
02 (4.26)
Four
05 (11.36)
09 (19.15)
Five
17 (38.64)
26 (55.32)
Not disclosed
04 (9.09)
03 (6.38)

Table 3: Medical students awareness about MBBS


course
Boys (%)
Duration of study in years
4
02 (4.55)
4
38 (86.36)
5
02 (4.55)
5
01 (2.27)
Not disclosed
01 (2.27)
Awareness of Internship duration
1
42 (95.45)
1
0 (0.00)
Not disclosed
02 (4.55)
Parameter
Boys (%)
Names of subjects in I MBBS
3
35 (79.55)
4
02 (4.55)
Not disclosed
07 (15.90)
Names of subjects in II MBBS
2
03 (6.82)
3
10 (22.72)
4
18 (40.90)
5
01 (2.27)
Not disclosed
12 (27.27)
Names of subjects in III MBBS
2
03 (6.82)
3
02 (4.55)
4
06 (13.66)
5
05 (11.36)
6
10 (22.72)
7
14 (31.82)
8
01 (2.27)
Number of attempts to clear University Exam
1
09 (20.45)
2
01(2.27)
3
12 (27.27)
4
0 (0.00)
Not disclosed
22 (50.00)

Girls (%)
02 (4.25)
41 (87.23)
0 (0.00)
04 (8.51)
0 (0.00)
42 (89.36)
02 (4.25)
03 (6.38)
Girls (%)
43 (91.49)
02 (4.26)
02 (4.26)
07 (14.89)
13 (27.66)
12 (25.53)
02 (4.26)
12 (27.66)
03 (6.38)
02 (4.26)
07 (14.89)
10 (21.28)
13 (27.65)
12 (25.53)
0 (0.00)
04 (8.51)
02 (4.26)
0 (0.00)
0 (0.00)
41 (87.23)

368
Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

Table 4: Decision about future after opting for


MBBS
Boys (%)
Girls (%)
After MBBS opting for
Post-graduation
35 (86.36) 42 (89.36)
Private practice
01 (2.27)
04 (8.51)
Teaching
02 (4.55)
0 (0.00)
Any other
02 (4.55)
0 (0.00)
Not disclosed
01 (2.27)
01 (2.13)
Aware of USMLE Exam
Yes
16 (36.36) 13 (27.66)
No
28 (61.36) 29 (63.83)
Not disclosed
01 (2.27)
04 (8.51)
Total
44
47
The number of students admitted to the first semester
of Ist MBBS in 2014 was 125.On the day of the study
91 students were available who duly filled the
questionnaire and all were included in the study. As
depicted in Figure 1 of age and gender wise
distribution of Ist year MBBS students, amongst the
total number of newly admitted students 51.06% were
girl students of 17 years age group and 23.4% were
girls in the age group of 19 years which were higher
in percentage when compared to boy students of the
same age group. Whereas there was a majority of boy
students as compared to girl students in the age group
of 18 years (31.82%) and 20 years (9.09%).
Success in an entrance exam conducted by the
Pravara Institute of Medical Sciences- Deemed
University (PIMS-DU) is a pre-requisite to gain
admission into PIMS-DU. A higher percentage of girl
students made their first attempt (76.6%) as compared
to boy students. Whereas higher percentage of boy
students (36.36%) as compared to girl students were
attempting the second time to secure admission. Girl
students (2.13%) were more competent and ensured
their chances of gaining admission by making more
than two attempts. These data are represented in
Table 1.
Table 1 also the time period during which the I st year
MBBS students had made their decision to uptake
MBBS course, As compared to boy students 63.83%
of the girl students had made their firm decision in
10th standard. But 38.64%of the boy students as
compared to girl students had made their choice
during Junior College. All the girl students were
prompt in disclosing but 4.55% of boy students
preferred not to disclose about when they had made

their decision. Ragging is strictly prohibited amongst


students at Pravara Institute of Medical Sciences
Deemed University. Amongst the newly admitted
first year MBBS students; all girl students were fully
aware about this fact as compared to boy
students.4.55% of the boy students were unaware that
ragging is prohibited at PIMS DU. Table 1 further
depicts the consideration of other options if not
admitted to MBBS. 31.81% of the boy students
preferred BDS as next option .The same percentage
(6.82%) of boy students would have opted for either
of the streams that Biotechnology or B.Sc as next
option. For girl students (42.55%) their next choice
was BPT. None of the boy students were interested in
opting for B.Pharm. Whereas none of the girl students
showed interest in opting for B.Sc.6.82%of the girl
students were interested in Engineering or 4.26% for
any other course as next option.18.18% of the boy
students and 17.02% of girl students preferred not to
disclose about their consideration for of other option
of study courses. As shown in Table1 a higher
percentage of girl students (42.55%) had their
mothers in medical profession and (23.4%) had their
maternal uncles in medical profession. Fathers
(20.45%), paternal uncles (15.9%), grandparents
(11.36%), sisters (6.82%) of the boy students were
involved in medical profession. However, 2.27% of
boy students did not disclose about which member in
the family were in medical profession; but all girl
students were prompt in their response.
The data shown Table 1 ascertains that larger
numbers of family members of girl students are in
nursing field (48.94%) and education (4.26%). As
compared to girl students the family members of boy
students were in hospital administration (27.27%),
pharmaceuticals (18.18%), business (18.18%) and
banking (4.26%).However, 2.27% of boy students
and 2.13 % of girl students did not divulge
information about the profession of their family
members. Since, 42.55% of the mothers and 23.4% of
maternal uncles of girl students (as depicted in Table
1) were in medical profession they must have
encouraged and influenced their daughters and nieces
to choose MBBS course. Fathers (13.64%), paternal
uncles (15.9%), friends (18.18%) were pivotal in
encouraging the boy students but had lesser influence
of the same family members on the girl students to
choose MBBS course.

Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

369

However, none of the girl students were encouraged


by their grandmothers. Whereas, 13.64% of boy
students and 4.25% of the girl students preferred not
to disclose about their kins are influential in their
decision to choose MBBS course. These data are
represented in figures in Table 2.The inner voice was
also an encouraging factor in 2.27% boys and 2.13%
girl students. As represented in Table 2 , girl students
(46.8%) as compared to boy students were career
conscious and cautious enough to have undergone a
prior an aptitude test.13.64% of the boy students
were unaware as compared to girl students about the
aptitude tests.Whereas,15.91% of the boy students
and 6.38% of the girl students preferred not to
disclose. According to Table 2, 38.64% of the boy
students and 55.34% of the girl students had applied
for more than 5 entrance tests other than tests
conducted by Pravara Institute of Medical Sciences
Deemed University thus causing economic burden,
stress and anxiety to them and their families.
With reference to Table 3, as compared to boy
students 87.23% of girl students were aware
regarding the duration of the MBBS course; as
compared to girl students 95.45% of the boy students
were aware of the internship duration.
Table 4 represents that 36.36%of the boy students
were aware of USMLE exam and 63.83% of the girl
students were totally unaware of the competitive
USMLE exam. 2.27% of the boys and 8.51% of the
girls preferred not to disclose. Table 1 depicts the
reasoning amongst medical students regarding MBBS
course selection. Most of the girl students (95.74%)
have perfect understanding regarding their career
choice and made conscientious decision to choose
MBBS course. According to Table 3 most of the girl
students (87.23%) were totally unaware regarding the
number of attempts required to pass the University
Exam. As depicted in Table 3 only 4.55 % of boy
students and 4.26% of the girl students correctly
reported the number of subjects that is Anatomy,
Physiology, Biochemistry and Preventive & Social
Medicine taught in I st year MBBS. It is evident from
Table 3 that uncertainty and ignorance existed
amongst the boys and girls regarding the number and
names of subjects taught in II nd and III rd year MBBS.
Table 4 represents that majority of boy students
(86.36%) as well as girl students (89.36%) were
interested in doing post-graduation and a negligible
percentage opted for private practice amongst both

boy students (2.27%) and girl students (8.51%).None


of the girl students were interested in teaching
profession as future career after completion of MBBS
course.

Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

DISCUSSION
Our study indicates that amongst the total students
admitted for MBBS course at Pravara Institute of
Medical Sciences Deemed University (PIMS-DU)
the number of girl students admitted had
outnumbered the boy students. This trend of statistics
even extends to the number of attempts at the
entrance exam whether at PIMS-DU or at other
university entrance exam. Thus it appears that the girl
students are found to maintain their perseverance
regarding their career choice even when selecting
their course of study.
The medical profession faces a changing gender
composition with larger number of girls opting for
medicine as their career choice. Our study findings
are in unison with this fact. A study in the United
Kingdom showed an increase in feminization of the
medical profession [11].
The choice of a particular career is largely influenced
by certain factors; such as peer group influence and
parental influence. Family influence is an important
factor in career choice of the students [12].
Adolescents have young minds therefore develop
many attitudes about occupation and career as a
resultant effect of interactions with their families.
Family background according to our study provides
the basis from which their career plans and decision
making evolves.
Our study indicates that parents and other members in
the family have significant influence on career
choice. Teachers and friends contribute equally to the
decision of choosing MBBS as course of study.
Parents, family members of medical students
probably recognized their wards ability at an early
age and guided them into academically suitable
careers [13]. A study by Penick and Jepsen reported
that parental influence surpasses that of peer
influence [14].This fact bears resemblance to findings
of our study. But this is a variable factor since it is
pertaining to the students rapport with their parents
and peers. Our study also indicates that inner voice of
students can also influence and can be a guiding
factor regarding career choice. A study by Csinady et
al found that altruistic motivations were the most

370

significant career choice reason among medical


students [15].
It is also observed that nearly majority of the students
had their parents and family members in medical
profession; which means that the students had prior
idea regarding the type of scenario awaiting them. It
also ascertains the findings of a previous study that
family is a very strong motivating force regarding
career choice in India [9]. In our study, the medical
students have made the decision of their career choice
before 10th standard and in Junior College. In a
similar study by Noble et al who dealt with factors
influencing career choice of orthodontic residents in
the United States, found that career decision was
made at an early stage in life [16].However, this fact is
debatable that students at the tender schooling age
and junior college days are able to make such an
important decision such as career choice in medicine.
Aptitude career tests are specially designed and
developed by trained, expert psychologists; who
guide and enable the students to decide their career in
future. The test analyses the inclinations and skill sets
of students like logical thinking skills, analytical
skills,
leadership
capabilities,
power
of
comprehension, communi- cation skills etc along
with capabilities that can be improvised. Hidden
potential or talents can be assessed and explored [16].
Our study depicts a significant number of students did
not appear for aptitude tests or were not aware of the
same. There is also a notable observation that girls
outnumbered the boy students in appearing at the
aptitude tests, a clear indication of their conscientious
decision taken especially by the girl students. The
fact lies that by appearing for aptitude tests prior to
entering any profession can be beneficial and
directional to the students immensely. Aptitude tests
can be used to narrow down the career options and
also give a definite motivation which navigates and
gives a head start to their careers [17]. Our study
indicates that majority of medical students had
appeared for five entrance exams other than that at
our institution. Also to be noted is the fact the
remaining students had appeared for more than one
entrance exam. This may result in unnecessary
economic burden, stress and anxiety to the students as
well as their family members. But when considering
the same scenario in a different perspective, it also
means that the students were keeping their options
and probability of securing admissions to various

institutions wide open. According to findings of the


present study the awareness amongst the students
regarding the medical curriculum was limited. Most
of the medical students did not have correct
information hence knowledge regarding the duration
of the study, internship duration, about the number of
attempts required to clear the university exam nor the
subjects taught at the level of first year, second year
or final year MBBS. However, nearly all students
which included all girl students were aware that
ragging is prohibited in college and college premises.
A majority of the medical students had a clear
decisive idea regarding their future career choice after
MBBS course and would opt for further studies or
post-graduation. However, an insignificant number
will opt for private practice and teaching. According
to our study teaching profession was an unpopular
choice amongst the girl students since none opted for
it. The present study also indicates that majority of
the medical students were unaware regarding the
qualifying exams for education aboard after
completion of MBBS course. But, it is satisfying to
observe that students had a perfect understanding,
reasoning and firm ideas as to why they had
eventually chosen MBBS as course of study?
Students should not be encouraged to make a career
out of medicine unless they are explained in detail
about the dedication and hardwork that awaits them
in future. Perhaps students who make an informed
choice and have a prior idea will excel, perform and
score in the study course selected [18, 19]. Our study
has limitations that the findings are confined to a
single medical college and does not generalize to
other medical colleges in India. Gender issues, as
well as socio-economic and cultural issues may also
influence the decision to opt for MBBS course, into
which we did not study or delve; perhaps further
studies may enlighten the possible associations and
outcomes. However, the strength of the study is that it
denotes the major motivational force of family and its
members in the students life in choice of selecting
medicine as study course. But these newly recruited
medical students are not fully informed regarding the
study course of MBBS which suggests scope for
improvement in the form of new reforms and policies
that would enable the students to be better informed.

Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

CONCLUSION
The study is a subjective evaluation of the prior

371

knowledge, awareness and preparedness regarding


MBBS course. The findings suggest that students
themselves are responsible for the choice with strong
motivation from family and members quite early in
their lives. But they have not undergone aptitude tests
to strengthen their candidature as a medical student.
However, they have appeared in more than one
entrance tests in order to ensure a seat in a medical
college. Their knowledge about the medical
curriculum and future prospects are poor which may
lead to a burnout in future. Hence it is suggestive that
since family is the strong motivating factor they
should encourage the students to take aptitude tests,
career guidance courses and give picture of future
that would create a strong foundation for their future
course as MBBS students.
ACKNOWLEDGMENT: None
Conflict of Interest: Nil
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Padmanabhan et al.,

Int J Med Res Health Sci. 2015;4(2):366-372

DOI: 10.5958/2319-5886.2015.00069.7

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 28 Jan 2015
Research article

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 5 Mar 2015
Accepted: 18th Mar 2015

ROLE OF COMPUTED TOMOGRAPHY IN EVALUATION OF PANCREATIC DISEASES


*Santosh N. Pawar1, Aruna S. Deshmukh2, Bharati P. Chavan3
1

Assistant Professor, 2Professor, Dept. of Radio diagnosis, S.R. T. R. Govt. Medical College, Ambajogai, Beed,
Maharashtra, India
3
Resident, Dept. of Pediatric, S. R. T. R. Govt. Medical College, Ambajogai, Beed, Maharashtra, India
*Corresponding author email: drsantoshnpawar@gmail.com
ABSTRACT
Context: The evolving role of CT in the study of pancreas is not only in its ability to directly define the presence
of an abnormality but it also surpasses the other imaging modalities in being able to demonstrate the extent of the
disease and its spread to contiguous areas by virtue of its being a non-organ specific investigation. The ability of
CT to image the pancreas adequately regardless of the bowel gas and fat gives it an advantage over ultrasound.
Objectives: To study age and size distribution in pancreatic diseases. To differentiate cystic from solid pancreatic
lesions. To differentiate inflammatory and neoplastic conditions with their characteristic imaging features. To
classify and grade pancreatitis with the help of CT imaging features. Methods: This study comprises 50 patients
of different age groups in whom there was clinical suspicion of pancreatic disorder. This includes 35 male and 15
female patients. Each patient had been studied by using plain and contrast computed tomography. Results:
Maximum no. of patients age was from 23 30. Pancreatic diseases were more commonly found in males than in
females. Inflammatory diseases were found to be more common than neoplastic masses. Chronic pancreatitis
were showing pancreatic duct dilatation, pancreatic atrophy and pancreatic calcification. Pseudocysts were
associated with chronic pancreatitis. Pancreatic carcinomas extent and metastases was studied accordingly.
Conclusion: CT alone is an excellent noninvasive imaging modality with a sensitivity of about 94% in diagnosing
pancreatic diseases when used judiciously in good clinical settings and accuracy of almost 100% when used in
conjunction with other imaging modalities like endoscopic retrograde colangiopancreatography, angiography and
biopsy whenever indicated.
Key words: pancreatic diseases, acute chronic pancreatitis, computed tomography
INTRODUCTION
Computed Tomography (CT) is a highly accurate,
non-invasive imaging modality of choice in
evaluating the pancreas[1]. CT enables the imaging of
the entire pancreas easily from the surrounding fat
and bowel air together with simultaneous imaging of
other abdominal organs.[2] It also enables detection of
unsuspected additional or ancillary abnormalities
which
may
be
responsible
for
clinical
[3,4]
manifestations .

The evolving role of CT in the study of pancreas is


not only in its ability to directly define the presence
of an abnormality but it also surpasses the other
imaging modalities in being able to demonstrate the
extent of the disease and its spread to contiguous
areas by virtue of its being a non-organ specific
investigation. The ability of CT to image the pancreas
adequately regardless of the bowel gas and fat gives
it an advantage over ultrasound[5].
373

Santosh et al.,

Int J Med Res Health Sci. 2014;4(2):373-379

In present study the role of CT to evaluation of


pancreatic disease by studying the following
parameters. The normal anatomy of the pancreas and
various CT appearances in pancreatic disease with
regards to sizes, shape, position, margins (contour)
volume, density characteristics, enhancement
patterns, vascular landmarks, pancreatic and common
bile ducts and the surrounding organs.
MATERIALS & METHODS
This was the prospective study carried out in the
Department of Radio diagnosis, Dr. V.M.Govt.
Medical College and Shri. Chatrapati Shivaji Maharaj
General Hospital. Ethics committee clearance was
obtained for the present study. Informed consent of
patients also taken from each patient.
Inclusion criteria: This study comprises 50 patients
of different age groups in whom there was clinical
suspicion of pancreatic disorder complaining pain in
abdomen, weight loss and increased serum amylase
levels. This includes 35 male and 15 female patients.
General clinical history of each patient had been
taken and CT scan was done by using plain and
contrast dedicated pancreatic imaging on : Third
Generation spiral CT- Philips Company (CT Model
CT vision, CT-secura).
The following finding were selected for the
evaluation of pancreatic diseases
Ultrasonographic findings: CT findings
Contour (Regular / irregular/Nodular), Size (Focal
enlargement, Diffuse
enlargement,
Diffuse
atrophy, Focal atrophy), Attenuation ( Plain,
Arterial, Venous), Pancreas (Aorta, IVC),
Density(Homogenous/
heterogenous,
Focal
Hypodense Areas, Focal Isodense areas, Focal
hyperdense
areas),
Necrosis,
Calcification
(Parenchymal, Ductal, Both), Pancreatic duct (Size,
Calculi), Commone Bile duct, (Size, Calculi),
Pancreatic abscess, Pancreatic gas, Peripancreatic fat
stranding, Phlegmonous changes, Mesentery,
Transverse mesocolon, Anterior pararenal fascia,
Lesser sac, Pelvis, Acute fluid Accumulations,
Intrapancreatic/ Extrapancreatic, Psuedocyst, Ascites,
Pleural effusion, Vascular structures,Varices, Fat
plane around the vessels, Liver, Intrahepatic biliary
radicals.Investigations: Biochemical investigations
are done to rule out pancreatic diseases (BSL, Serum
Amylase, Serum Bilirubin).

RESULTS
Table 1: Distribution of pancreatic Disorders
Diagnosed on CT (n=50)
Age( years) Male
%
Female
%
0-10
00
00
01
02
11-20
02
04
02
04
21-30
06
12
03
06
31-40
09
18
03
06
41-50
08
16
03
06
51-60
05
10
01
02
61-70
05
10
01
02
>70
00
00
01
02
Total
35
75%
15
30%
Comments: Pancreatic disorders were more common
in males than in females in this study. The
commonest age group affected was between 30 to 50
years.
Table 2 : Distribution of patients according to
various pancreatic pathologies.
Pathology
No.
%
Acute pancreatitis
16
32
Chronic pancreatitis
24
48
Pancreatic carcinoma 09
18
Other
01
02
Total
50
100
Comments: The other constitute of only one case of
pancreatic cyst associated with VHL ( von Hipple
Lindau) syndrome.The commonest pathology in this
study was chronic pancreatitis followed by acute
pancreatitis and pancreatic carcinoma.
Table 3: Age and sex distribution of acute
pancreatitis ( n=16)
Age
( years)
0-10
11-20
21-30
31-40
41-50
51-60
61-70
>70
Total

Male

--1
5
3
1
2
-12

--6.2
31.2
18.7
06.2
12.5
-75%

Female
--1
2
---1
4

Total

--6.25
12.5
----6.2

--2
7
3
1
2
1
16

--12.50
43.75
18.75
6.25
12.50
6.25
100%

Comments: Acute pancreatitis was more common in


males than in females in this study.The commonest
age group affected was between 30-50 yrs.

374
Santosh et al.,

Int J Med Res Health Sci. 2014;4(2):373-379

Table 4: Showing the CT signs of acute


pancreatitis.
Signs
No.
%
Gland
Normal
0
0
Diffuse Enlargement 11
68.75
Focal Enlargement
5
31.25
Contour
Irregular
10
62.5
Regular
6
37.5
Density
Homogenous
5
31.25
Heterogeneous
11
68.75
Necrosis
<30%
3
18.75
30-50%
1
6.25
>50%
2
12.50
Phlegmonous
7
43.75
changes
Fluid
Intrapancreatic
3
18.75
accumulation Extrapancreatic
4
25.00
Both
2
12.50
Presence of
0
0
gas/Abscess
Pseudocyst
3
18.75
Ascites
3
18.75
Pleural
8
50.00
effusion
Comments: Fluid accumulation is defined as a
localized collection of pancreatic fluid in the
pancreas, lesser sac, anterior, pararenal space or
subperitoneal space.4 patients had extrapancreatic
fluid accumulation, while 3 patients had
intrapancreatic fluid accumulation and 2 patients had
both intra and extrapancreatic fluid accumulations.
Extrapancreatic fluid collections noted in Lesser sac
and subperitoneal space.
Table 5 : Distribution of patients of acute pancreatitis
according to grade of pancreatits (n=16)

Grade [7]
No. of patients
%
A
0
-B
4
25.00
C
3
18.75
D
7
43.75
E
2
12.50
Grading : [7]
Grade A: Normal pancreas
Grade B: Focal or diffuse enlargement of the gland,
including contour irregularity, non homogenous
attenuation of gland, dilatation of the pancreatic duct,
foci of small fluid collections with in the gland.

Grade C: Intrinsic pancreatic abnormality associated


with haziness and streaky densities representing
inflammatory changes in the peripancreatic fat.
Grade D: single ill defined fluid collection.
Grade E: Two or multiple poorly defined fluid
collections as presence of gas in or adjacent to
pancreas.
Table 6 Distribution of Necrosis in various grades
of Pancreatitis. (n=6) [5]
Grade
No. of patients
%
A
--B
--C
2
33.33
D
3
50.00
E
1
16.66
Total
6
100%
Comments: Necrosis is the non enhancing areas of
pancreas on dynamic contrast CT. Necrosis is
identified in 6 patients in this study.
Table 7 : Age and Sex distribution of chronic
pancreatitis.
Age
( years)
0-10
11-20
21-30
31-40
41-50
51-60
61-70
Total

Male

Female

Total

-02
05
04
03
03
01
18

-8.33
20.83
16.66
12.5
12.5
4.16
75%

01
01
02
-01
-01
06

4.16
4.16
8.33
-4.16
-4.16
25%

01
03
07
04
04
03
02
24

4.16
12.5
29.16
16.66
16.66
12.5
8.33
100%

Comments: Incidence of chronic pancreatitis was


more in males as compared to females. The
commonest age group affected was between 20-40
years.
Table 8: Distribution of signs of Chronic
pancreatitis.
Signs
No.
%
Size
Normal
03
12.5
Diffuse atrophy
13
54.16
Focal atrophy
04
16.66
Focal enlargement
04
16.66
Pancreatic Dilatation
19
79.16
duct
Calculus
05
20.83
CBD
Dilatation
07
29.16
Calculus
01
04.16
Pancreatic Parenchymal Calcification
03
12.5
Pseudocyst
20
83.33
Alternation in peripancreatic fat/fascia
04
16.66
375

Santosh et al.,

Int J Med Res Health Sci. 2014;4(2):373-379

Comments: Pancreatic ductal dilatation is defined as


maximum AP diameter of the duct 5mm in the
pancreatic head and 3mm in the body and tail.
Pancreatic Neoplasms
Table 9: Age and Sex distribution (n=9)
Age
Male %
Female %
Total %
( years)
31-40
00
-01
11.1 01
11.1
41-50
03
33.3 02
22.2 05
55.5
51-60
01
11.1 01
11.1 02
22.2
61-70
01
11.1 00
-01
11.1
Comments : The commonest age group affected in
this study was elderly ie. Above 40 years with almost
equal sex incidence.
CT signs of pancreatic carcinomas:
Table 10: CT signs of primary mass.
Sign
No.
%
Enlargement
Head
04
44.44
Head
01
11.11
+Uncinateprocess
Body
01
11.11
Head + Body
02
22.22
Tail
01
11.11
Density
Hypodense
07
77.77
Isodense
02
22.22
Hyperdense
--Size
< 3 cm
02
22.22
> 3 cm
07
77.77
PD dilatation
06
66.66
CBD dilatation
05
55.55
IHBR dilatation
05
55.55
Associated pancreatic atrophy
07
77.77
Table 11: Extra pancreatic CT signs:
Signs
No.
%
Hepatic metastasis
05
55
Lymph node involvement
04
44
Vascular involvement
Encasement
02
22
Occlusion
01
11
Peripancreatic infiltration
06
66
Involvement
of
Contiguous 03
33
organs
Ascites
05
55
Pleural effusion
02
22
Comments: One patient showed presence of direct
portal vein invasion and thrombosis. In 3 patients
misdiagnosed as pancreatic head adenocarcinoma on
USG, CT revealed periampullary carcinoma in one
Santosh et al.,

patient and cholangiocarcinoma in two patients.


These patients are not taken in this study.
DISCUSSION
In our two and half years experience with patients
referred for CT scanning of abdomen for pancreatic
region, we singled out 50 patients for our study. We
had a highly selected group of patients for CT study,
because of the availability of US in the hospital and
strongly clinically suspected patients were taken for
CT examination. Acute pancreatitis: In our study 16
patients were diagnosed as having acute pancreatitis.
(32%). 12 patients (75%) were of the male sex and
this was correlated with the high incidence of alcohol
abuse in these patients as being the commonest cause
of acute pancreatitis. Brooke Jeffery et al (1982 )[1]
the cause of acute pancreatitis in 24 of 36 patients to
be due to alcohol abuse, as was also noted by Gaston
Mendez et al (1980) [2].
Peak age of incidence was noted in the 30-50 years
age range. In B Jeffery study (1982) [1] the mean age
was 41 years. In our study, 11 of 16 patients
(68.75%) had diffuse enlargement of the pancreas,
with focal enlargement of the pancreas seen in the 5
patients (31.25%). This correlated with Brooke
Jeffery et al (1982) [1] study in which 31 of 36
patients showed diffuse enlargement and 2 patients
showed focal enlargement. This also compared with
Mendez et al (1980) [2] in which 32 patients showed
gland enlargement.
In this study, peripancreatic phlegmonous changes
were noted in 7 patients (43.75%) with involvement
of mesenteric root in 5(71%), perinephric spaces in 4
(57%) lesser sac in 3(42%), paraconal spaces in
2(28%) and pelvis in 1 (14%) patient. Out of 7
patients 85.7% (6 patients) were of necrotizing
pacreatitis and 14.28% (1 patient) of acute edematous
pancreatitis. This correlated with Hill et al (1982) [3]
in which phlegmonous changes were reported in 11%
of acute edematous pancreatitis and 89% of
necrotizing pancreatitis.
In our study, 9 patients (56.25%) had acute fluid
accumulations, of which 3 patients (18.7%) had
intrapancreatic, 4 patients (25%) had extrapancreatic
fluid accumulations, and 2 patients (12.50%) had
both extra and intrapancreatic fluid collections.
Seigleman Stanley et al (1980)[4] also reported
pancreatic and extrapancreatic fluid accumulations in
54% cases with 16% having intrapancreatic and 42%
376
Int J Med Res Health Sci. 2014;4(2):373-379

having extrapancreatic collections. Balthazar E J et al


[5]
also reported acute fluid collections in 40% of
patients early in the course of acute pancreatitis of
which 50% resolved spontaneously. In our study, the
natural history of acute fluid collections could not be
followed up, as our patients could not afford rescans.
In our study we had 3 cases of pseudocyst, 2 in
intrapancreatic locations and one in lesser sac. The
commonest site of pseudocyst; a late sequlae of the
disease, in our study was intrapancreatic location
(66%) in acute pancreatitis.
CT is a better
investigation than US for detection of remote
pseudocysts[6]. Kresses says that CT has 100%
sensitivity while US has 50% in detection of
extrapancreatic predocysts.
In our study, no patient had Grade A, 25% had Grade
B, 18.75% Grade C, 43.75% Grade D and 12.50%
Grade E pancreatitis. The patients who developed two
or multiple poorly defined fluid collections were of
Grade E pancreatitis. Further pleural effusion in 50%
cases and ascites in 25% were found in more sever
grades, Grade D and E pancreatitis. The patients of
Grade A, B, C had no or less number of
complications like pleural effusion and ascites.
Balthazar E. J (1985) [7] reported the following:
Grade A 14.5%, Grade B 22.9%, Grade C 25%,
Grade D 14.5%, Grade E 27.7%. Our study correlated
with the study of Balthazar E J (1985) [7] for the
presence of pleural effusion and ascites like
complications occurs more in Grade D and E
pancreatitis. Pancreatic necrosis described as focal
nonenhancing low attenuation areas was noted in 6
patients (37.5%) in our study. Necrosis was not found
in Grade A and B pancreatitis, but was found 33.33%
in Grade C, 50% in Grade D and 16.66% in Grade E
pancreatitis. These findings correlated with Balthazar
E J et al (1990) [5] noted total necrosis being 20.4%.
Necrosis was not found in Grade A and B
pancreatitis, but was found 25% in Grade C, 50% in
Grade D and 25% in grade E. Most patients with
Grade D and E pancreatitis exhibited higher
incidence of pancreatic necrosis detected in our study
could be attributed to spiral acquisition of data during
peak pancreatic parenchymal enhancement, thus
allowing good discrimination between necrosed and
viable portions of the gland.
Chronic pancreatitis: In our study of total 24
patients were diagnosed on CT having chronic
pancreatitis of these 18 were males (75%) and 6 were

females (25%) with maximum patients being in the


age range of 20 to 40 years (18-70 year range). The
commonest findings of chronic pancreatitis in our
study were pancreatic duct dilatation 79% (19 out of
24 cases), pancreatic atrophy (70%) (17 out of 24
cases), pancreatic calcification (Ducal and
parenchymal) 33.33% (8 out of 24 cases). These
findings co-related with the findings of P Luetmer et
al (1989)[8] which were pancreatic duct dilatation
(68%), pancreatic gland atrophy (54%) and
pancreatic calcification (56%).
Pancreatic duct dilatation has been found with
varying degrees of sensitivity on CT ranging from 4%
(J. Ferrucci et al 1979) [9] to 68% ( P Luetmer 1989)
[8]
. In our study the frequency of duct dilatation was
found to be 79%. 5 out of 19 patients showed
dilatation of the duct up to the Ampulla of Vater,
While this sign is useful in ruling out a proximal
pancreatic malignancy, it does not exclude an
ampullary carcinoma (P Leutemer 1989) [10].
In our study pancreatic calcification was seen in 8 out
of 24 patients (33.3%) showed presence of intraductal
and
parenchymal
calcification.
Intraductal
calcification was noted in 5 patients while
parenchymal calcification noted in 3 patients. This
was in comparison to variable reported incidence of
calcification in chronic pancreatitis from 36%[9],
52%[11], to 50%[8]. In our study we were able to
differentiate intraparenchymal from intraductal
calcification. This distinction could be important
from the management point of view in patients with
chronic pancreatitis [12].
Pseudocyst had an incidence of 83.3% in our study
(20 out of 24 patients). We found 24 pseudocysts in
20 patients, with 14 being intrapancreatic located
mainly in the head region and 10 being
extrapancreatic region mainly in the lesser sac. One
patient had the pseudocyst in the spleen. In our study
incidence of preudocysts was higher as compared to
other studies: 30%[9], 28% [11] and 30 %[8]. This could
be attributed to later presentation of our patients of
chronic pancreatitis with more severe disease and due
to bias of clinical selection of patients undergoing
CT. Of the 24 pseudocysts diagnosed, 9 were <6 cms
size, while 15 were >6cms size. Patients with
pseudocysts >6 cms presented with abdominal pain
and an epigastria lump. 6 pseudocysts >6 cms were
drained surgically and this correlated with the
377

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Int J Med Res Health Sci. 2014;4(2):373-379

findings of Yehoules Yeo and Augusto Batisdas


(1990)[13].
Pancreatic atrophy was noted in 70% (17 out of 24)
patients with chronic pancreatitis. Out of 17 patients,
13 patients shows diffuse atrophy and 4 patients
shows focal atrophy. Of these patients, 45.8% had
associated pancreatic ductal dilatation. Earlier study
found frequency of atrophy to be 54%[8]. In this
study, 4 patients showed focal enlargement (16.6%);
3 patients normal gland size (12.5%) but no one
shows diffuse enlargement. This is comparable to the
study of P Luetmer (1989) [8] (16.6%) reported foal
enlargement in 30% with no diffuse enlargement.
Alterations in the peripancreatic fat and fascia were
noted in 16.60% (4 patients) which correlated with P
Luetmer et al (1989) [8] study, in which 9% showed
fascial thickening.
Pancreatic neoplasms: Majority of the neoplasms
are solid, adenocarcinomas representing 95% of
these. They arise from the epithelium of the main
pancreatic duct, accessory duct or their side branches.
In our study, a total number of 9 patients with
pancreatic carcinomas were diagnosed (18%) with
most patients presenting in elderly age group beyond
40 years. Sex incidence is almost equal (55.5% males
and 44.4% females).
All tumors showed focal enlargement of the pancreas
with contour deformation. The tumors were 4
(44.4%) from head, 2 from head and body and 1 each
from head and uncinate process, body and tail regions
of pancreas, which was in keeping with the findings
of Patrick Freeny et al (1988) [14] in which 96% of
pancreatic adenocorcinomas presented with focal
mass, 62% of which were found in the region of the
head.
In our study 77.7% of tumors were found to be
hypodense and 22.2% were isodense compared to
parenchyma. This was in accordance with Alec
Megibows study (1992)[15], in which 78% of patients
had hypoattenuating lesion. This was attributed to the
schirrous nature of the tumor, which was the same
biologic characteristic that results encasement of
vessels.
In our study 77.7% of patients had tumor size >3cms.
These tumors were found to be non-resectable at
surgery. This was in accordance with the findings of
David A Bluemke (1995)[16] who found that the
average size of resectable tumors was <3.1 cms. The
larger size of tumors at presentation could be due to

the fact that pancreatic neoplasms are notoriously


asymptomatic when small and only on enlarging in
size causes symptoms of obstructive jaundice, that
they are detected.
Upstream dilatation of the main pancreatic duct was
noted in 66.6% of our patients with associated
pancreatic atrophy seen in 77.7% of cases. Dilatation
of the common bile duct was seen in 55.5% patients
with intrahepatic biliary dilatation noted in 55.5% of
patients. Patrick Freeny et al (1988)[14] noted
upstream dilatation of main pancreatic duct in 68%
patients with associated pancreatic atrophy in 82%.
Intrahepatic biliary ductal dilatation was noted in
58%.
As compared to Patrick Freenys (1988) [14] study,
of 68% local tumor extension and 42% contiguous
organ involvement infiltration was noted in 66% and
33% respectively. This could be accounted for the
better contrast difference between the tumor, the
enhanced pancreas and the surrounding peripancretic
tissue due to scanning in the peak enhancement phase
of the pancreatic parenchyma using spiral CT, as
compared to dynamic contrast enhanced scanning.
Hepatic metastasis was discovered in 55% and
enlarged nodes in 44% of our patients. Patrick Freeny
(1988)[14] in his study noted metastasis to liver (36%)
and regional lymph nodes (nodes greater than 2 cm.)
(28%).
Ascites was noted in 55% of our study patients. The
above findings determined the presence of non
respectable carcinomas.
Vascular involvement by pancreatic carcinomas was
noted in 5 patients (55.5%). 2 patients showed loss of
perivascular fat planes, 2 patients showed vascular
encasement and soft tissue cuffing of the vessels. In 1
patient, portal vein thrombosis was noted.
Thrombosis was due to direct infiltration of the tumor
into the portal vein. David Bluemke et al (1995) [16]
noted portal vein invasion in 2 of 19 patients. Patrick
Freeny (1989) [14] showed vascular involvement in
84% of patients.
CONCLUSION
In present study an attempt has been made to evaluate
the role of computed tomography for evaluation of
pancreatic diseases. In this study, a total number of
50 patients of pancreatic pathology were studied
using spiral CT (35 male and 15 female patients). 24
378

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Int J Med Res Health Sci. 2014;4(2):373-379

patients were diagnosed as having chronic


pancreatitis, 16 acute pancreatitis, 9 pancreatic
neoplasms and 1 had simple pancreatic cyst. In
conclusion, therefore, CT alone is an excellent
noninvasive imaging modality with a sensitivity of
about 94% in diagnosing pancreatic diseases when
used judiciously in good clinical settings and
accuracy of almost 100% when used in conjunction
with other imaging modalities like ERCP,
angiography and biopsy whenever indicated.
Conflict of interest: Nil
REFERENCES
1. Brooke Jeffery R, Federle Michael P, Jeffery
Brooke R, Cello John P : Early computed
Tomographic scanning in Acute Severe
Pancreatitis ; Surgery, Gynecology & Obstetrics ;
February 1982, Volume 154.
2. Mendez Gaston Jr., Isikoff Michael B, Hill
Michael C: CT of Acute Pancreatitis : Interim
Assessment
;
American
Journal
of
Roentgenology 135 : 463-469, September 1980.
3. Hill Michael C, Barkin Jamie, Isikoff Michael B,
Silverstein William, Kaster Martin : Acute
pancreatitis: Clinical vs. CT findings ; American
Journal of Roentgenology 139 : 263-269, August
1982.
4. Seigelman Stanley S; Copeland Bruce E, Saba
George P, et al : CT of fluid collections
Associated with Pancreatitis ; American Journal
of Roentgenology 134 : 1121-1132, June 1980.
5. Balthazar Emil J, Ranson J H C, Naidich David
P, Megibow Alec J et al : Acute pancreatitis :
Prognostic value of CT; Radiology 1985 ; 156767-772.
6. Margulis A, Kressel, Gooding , Filly , Moss,
Kerobkin: CT scanning and US in the evaluation
of pancreatic preudocyst A preliminary
comparison , Radiology , 126:53-157, 19778.
7. Baltharar Emil J, Robinson David L, Megibow
Alec J, Ranson John HC: Value of CT in
Establishing Prognosis; Radiology 1990;
174:331-336.
8. Luetmer Patrick H, Stephens David H, Ward
Ellen M : Chronic pancreatitis: Reassessment
with current CT; Radiology 1989, 171:353-357.
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Edward B., Kirkpatrick Rob H., Hall Deborah A.,
computed Body tomography in chronic

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pancreatitis; Radiology 130:175-182, January


1979.
Luetmer Patrick H, Stephens David H, Fisher
Albert P: Obliteration of the Periarterial
Retropancreatic fat on CT in pancreatitis: An
exception to the rule; American Journal of
Roentgenology 153:63-64, July 1989.
Kolmannskoy F., Schrumpt E., Bergan A,
Larsens: Diagnostic value of computer
tomography in chronic Pancreatitis : Acta
Radiologica Diagnosis 22(1981).
Haaga John R: The pancreas : In computed
Tomography and magnetic Resonance imaging of
the whole body (vol.2): Haaga John R. Lanzieri
Charles F, Sartoris David J, Zerhouni Elias A;
Third Edition 1994; Mosby, Harcourt, Brace &
Co. Asia Pvt.Ltd. pg. 1037-1130.
Yeo Charles J, Bastidas Augusto, Lynch-Nyhan
Alma et al : The Natural History of pancreatic
pseudocysts
Documented
by
Computed
Tomography;
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Gynecol
Obstet
1990;170:441-417.
Freeny Patrick C, Marks William M, Ryan John
A, et al : Pancreatic Ductal Adenocarcinoma :
Diagnosis and Staging with Dynamic CT;
Radiology 1988; 166:125-133.
Megibow Alec J: Pancreatic Adenocarcinoma :
Designing the examination to evaluate the
clinical question; Radiology 1992;183:297-303.
Bluemke David A, Cameron John L, Hruban
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Adenocarcinoma: Spiral CT Assessment with
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Int J Med Res Health Sci. 2014;4(2):373-379

DOI: 10.5958/2319-5886.2015.00070.3

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
Copyright @2015
th
th
Received: 29 Jan 2015
Revised: 15 Feb 2015
Research article

ISSN: 2319-5886
Accepted: 21st Mar 2015

MANAGEMENT OF SUPRACONDYLAR HUMERUS FRACTURE WITH CROSS K WIRES BY


TRICEPS SPARING APPROACH
Mattam Sanjay1, Pandurangarao KR1, Mallikarjuna Reddy C2*
1

Department of Orthopedics, MNR Medical College, Sangareddy, Medak Dist-, Telangana 500055
Department of Microbiology, Mallareddy Medical College for Women, Suraram X Roads, Hyderabad 500055

*Corresponding author email: cpmreddy@gmail.com


ABSTRACT
Background: Supracondylar fracture accounts for 60% of all fractures about elbow in children and represent 3 %
of all fractures in children. The rate of supra condylar fractures steadily increases with age and reaches peak by 57 years. It is a fracture involving thin portion through coronoid, olecranon fossa or above the fossa or metaphysis
of humerus. Aim: This study aimed to anatomical stable reduction of fracture and prevention of injury to ulnar
nerve. Material and Methods: We performed prospective study of 122 supracondylar humerus fracture type 3 in
children by open reduction and internal fixation with crossed Kirshner wires over 7years duration. The method of
surgery was posterior triceps sparing. Diagnoses were made on Gartlands classification. To study the technique
[triceps sparing approach] and evaluate results of open reduction internal fixation with cross k wires. Results:
Average duration of follow up of each child was one year and on overall 94 % of parents was satisfied with the
results and 6% were unsatisfactory. Boys were more in number compared to girls and left elbow being more in
incidence compared to right. Triceps sparing approach showed better elbow movements. Conclusion: Our study
concludes that posterior approach gives better visualization of fracture, the delineated ulnar nerve enables passing
of k wires without injury.
Keywords: Supracondylar fracture, Anatomical stable reduction of fracture, Ulnar nerve
INTRODUCTION
Supracondylar fracture accounts for 60% of all
fractures about elbow in children and represent 3 %
of all fractures in children [1]. The rate of supra
condylar fractures steadily increases with age and
reaches peak by 5-7 years[2]. It is a fracture involving
thin portion through coronoid, olecranon fossa or
above the fossa or metaphysis of humerus. Pitfalls in
management occur frequently and continue to plague
the doctor and patients especially in respect to
displaced supracondylar humerus fractures even to
the most experienced surgeon [3].
Closed manipulation reduction with splint or cast
immobilization has tradionally been recommended
Mallikarjuna et al.,

for supracondylar humerus fractures, impending


vascular compromise reported, however loss of
reduction resulting in malunion of valgus and varus
deformity [4]. In displaced fractures trial closed
reduction should be discouraged because it
predisposes to myositis ossificans, wastes time,
energy and anaesthesia. Displaced Supracondylar
fracture is juxtaarticular fracture, hence require
perfect anatomic restoration and early mobilization.
This is difficult; almost impossible to achieve by
closed methods [5]. Surgical treatment has the
advantage of decreased hospital stay, anatomical
stable fixation and early mobilization [6] as the
380
Int J Med Res Health Sci. 2015;4(2):380-385

hematoma is washed away myositis ossificans is


prevented[3]. Lateral divergent k wires fixation is
equally stable however cross k wires usage is more
stable as it prevents axial rotation[7,8]. Triceps sparing
approach causes less soft tissue damage.
MATERIALS AND METHODS
Study design: We conducted cohort prospective
study
Sample size & study place: 122 supracondylar
humerus fractures of type 3 with age range of 1-12
years, 87 male children and remaining female were
studied and followed up in MNR medical college,
Sangareddy from January 2007 to February 2014.
Ethical clearance and informed consent were taken
from patient.
Inclusion criteria: Cases selected were displaced
humerus fractures extension type 3 supracondylar,
irreducible fractures and fractures with neurovascular
complications.
Each case was examined clinically and radiologically
on arrival, detail status of neuro vascular structures
and soft tissue injuries were noted. Pre operatively
carrying angle of unaffected elbow noted. Injection
tetanus toxoid and prophylactic antibiotic were
administered. 1mm to 1.5 mm k wires thickness used
in this series[2]All patients were given posterior elbow
slab in flexion and monitoring of pulse is done and
the limb kept in elevation. Surgery performed in
lateral position under general anesthesia. Under
tourniquet control posterior midline incision given
Ulnar nerve identified and isolated figure (2). Triceps
sparing approach was used in all cases. Triceps
mobilized from medial and lateral side helping in
better visualization of lateral, medial pillar and
fracture could be manipulated with ease figure (1),
(2). Under vision fracture reduction, k wire was
passed figure (3). In some cases of metaphyseal
comminution 3 k wires were used and the rest with
two. Lateral wire passed through lateral epicondyle
directed upward and medially at angle of 350 to 450 to
sagittal plane of humerus at 100 posterior to coronal
plane of humerus [9], medial pin passed through center
of medial epicondyle which crossed 3 cm above
fracture\ and the position confirmed with c-arm. Postoperative vascular status monitoring was performed.
All cases were discharged on 3rd post-operative day.
Every 10 days patients were called for follow up. On

12th day sutures removed slab weakened at elbow and


gentle active motion started. The slab was removed at
the end of third week. Pre-operative and postoperative x rays figure (4). Patients follow up was
done on 3rdmonth, 6th month, and at one year. Clinical
analysis of photos after consent figure (5). Range of
motion and carrying angle were compared to normal
side by Flynn criteria [9].
RESULTS
Our observations made in this study were: incidence
was higher in boys(72%) than girls (28%), peak age
of incidence was 4-6 years, non-dominant elbow was
more prone to injury compared to dominant. All cases
were of extension type. 84% were postero medial
type and 16% were lateral displacement. Age and Sex
wise distribution shown in Table 1&2.In present
study maximum age incidence of supracondylar
fracture is in 4-6 years (48% ) the next was 10-12
years (28%). The average age incidence is 7.6 years.
(Table 2).Non dominant elbow was more commonly
involved in supracondylar fractures. (Table 3).All
cases in this report were of extension type
supracondylar fractures with postero medial
displacement. (Table 4). In our series 52% came by
12hrs but 48% presented late. (Table 5).7.2% of
complications was due to injury itself. Associated
fractures were lower end radius. Two crossed k used
wires in 93 patients. 3 k wires used in 23patients with
medial comminution(Table 6).In our series the
overall incidence of postoperative complication was
3% patients had restriction range of motion. Not a
single case of cubtis valgus or varus deformity or
other complications seen (Table 7). 3.2 % of patients
had poor result, 13.2 % were good and 83% had
excellent range of movement. As regards the carrying
angle 92 % were excellent and 8% were good. In
overall para meters according to Flynn criteria is
cosmetic factor is carrying angle, functional factor is
movement. (Table 8).Grading of results [Flynn 9
criteria] shown in (Table 9).
Table1. Sex wise distribution
Sex
No of cases
Percentage %
Male
87
72%
Female
35
28%

381
Mallikarjuna et al.,

Int J Med Res Health Sci. 2015;4(2):380-385

Table 9: Grading of results [Flynn [9] criteria]

Table 2: Age wise distribution


Age group
0-3 years
4-6 years
7-9 years
10-12years

No. of patients
1
58
29
34

Percentage%
0.8%
48.%
23.8%
28%

Table 3: Side distribution


Side
No. cases
Percentage%
Right side
14
12%
Left side
107
88%
[10]
Table 4: Fracture type [Gartlands classification]
Radiological displacement of distal fragment as follows.
Displacement No of cases %
Type
Extension type Posteromedial 103
88
Posterolateral
Anterior

Flexion type

19
0

Results

Loss of
carrying
angle
No. of
cases

Loss of
carrying
angle %
of cases

Loss of
movement
No. of
cases

Loss of
movement
.% of
cases

Excellent

112

92%

102

83,6%

Good
Fair
Poor

010
00
00

08%
00
00

16
00
O4

13.2%
00
3.2%

12
0

Table 5: Duration of presentation since trauma


Duration
0-12 hours
12-48 hours
2-7 days
More than 7 days

No. of .cases.
64
39
19
0

Percentage%
52%
32%
16%
0

Table 6: Preoperative complications


Complications
Severe edema
Nerve injury
(median nerve)
Puncture wound
Associated factures
total

No. of cases
3
4

Percentage
2.4%
3.2%

0
2
9

0
1.6%
7.2%

Fig1: Triceps sparing approach, lateral k wire


passed after fracture reduction(Triceps sparring
method)

Table 7: Post-operative complications


Complications

No of cases

Vascular injury
Nerve injury
Infection
Restriction of motion
Deformity [varus or valgus]
Myositis ossificans
Total

00
00
00
04
00
00
04 patients

00
00
00
3%
00
00
3.2

Fig 2: Triceps retracted ulnar nerve isolate

Table 8: Restriction of motion


Result
excellent

Loss of
(range)
0-50

Good

6-100

Fair

10-150

Poor

15-20

movement

No
cases
102

00

83.6
%
13.2
%
00

3.2%

16

of

382
Mallikarjuna et al.,

Int J Med Res Health Sci. 2015;4(2):380-385

Fig3: k wire passed under vision after fracture


reduction

Fig 5: a) Elbow in Extension b) Elbow in Flexion


with comparison
DISCUSSION

Fig 4: a) Pre Operative AP b) Pre Operative LAT

4c) Pre Operative AP 4d)Post Operative LAT

4e) Post Operative AP 3 months later 4f) Post


Operative LAT 3 months

Displaced supracondylar fracture is a dilemma11.


Type 3 supracondylar fractures can lead to adverse
physical, social and emotional consequences if they
are not treated well [12]. Displaced supracondylar
fracture should be reduced accurately and stabilized
to have satisfactory results [13, 14]. Acceptance of
compromised fracture position leads to imperfect
results leading to elbow varus or valgus deformity.
Peak age incidence in our article was 7.6 years which
is comparable to other studies [15, 16], incidence was
related to weak bone architecture and also anatomical
factors [17, 18]. Our study and other authors articles
were similar in sex wise distribution of supracondylar
fractures. Non-dominant or left limb is frequently
used in protective reflex to support a fall [19] hence the
predominance of left.
Extension type of supracondylar humerus fracture
were more common [20, 21] and posteromedial
displacement is probably secondary to pull of triceps
which originates medially and also aided by biceps,
the pull of which is also medial.
Majority of patients came within 12 hours of injury
whereas others came late as they were referred from
primary health care center or had some treatment
elsewhere which is comparable.
In our study we had 3.2% of pre-operative median
nerve palsy which almost recovered by 5weeks
comparable to fowels about 2.7 and bhan 3.0%. We
didnt have pre-operative or post-operative vascular
injuries. Associated with lower end fracture of radius
were 3.2% almost the same [22].
We had no pin tract infection as we buried k wires
under skin unlike other articles which had pin tract
infection [23] due to the percutaneous placement. We
had no ulnar nerve injury as k-wires were passed
under vision and buried away from the nerves course
while others [24] with percutaneous insertion had 1.1%
ulnar nerve injury [25], out of 375 patients 19
recovered but 2 had permanent damage [26] lateral
pinning showed 3.4 % nerve injury, 4% with medial
pinning [27].
Range of motion was 96% satisfactory, comparing to
other studies ours was much better. This probably is
due to the sparing of the entire triceps from any injury
383

Mallikarjuna et al.,

Int J Med Res Health Sci. 2015;4(2):380-385

and scarring which would allow recovery of flexion


and extension as its tone and strength are maintained.
Over and above the posterior approach allows
anatomic reduction and the usage of crossed k wires
in addition to giving a stable fixation prevents angular
rotation [28]. 3.2% had poor results as they were little
irregular in follow-up due to economic (poverty) and
social (far off distance) factors.
Imperfect anatomical alignment and unstable fracture
fixation leads to loss of carrying angle [29]. We had 24
% medial comminution so in those patients, we used
lateral two pins and medial pin to give better
rotational stability [30, 31], and probably this is reason
for no cubitus varus cases in our study. We didnt
have migration of k-wire as they were bent and
flushed with bone. No pin tract infection was seen as
the k wires were not left outside the skin.

5.

6.

7.

8.

CONCLUSION
Our study concludes that posterior approach gives
better visualization of fracture, the delineated ulnar
nerve enables passing of k wires without injury.
Median nerve injuries protected by pinning the k wire
100 postero-lateral to coronal plane. Triceps sparing
approach has less scaring so better flexion and
extension, cross k wire gives more stability to enable
early mobilization.

9.

10.

ACKNOWLEDGEMENT

11.

We sincerely thank, Mr. M. RaviVerma, Director,


MNR Medical College for his encouragement.

12.

Conflict of Interest: Nil


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Obstet.; 1937; 64: 447-53.
30. Mubarak S J, David S J R: Closed reduction and
percutaneous pining of supracondylar fracture of
humerus in child. Master techniques in
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New York: Raven press 1994: 6:37 51.
31. Jong Sup Shim, and Yong Seuk Lee: Treatment
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Int J Med Res Health Sci. 2015;4(2):380-385

DOI: 10.5958/2319-5886.2015.00071.5

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
st
Received: 31 Jan 2015
Revised: 10th Feb 2015
Research article

Copyright @2015
ISSN: 2319-5886
Accepted: 9th Mar 2015

PATTERN OF ANTIMICROBIAL USE FOR URINARY TRACT INFECTION DURING PREGNANCY


IN A TERTIARY CARE TEACHING HOSPITAL
*Haldia Priyanka1, Sharma Taruna2, Nautiyal Ruchira3
1,2

Department of Pharmacology, 3Department of Obstetrics & Gynaecology, Himalayan Institute of Medical


Sciences (HIMS), Swami Rama Himalayan University (SRHU), India

*Corresponding author email: priyankahaldia@gmail.com


ABSTRACT
Background: Urinary Tract Infection (UTI) may be classified as lower (cystitis and asymptomatic bacteriuria) or
upper urinary tract infections (pyelonephritis). The recommended antibiotics for use in pregnancy for
management of ASB include amoxicillin, oral cephalosporins and nitrofurantoin; and for the treatment of lower
UTI during pregnancy include penicillins, oral cephalosporins. Data from the antibiotic usage study in UTI during
pregnancy will help in establishing a proper antibiotic utilisation guideline and promotes rational prescribing of
medicines. Aim: To study the antimicrobial prescription practices for urinary tract infection during pregnancy.
Materials & Methods: The study was conducted in the Department of Pharmacology and Department of
Obstetrics & Gynaecology, Himalayan Institute of Medical Sciences (HIMS), Dehradun, over a period of 12
months. This was an observational cross sectional study done in 45 pregnant women with or without symptoms of
UTI. Results: 29.4% of the pregnant women with symptomatic UTI were culture positive while all were culture
positive who had asymptomatic UTI. Cephalosporins were most frequently prescribed followed by nitrofurantoin.
Conclusion: Urine culture should be performed as a screening and diagnostic tool for UTI during pregnancy.
Various classes of antimicrobials were being prescribed for UTI during pregnancy.
Keywords: Antimicrobials, Urinary Tract Infection, Pregnancy
INTRODUCTION
Urinary Tract Infection (UTI) is caused by
pathogenic invasion of the urinary tract which leads
to inflammatory response of the urothelium [1].
Organisms causing bacteriuria are similar in both
pregnant and non pregnant women, with Escherichia
coli [E. coli] being the most common pathogen [2].
UTI may be classified as lower [cystitis and
asymptomatic bacteriuria] or upper urinary tract
infections (pyelonephritis). Pregnancy enhances the
progression from asymptomatic to symptomatic
bacteriuria (abdominal pain, urinary frequency,
urgency, fever, loin tenderness) which could lead to
pyelonephritis and adverse maternal and fetal

outcomes [3]. Early screening of asymptomatic


bacteriuria (ASB) in pregnant women should be done
[4]
. Quantitative urine culture is the gold standard for
the diagnosis of bacteriuria [5]. The recommended
antibiotics for use in pregnancy for management of
ASB include amoxicillin, oral cephalosporins and
nitrofurantoin (50-100mg four times daily or 100mg
twice daily for 3 days) [6]. Recommended antibiotics
for the treatment of lower UTI during pregnancy
include the Food & Drug Administration (FDA)
category B antimicrobials including penicillins
(amoxiciilin 500mg three times daily for 3 days or
ampicillin 250mg four times daily for 3 days), oral

Priyanka et al.,

Int J Med Res Health Sci. 2015;4(2):386-390

386

cephalosporins (250mg four times daily for 3 days).


Upper UTI during pregnancy should be treated
preferably with parenteral cephalosporins, penicillins
with beta lactamase inhibitors or monobactams [7].
The antibiotic chosen should have a good maternal &
foetal safety profile, excellent efficacy and low
resistance rates in a given population [8]. Antibiotics
are usually given empirically before the laboratory
results of urine culture are available. To ensure
appropriate therapy, current knowledge of the
organism that causes UTI and their antibiotic
susceptibility pattern is mandatory [9]. Data from the
antibiotic usage study in UTI during pregnancy will
help in establishing a proper antibiotic utilisation
guideline and promotes rational prescribing of
medicines. Hence this study was carried out to study
the pattern of use of antimicrobials for UTI during
pregnancy.
MATERIAL AND METHODS
Ethics clearance: Ethical clearance was obtained
from the Ethics Committee prior to initiation of
study. Written informed consent was obtained from
each subject prior to sample collection.
Study design: This was an observational cross
sectional study
Sample size: 45 pregnant women (20-40 years).
Study place & period: The study was conducted in
the Department of Pharmacology and Department of
Obstetrics & Gynaecology, Himalayan Institute of
Medical Sciences (HIMS), Dehradun, over a period
of 12 months from November 2012 till October 2013.
Inclusion criteria: Pregnant women with or without
symptoms of UTI were recruited in the study
irrespective of their age, race, parity, gravida and
trimester.
Exclusion criteria:
Those on antimicrobial therapy for any preexisting infection
Previous history of UTI, pyelonephritis,
obstructive uropathy, chronic renal disease
Urine bag collected specimens
Specimens submitted in leaking or dirty unsterile
container
Specimens revealing growth of more than two
types of bacteria on culture
Relevant information reviewing socio demographic
details,
medical
history,
obstetrical
and
gynaecological history, UTI signs and symptoms and
Priyanka et al.,

drug history were taken on case reporting form.


Pregnant women were started on empirical
antimicrobial treatment which was modified later
according to the susceptibility pattern of the urine
culture report. Fresh midstream urine was collected
aseptically in sterile wide mouth capped disposable
universal container on the same day of enrolment.
Urine samples were labelled and immediately the
sample was processed for microbiology and
parasitology with the help of expert microbiologist.
Urine culture was done to study the distribution of
pathogens. The isolated organisms from culture plates
were identified by standard laboratory techniques.
Antimicrobial susceptibility testing was done by
Kirby Bauer disc diffusion method as recommended
by Clinical Laboratory Standards Institute (CLSI)
M2-A9 [10]. Women were followed up weekly for one
month to look for symptomatic cure, recurrence due
to inadequate therapy or resistance. Repeat urine
culture was done on the last follow up to confirm
bacteriological cure. Data was analysed using
Microsoft (MS) Excel & Statistical Package for
Social Sciences (SPSS) version 22. Graphical
representation of the data was done in terms of
figures using MS Excel 2007. Data was presented in
descriptive statistics using percentage and
proportions.
RESULTS
A total of 45 pregnant women were included in the
study and followed up weekly till one month. Table 1
show that out of 45 pregnant women, maximum
women were found in 20-25 age group. Overall mean
of age was 25.04 3.29 years. Figure 1 show that out
of 45 pregnant women, maximum were symptomatic.
Of the asymptomatic women, all were culture
positive while of the symptomatic women only 29.4%
were culture positive. Table 2 shows that of the 19
cases, Gram negative bacteria were isolated in 52.3%
and Gram positive in 38.1% of the culture isolates. E.
coli was the predominant organism among the gram
negatives and CONS (Coagulase Negative
Staphylococci) among the gram positives. Yeast was
also present in 9.6% cases. Table 3 shows that
cephalosporins were the most commonly used class
of antimicrobials 41.7% followed by nitrofurantoin
29.2%. Figure 2 show that Nitrofurantoin was the
most commonly prescribed antimicrobial followed by
Cefuroxime axetil. All these antimicrobials were
387
Int J Med Res Health Sci. 2015;4(2):386-390

prescribed empirically while Linezolid and


Fluconazole were prescribed after the culture report
showed resistance to the initial antibiotic being
prescribed.
Table 1: Age wise distribution of pregnant women
(n=45)
Age Group [years]

Percentage
[%]
64.5
33.3
2.2

Number

20 25
26 30
> 30

29
15
1

Fig 2: Distribution of various antimicrobials in


pregnant women with UTI (n=45)
DISCUSSION

Fig 1: Clinical presentation of UTI in pregnant


women (n=45)
Table 2: Distribution of culture isolates in
pregnant women with UTI (n=21)
Organism
E.coli
Klebsiella oxytoca
Proteus vulgaris
Enterobacter
aerogenes
CONS
Staph aureus
Enterococcus
faecalis
Yeast

Gram stain
GNB
GNB
GNB

Number
8
1
1

%
38.2
4.7
4.7

GNB

4.7

GPC
GPC

5
2

23.8
9.6

GPC

4.7

9.6

GNB Gram Negative Bacilli; GPC Gram Positive


Cocci
Table 3: Distribution of class of antimicrobials in
pregnant women with UTI (n=45)
Class of Antimicrobials
Penicillin-beta
lactamase inhibitor
Cephalosporins
2nd generation
3rd generation

Number

14.5

20
14
6

41.7
29.2
12.5

Cephalosporin-beta lactamase
inhibitor

10.4

Nitrofurantoin

14

29.2

Miscellaneous

4.2

Pregnancy is a unique state with profound anatomic


and physiologic urinary tract changes that facilitate
the development of symptomatic UTI. UTI itself is no
threat to the pregnant women or the foetus, but it may
progressively spread to the bladder and kidneys
causing cystitis and pyelonephritis respectively as
well as prematurity, low birth weight, foetal growth
retardation,
still
birth,
mental
retardation,
developmental delay and increased perinatal
mortality in the foetus. It is clear that ASB is a major
risk factor for developing symptomatic UTI.
Screening of ASB in pregnancy has become a
standard of obstetric care. All women should be
screened at the first antenatal visit preferably in the
first trimester for the presence of bacteriuria with
urine culture. Prompt treatment is needed to prevent
the serious life threatening condition and morbidity
due to UTI. It has been recommended that after
patients have completed their treatment course, a
repeat culture should be done to document successful
eradication of bacteriuria. The aim of the treatment is
to maintain sterile urine throughout pregnancy
without causing toxicity to the mother or foetus [11].
The present study was conducted to study the pattern
of antimicrobial usage for UTI during pregnancy. In
the current study maximum numbers of women were
in age group 20-25 years. Similarly Okonko and
Ijandipe et al; and Olsen and Hinderaker et al also
showed that maximum number of women were in the
age group 15-24 years [12]. The higher prevalence of
UTI in younger age group may be attributed to
various factors like lack of personal hygiene and
388

Priyanka et al.,

Int J Med Res Health Sci. 2015;4(2):386-390

health awareness, low education status and early age


of marriage in developing countries. Majority of the
pregnant women had ASB which is higher than that
reported by Sabharwal [13]. Higher prevalence of UTI
may be attributed to various factors such as low
socioeconomic status, illiteracy, poor housing and
drainage system. Furthermore, HIMS acts a tertiary
care referral hospital in a rural setting where more
serious high risk pregnancies, symptomatic patients
with bad obstetric history are referred from nearby
nursing homes and private practitioners. Early
screening of all pregnant women is therefore
recommended because timely intervention with the
appropriate antibiotics can prevent drastic
consequences. Prevalence of symptomatic bacteriuria
in the present study was 29.4% which was similarly
seen by Rizvi and Khan et al 25.2% [14]. Gram
negative bacterial isolates on culture were more
prevalent than gram positive bacterial isolates.
Similar pattern has been observed in all other studies.
E. coli was the most common gram negative
pathogen isolated which is in accordance with all
other studies. More prevalence of E. coli could be due
to the fact that urinary stasis is common in pregnancy
and since most E. coli strains prefer that environment,
they cause UTI. Among the gram positive cocci,
CONS was isolated more frequently which matches
with many other studies. In few cases yeast was also
isolated in the present study. They are less common
organisms causing UTI. In the present study all
pregnant women were screened by urine culture and
were started on empirical therapy initially which was
modified later according to susceptibility pattern.
Linezolid and Fluconazole were prescribed as
definitive therapy after the culture report of antibiotic
susceptibility pattern showed resistance to the initial
antimicrobial prescribed. The study of prescribing
pattern is a component of medical audit, which seeks
monitoring, evaluation in the prescribing practices of
prescribers to achieve rational medical care. Various
classes of antimicrobials were prescribed for UTI
during
pregnancy
in
the
present
study.
Cephalosporins were most frequently prescribed
followed by Nitrofurantoin. Nitrofurantoin has
minimal side effects and can be safely used for the
treatment of uncomplicated cystitis and ASB even
during pregnancy[8].Cephalosporins are recommended
for initiating therapy for pyelonephritis[15] and they
were the most commonly used antimicrobials in the

present study. Widespread empiric use of antibiotics,


while convenient, potentially contributes to
development of antimicrobial resistance. Although
irrational and unnecessary use of drugs in India has
been documented before, to the best of our
knowledge there are no other studies from India
where antibiotic use in pregnant women has been
addressed. It is likely that our findings reflect the
reality in many other developing countries.
Encouraging guideline based treatment is an
important aspect of changing prescribing behaviour, a
goal of antibiotic stewardship. The main limitation of
the study was short duration and small number of
pregnant women with UTI. Future studies are
recommended with a large sample size and conducted
over a longer period of time to establish a trend in
antibiotic prescription. The present study has
highlighted the need to raise awareness of UTIs
during pregnancy and to expand services for
prevention and treatment of UTI in pregnant women.

Priyanka et al.,

Int J Med Res Health Sci. 2015;4(2):386-390

CONCLUSION
It is concluded from the present study that there was a
high prevalence of ASB among pregnant women. It is
therefore imperative that early screening of
bacteriuria in pregnancy must be considered as a part
of routine antenatal care. Urine culture should be
performed as screening and diagnostic tool of UTI in
pregnancy. Escherichia coli was the most common
isolated organism followed by CONS. All pregnant
women with UTI should be treated. Cephalosporins
were the most commonly prescribed antimicrobials
followed by Nitrofurantoin. Periodic and continuous
follow up is mandatory to reduce the consequences of
ASB and symptomatic UTI.
ACKNOWLEDGEMENT
We sincerely thank all the subjects who gave consent
and participated in the present study.
Conflict of Interest: Nil
REFERENCES
1. Prakasam KA, Kumar KD, Vijayan M. A cross
sectional study on distribution of urinary tract
infection and their antibiotic utilisation in Kerala.
International
Journal
of
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Pharmaceutical and Biomedical Sciences.
2012;3(3):1125-30.
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2. Macejko AM, Schaeffer AJ. Asymptomatic


Bacteriuria and Symptomatic Urinary Tract
Infections During Pregnancy. Urologic Clinics of
North America. 2007;34(1):35-42.
3. Nicolle LE. Screening for asymptomatic
bacteriuria in pregnancy. Canadian Guide to
Clinical and Preventative Health Care. Ottawa:
Health Canada; 1994;(2) 100-6.
4. Nicolle LE. Asymptomatic bacteriuria: review
and discussion of the IDSA guidelines.
International Journal of Antimicrobial Agents.
2006;28:42-8.
5. Jennifer P, Cyril R, Pyumi P, Nimesha G, Renuka
J. Asymptomatic Bacteriuria in Pregnancy:
Prevalence, Risk factors and Causative
organisms. Sri Lankan Journal of Infectious
Diseases. 2012;1(2):42-6.
6. Law H, Fiadjoe P. Urogynaecological problems
in pregnancy. Journal of Obstetrics and
Gynaecology. 2012;32:109-12.
7. Krcmery S, Hromec J, Demesova D. Treatment
of lower urinary tract infection in pregnancy.
International Journal of Antimicrobial Agents.
2001;17(4):279-82.
8. Schnarr J, Smaill F. Asymptomatic bacteriuria
and symptomatic urinary tract infections in
pregnancy. European Journal of Clinical
Investigation. 2008;38(S2):50-7.
9. Alemu A, Moges F, Shiferaw Y, Tafess K, Kassu
A, Anagaw B. Bacterial profile and drug
susceptibilty pattern of urinary tract infection in
pregnant women at University of Gondar
teaching Hospital, Northwest Ethiopia.2012;
5:197
10. CLSI. Performance standards for antimicrobial
disk susceptibility tests. Clinical Laboratory
Standards Institute: M2-A9: Wayne, PA; 2006.
11. Mathai E, Thomas RJ, Chandy S, Mathai M,
Bergstrom S. Antimicrobials for the treatment of
urinary tract infection in pregnancy: practices in
Southern India. Pharmacoepidemiology and Drug
Safety. 2004;13:645-52.
12. Okonko IO, Ijandipe LA, Ilusanya OA,
Donbraye-Emmanuel OB, Ejembi J, Udeze AO,
et al. Incidence of urinary tract infection (UTI)
among pregnant women in Ibadan, SouthWestern
Nigeria.
African
Journal
of
Biotechnology. 2009;8(23):6649-57.

13. Sabharwal ER. Antibiotic Susceptibility Patterns


of Uropathogens in Obstetric Patients. North
American Journal of Medical Sciences.
2012;4:316-9.
14. Rizvi M, Khan F, Shukla I, Malik A, Shaheen.
Rising Prevalene of Antimicrobial Resistance in
Urinary Tract Infections During Pregnancy :
Necessity for Exploring Newer Treatment
Options. Journal of Laboratory Physicians.
2011;3(2):98-03.
15. Duff P. Antibiotic selection in obstetrics: making
cost-effective choices. Clin Obstet Gynecol.
2002;45:59-72.

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Int J Med Res Health Sci. 2015;4(2):386-390

390

DOI: 10.5958/2319-5886.2015.00072.7

International Journal of Medical Research


10.5958/2319&
Health Sciences5886.2015.00072.7
www.ijmrhs.com
Volume 4 Issue 2
rd
Received: 3 Feb 2015
Research article

Coden: IJMRHS
Copyright @2015 ISSN: 2319-5886
th
Revised: 28 Feb 2015
Accepted: 16th Mar 2015

SEX PREFERENCESAMONG RURAL COMMUNITY: PUBLIC HEALTH AND SOCIAL CONCERN


*Aalok Kumar Singh1, Dr. Sunil Thitame2, Reecha Ghimire3
1,3

M. Sc. Public Health (PG Student), Centre for Social Medicine, Pravara Institute of Medical Science, Loni,
Ahmednagar, Maharshtra
2

Assistant Professor, Centre for Social Medicine, Pravara Institute of Medical Science, Loni, Ahmednagar,
Maharshtra
*Corresponding author email: aaloksinghph@gmail.com/aaloksinghph@outlook.com
ABSTRACT
Background: Sex preference is choice of selecting the sex of children by their parents or family members. The
objective of the study was to study the existence of sex preference among rural community. Material and
methods: A Cross-sectional study was carried out among 200 ever married women of reproductive age group.
Random digits sampling method was used to select 10 villages in Rahata Tehsil of Ahmednagar, while systematic
sampling was applied for selection of 20 samples in each village. Results: In the previous sex preference for male
child was 37.3%, 58.75%, 88.5%, 100% and 100% from firstchild to fifth respectively, while female preference
and either sexpreference was decreasing. In the current sex preference for male, female and either was 36.8%,
25% and 38.2% respectively. Future sex preference was 40.9% for male child, 22.7% for female child and 36.4%
for either sex. The main reason for son preference was for old age care and support, to continue the family name
and earning member in the family. Conclusion: Study confirms that son preference still existsin the rural
community of Maharashtra. Attitude for son preference is mainly because of the economic earning, old age care
and continuation of the family nameamong all groups.
Keywords:Fertility preference, Sex preference, Son preference
INTRODUCTION
Sex preference is choice of selecting the sex of
children by their parents or family members. It is
observed from historical evidences that, human
beings have tried to influence the sex of their
offsprings, through termination of pregnancy,
infanticide and neglected care. In the mid of the 20th
century, due to revolution in technologies, easy
detection of sex in pregnancy became possible which
then led to sex selective abortions. Parents mostly
prefer male child and ultimately the sex ratio is
imbalanced. Son preference, low status of women,
social and financial security associated with sons,
socio-cultural practices, including a dowry and

violence against women are the major reasons for the


imbalance in sex ratio.[1,2,3]
Though the sex selective abortion is a fairly modern
phenomenon, its roots can be traced back to the age
old practice of female infanticide.[1]One of the major
causes of son preference in India is related to the
perceived economic utility of having sons and old age
care. Indian men are also responsible for the funeral
rites of their parents and are the only ones who can
light the funeral pyre. [1,2,4]
Sex preference is the social issue and it is also a bad
indicator of a healthy society. Hence, this study was
carried out to study the existence of sex preference
391

Aalok et al.,

Int J Med Res Health Sci. 2015;4(2):391-395

among rural community of Rahata tehsil of


Ahmednagar district of Maharashtra.
MATERIAL AND METHODS
Type of study: The cross-sectional study was carried
out in the rural community of Ahmednagar district of
Maharashtra (November 2013 to April 2014).
Sample size:The sample size was calculated by
n=z2pq/d2, where p=0.59, q=0.41, d=0.07 and z=1.96.
10 villages were selected by simple random sampling
(random digits) method, while in each village 20
samples were selected by a systematic sampling
method.This study was carried out among 200 ever
married women who had achild less than five years
old (unsterilized mother) or had no child.
Ethical approval: Ethical clearance was obtained
from the Institutional Research Committee prior to
research. Confidentiality and privacy were
maintained during the interview process and
participation in the study was voluntary.
Methodology:All the respondents were interviewed
with semi-structured questionnaire, which included
37 questions.Sex preference related questions were
taken from NFHS-3 survey, other related research
and some were designed by research guide and
myself and pilot study was conducted in 15 sample
cases; finalcorrection was made and approved by
institutional research committee.Collected data was
analyzed by using SPSS software (version 21).
RESULTS
Socio-demographic information: Among the total
respondent, 51.5% were of the age 20-25 years,
followed by 23.5% (15-20 years), 21% (25-30 years)
and the remaining were above 30 years old.Nearly
one third of respondent got married at age less than
18 years i.e. 34.5% of total respondent and remaining
got married at age of 18 and more than 18
years.Among total respondents, 7% were illiterate,
3.5% were educated up to primary level,69%
educated up to secondary level, 12.5% higher
secondary level and 8% above the higher secondary
level. 81% of the respondents were housewife, 8.5%
daily wage labour, 6% agriculture worker and
remaining were govt. and private job holder. Among
the total, 39% of the families were dependent on daily
wages, 38.5% had a small business, while 16% had
private job, 9.5% had farming and 4.5% had a

government job. 66% of respondents belong to above


poverty line, while 34% belongs to below poverty
line.
Previous sex preferences: Previous sex preference is
the preference of a particular sex for a previous
pregnancy by individuals, couple or family. Out of
200 respondents in the study, 159 respondents had at
least one child.
Table1: Birth order of children for previous
fertility
Birth order of
child
1st Child
2nd Child
3rd Child
4th Child
5th Child
Total children

Male
(%)
84 (52.8)
29 (36.2)
9 (34.6)
1 (16.6)
1 (50)
124 (45.4)

Female
(%)
75 (47.1)
51 (63.7)
17 (65.3)
5 (83.3)
1 (50)
149(54.5)

Total
children(%)
n=159 (100)
n=80 (100)
n=26 (100)
n=6 (100)
n=2 (100)
N=273 (100)

The reasons for more than two children were, 76.9%


respondents continued for more than two children
because they wanted a son, 15.4% wanted more
children, while 7.7% had other reasons.
Table2: Sex preference of children in previous
fertility
1st
child
Male(%)
60
(37.7)
Female(%)
19
(11.9)
Either(%)
80
(50.3)
Total(%)
159
(100)

Preference

2nd
child
47
(58.75)
19
(23.75)
14
(17.5)
80
(100)

3rd
child
23
(88.5)
2 (7.7)

4th
child
6
(100)
0

1 (3.8)

26
(100)

6
(100)

5th
child
2
(100)
0

Total

138
(50.5)
40
(14.65)
0
95
(34.79)
2
273
(100) (100)

Table-2 revealed that; male child preference up to


fifth child has increased drastically. Male child
preference for the fourth and fifth children was 100%.
This may be in the case of families who were waiting
for a son.
Table 3: Sex preference for second child VS sex of
first child
Sex of first
child

Preference for second child


Male

Female

Either

Outcome
of
Total
2ndchild

Male (%)

7 (18.9) 18 (48.6) 12 (32.4)

37

29 (36.3)

Female(%)

40 (93)

43

51 (63.7)

Total (%)

47(59)

80

80 (100)

1 (2.3)

2 (4.7)

19 (23.8) 14 (17.5)

2 = 45.329, d. f. = 2, P = < 0.001 (CL=95%)


392

Aalok et al.,

Int J Med Res Health Sci. 2015;4(2):391-395

Among 200 respondents, 80 had at least two children.


Those women who had two children, the sex
preference for second child was very high and mainly
women who had first female child, 93% of them
wanted to have a second child as male.
Current sex preference: Current sex preference is
preference of sex of baby for the current pregnancy.
Among 200 respondents in the study, 76 respondents
(women) were pregnant. Out of which, 36.8% wanted
male child, 25% wanted female child, while
remaining 38.2% wanted either sex. For the current
pregnancy, sex of the baby was mostly preferred by
the couple that is 63.2%, followed by 22.4% by all
family members, 7.9% by the husband alone and
6.6% by herself.
Table 4: Current sex preference among
respondents had one child
Current sex preference
Sex of first
child
Male (%) Female (%) Either (%) Total (%)
Male
3 (10.3)
14 (48.3)
12 (41.4)
29
Female 18 (100)
0 (0)
0 (0)
18
Total
21(44.7)
14 (29.8)
12 (25.5)
47

2 = 36.118, d. f. = 2, P = < 0.001 (CL=95%)

22.72% want female child while remaining wants


either sex. There were 13 women who want at least
two children, among that 15.38% want male child,
23.07% want a female child, while 61.53% wants
either.
Table 6: Sex preference future child who had one
child
Future preference
Sex of
First child Male (%) Female (%) Either (%)
Male

2 (8.3)

Female 28 (93.3)
Total

30 (55.6)

Total (%)

16 (66.7)

6 (25)

24 (100)

0 (0 )

2 (6.7)

30 (100)

16 (29.6)

8 (14.8)

54 (100)

The respondents who had one child and desire for the
second child were 54, among those respondents who
had one female child, 93.3% of respondentspreferred
male child in the future.
Attitude towards sex preferences:According to the
majority of respondents, they preferred male child in
old age care and support, i.e. 66.5%, to continue the
family name (47%), active and earning member of
the family (26%), other reasons were business,
agriculture, funeral values, societal values etc.

Those who had a male child at their first pregnancy


(29), among them 10.3% wanted a male child again,
48.3 wanted female child and 41.4% wanted either
sex. Those who have a female child at their first
pregnancy (18), all 100% respondents wanted a male
child in their current pregnancy. The chi-square test
was applied to find out the association between sex of
the first child and preference of the current
pregnancy, it was found statistically significant.

Reasons for preference of daughter was totake care of


family i.e. 38.5%, attachment with the mother (35%),
daughter as a son (20%), old age care (8.5%),
daughter work hard in the family (7%), societal value
related to daughter (6%), take care of two families
(6%) and other reasons (8.5%) while 1.5%
respondent doesnt mention any reason or they dont
know.

Future sex preferences: Future sex preference is the


desire for particular sex of the future baby by
individuals, couple or family. Among the total
respondents (200) of study, 110 i.e. 55% did not want
any more children, 37.5% want one child, 6% want
two children and 0.5% want three children, while 1%
were not decided at the time of interview.
Table 5: Sex preference for future birth order

DISCUSSION

Sex preference

First child

Second child

Third child

Male(%)

36 (40.9)

2 (15.4)

1 (100)

Female(%)

20 (22.7)

3 (23.1)

Either(%)

32 (36.4)

8 (61.5)

Total(%)

88 (100)

13 (100)

1 (100)

There were 88 women who want at least one child in


the future, among them 40.9% want male child,
Aalok et al.,

The main reasons behind for not preferring a female


child was dowry (25.5%), she goes to her husbands
house (27.5%), burden for family (21%), not earning
member (4%) other reasons (3%).

A sex preference is the main reason for decreased sex


ratio in India.[5]From study, it is observed that, more
than half of the respondents had no preference for
sex. However, sex preference for male child was
high. A similar study was conducted in rural
Maharashtra among men showed; 53.8% preferred
son.[6] Another study was conducted among men and
women in rural area of Andhra Pradesh with regard to
sex preference for first child, 70% men and 55% of
women wanted first male child, which is more than
this study.[7] Research conducted in Chandigarh also
393
Int J Med Res Health Sci. 2015;4(2):391-395

showed that, 57.8% of mother wanted a first baby as


a boy and only 14.4% wanted a baby as a girl.[8] Sex
preference of the second child mainly depends on the
sex of a first child and preference is comparatively
very high in the second child. From table-2, it is seen
that sex preference for male child become stronger
for second child. A similar phenomenon was seen for
a third, fourth and fifth child. This study revealed that
women who had more than three children continued
in want of only a male child.
The current sex preference was, 36.8% wanted male
child, 25% wanted female child and 38.2% wanted
either. Among those women who had one child, and
currently pregnant; the sex preference was also very
high. 100% women who had a first female child
preferred male child on current pregnancy. They
think at least one son needs for the family. A study
on ideal sex composition showed that, 59.8% wanted
at least two sons and 31.1% wanted one son while
87.1% of women wanted at least one daughter.[9]
Sex preference for future children among the total
respondents who had a desire for future children was
40.9% for male child, 22.7% for female child and
36.36% for either sex. A study conducted in
Bangladesh among men, 31.5% prefer son, 1.4%
daughter while remaining 66.9% had no
preferences.[10]From cross-table (Table-6), it revealed
that 93.3% respondent those who had one female
child and willing to have a second child, they
preferred male child.
The most common reason for preferring a male child
was the old age care and support (66.5%), to continue
the family name (47%), economically active and
earning member for family (26%), agriculture work
(1.5%), business (2.5%), societal values (3.5%),
funeral values (1.5%) and other reasons were 9%. A
similar study was conducted in rural area of Pune
district of Maharashtra; the reasons for son preference
were support in old age i.e. 57.14%, while demand
for male child by other family member and
community (32.88%).[11]In another study in
Maharashtra showed that, 46% of men reported
strong son preference for supporting each other, while
another 23% preferred for old age support and 21%
felt that there is a risk of survival of the child and
remaining 8% felt the need of sons for continuity of
the family name.[6]A research conducted in Gujarat
found the reasons for male child preference was

social responsibilities carried out by male (42.5%),


family name continues (23%), dependable in old age
(16%), pressure from family (11%), to perform the
cremation (4%), dowry (3%) and females are
economic liability (3%).[12]Number of studies
conducted all over the India, the reason for the son
preference was nearly same.
In this study the reasons for female child preference
were to take care of family (38.5%), attachment to the
mother (35%), daughter as a son (20%), daughter is
lovely in the family (15%), old age care (8.5%), to
take care of two families (6%), societal values (6%)
and other reasons (8.5%). A research conducted in
rural area of Pune; the most common reason for
preference of girl child was like girl child i.e.
62.38%.[11] The belief of people now slowly changing
that only son can take care of parents and support the
family. Care taking by son is in alarming condition in
our society, while the responsibility of taking care of
parents is taken by daughter. So people also prefer the
daughter, but still daughter preference is low.
The reasons for not preferring a female child was she
goes to her husband's house (27.5%), dowry
(25.5%), burden for family (21%), not earning
member (4%) and other reasons (2%). Indian society
is patrilineal and patriarchal, where sons carry the
family name and task of supporting their parents in
old age. Parents live as extended families with their
sons, daughter-in-laws, and grandchildren. On the
other hand, parents of girls are typically socially
bound to find suitable husbands for their daughters at
an early age, often pay all marriage costs, and provide
a dowry. Social norms dictate that parents cannot
expect much emotional or economic and further
contribution to their birth parent from married
daughters, who typically move into and become part
of their husbands household.[2,3,13,14]
CONCLUSION
The study confirms that son preference exists in the
rural community of Maharashtra. Desire for next
child remains high where the percentage of female
children in previous fertility were high and the desire
for next child comes down with previous fertility with
a male child. Attitude for son preference is mainly
because of the economic earning, old age care and
continuation of the family name among all groups.
394

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Int J Med Res Health Sci. 2015;4(2):391-395

Social beliefs and sociocultural practices are the


reasons for not preferring a female child.
Acknowledgment: This work was undertaken
independently and there were no funding sources.
The views expressed in the manuscript reflect those
of the authors. I am greatly indebted to all individual,
who had supported directly or indirectly for
completion of research.
REFERENCES

1. Miller B. The Endangered Sex: Neglect of


Female Children in Rural North India. Ithaca:
Cornell University Press (1981).
2. Dyson T, Moore M. On kinship structure,
female
autonomy,
and
demographic
behaviour in India. Population and
Development Review. 1983; 9(1):3560.
3. Kishor, S. Gender differentials in child
mortality: A review of the evidence. In: Das
Gupta, MEA, editor. Womens health in
India: Risk and vulnerability. Bombay, India:
Oxford University Press; 1995. p. 19-54.
4. Pande R, Astone NM. Explaining son
preference in rural India: The independent
role of structural versus individual factors.
Population Research and Policy Review.
2007; 26(1):129.
5. Government of India. Census of India 2001Census 2001 provisional results- population
totals: India. Paper-I of 2001
6. Mohan Ghule, D. Balaiah and D. D. Naik,
Son Preference Among Rural Married Men
in Maharashtra, India The Journal of Family
Welfare, December 2005; vol. 51, No. 2
7. Varma GR. Son Preference and Desired
Family Size in a Rural Community of West
Godavari District, Andhra Pradesh, India
Journal of Social Science, 2007; 15(1): 5964.
8. Puri S, Bhatia V, Swami HM. Gender
Preference and Awareness Regarding Sex
Determination amongMarried Women in
Slums of Chandigarh Indian Journal of
Community Medicine January 2007; 32(1);
60-62.

9. RohiniPande, AnjuMalhotra. Son preference


and Daughter Neglect in India International
Center for Research on Women, 30th
anniversary report (UNFPA Publication
39764)
10. Rokhsana Reza. Factors influencing fertility
preference of men in Bangladesh Faculty of
Graduate Studies, Mahidol University for the
Degree of Master of Arts(Population and
Reproductive Health Research), 2001
11. MadhuraAshturkar. A Cross-Sectional Study
of Factors Influencing Sex Preference of a
Child Among Married Women in
Reproductive Age Group was carried out in
Rural Area of Pune, Maharashtra, Indian
Journal
of
Community
Medicine.
2010;35(3):442-443
12. VaderaBN. Study on knowledge, attitude and
practice regarding gender preference and
female feticide among pregnant women
Indian Journal of Community Medicine.
2007;32(4):239-307
13. Pande R, Astone NM. Explaining son
preference in rural India: The independent
role of structural versus individual factors.
Population Research and Policy Review.
2007; 26(1):129.
14. Jeffery R, Jeffery P. Female infanticide and
amniocentesis.
Social
Science
and
Medicine. 1984; 19 (11): 1207-12.

395
Aalok et al.,

Int J Med Res Health Sci. 2015;4(2):391-395

DOI: 10.5958/2319-5886.2015.00073.9

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Received: 31st Jan 2015
Research article

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
Revised: 10th Feb 2015
Accepted: 31st Mar 2015

IN VITRO EFFECT OF VITAMIN C ON THE LABORATORY ISOLATES OF MYCOBACTERIUM


TUBERCULOSIS WITH KNOWN SENSITIVITY AND RESISTANCE TO THE FIRST LINE ANTI
TUBERCULAR DRUGS: AN EXPERIMENTAL PILOT STUDY
Talaulikar Nikita.S 1, * Dsouza Delia.B 2, Rodrigues Savio 3, Kulkarni MS 2
1

II MBBS student, Goa Medical College, Bambolim, Goa, India


Department of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa,India
3
Department of Microbiology, Goa Medical College, Bambolim, Goa, India, 403202.
2

*Corresponding author email: deliadsouza@rediffmail.com


ABSTRACT
Background and Objectives: Globally, 3.5% of new cases of Tuberculosis (TB) and 20.5% of previously treated
cases are estimated to have multidrug- resistant tuberculosis, the corresponding estimates for India are 2.2%, and
15% respectively. Progress has been made in research and development of new drugs for TB over the last decade,
thus fuelling the need for more innovative options. Recent in-vitro studies that claim Vitamin C to have an
inhibitory effect on Mycobacterium tuberculosis could possibly prove to be a major breakthrough in Medicine.
Hence this experimental study was conducted on a pilot basis with the objective of studying the in -vitro effect of
the active ingredient of vitamin C on the laboratory isolates of Mycobacterium tuberculosis that were known to be
sensitive and resistant to the first line anti tubercular drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol)
and to compare the dose related response of both sensitive and resistant strains of Mycobacterium tuberculosis to
varying concentrations of Vitamin C. Materials and Methods: Using a Completely Randomized Design, a total
of 17 viable Mycobacterium tuberculosis strains, 10 of which were sensitive to all first line anti-TB drugs
(Isoniazid, Rifampicin, Pyrazinamide and Ethambutol) and seven strains resistant to all first line Anti-TB drugs
were experimented upon. Proportion method was used to determine drug susceptibility of Mycobacterium
tuberculosis to Ascorbic acid. Data is presented in a summary table. Results: With 1mM (millimole)
concentration of Ascorbic acid, growth of Mycobacterium tuberculosis was observed on both drug containing as
well as control media, but with higher concentration of Ascorbic acid (10 mM and 100mM), no growth was
observed on Ascorbic acid containing Lowenstein Jenson media. Conclusion: Although the findings of this pilot
study add to the supportive evidence of an in- vitro susceptibility of Mycobacterium tuberculosis to Vitamin C,
the authors recommend that additional studies with larger sample size may be conducted to support the
effectiveness of Ascorbic acid used alone or in combination with other anti-tubercular drugs to look for any drug
interactions.
Keywords: Proportion method, Ascorbic acid, Mycobacterium tuberculosis
INTRODUCTION
Nearly two decades after the World Health
Organizations declaration of Tuberculosis (TB) as a
global public health emergency, major progress has
been made towards 2015 global targets set within the

context of the Millennium Development Goals [1].


One of the five priority actions required to accelerate
progress towards 2015 targets, as listed in the Global
TB report, is to ensure rapid uptake of innovations
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Nikita et al.,

Int J Med Res Health Sci. 2015;4(2)396-400

[1]

. The increasing resistance of Mycobacterium


tuberculosis (M.tb) to first line anti tubercular drugs
is a cause for concern. Globally, 3.5% (95% CI: 2.24.7%) of new TB cases and 20.5% (95% CI: 13.627.5) of previously treated cases are estimated to
have multidrug- resistant tuberculosis (MDR-TB), the
corresponding estimates for India are 2.2(CI: 1.9-2.6),
and 15(CI: 11-19) respectively [2]. Although the
statistics reveal a very slow yet a hopeful decrease in
the TB related mortality in India over the last few
years [1-3], it is a known fact that the Tuberculosis
treatment regimen has faced many dead ends with
resistance developing rapidly both in vivo and in vitro
[4,5]
, and the subsequent rise in the MDR and
extensively drug-resistant tuberculosis cases has
fuelled the need for a more innovative option [1].
Researchers all over the world are looking for
innovative ways to treat Tuberculosis. Literature
search documents the findings of Dr. Frederick R
Klenner who claimed that Vitamin C fulfilled the
requirements of an antibiotic due to its capacity to
function as a reducing agent or the precursor of such
a substance [6]. In a study by McConkey M et al [7], of
the twenty-one animals which were given a
tuberculous sputum feed along with a diet deficient in
Vitamin C or A, C, D; seventeen developed open
tuberculous ulcers, three caseous non-ulcerative
lesions, and the intestinal tract of only one animal
was normal at necropsy. Nine out of the ten animals,
receiving supplements of Vitamin C along with
tuberculous sputum feed did not develop intestinal
TB. Taneja et al [8] showed that Vitamin C mimics
multiple intracellular stresses and has wide-ranging
regulatory effects on gene expression and physiology
of M. tuberculosis which leads to growth arrest and a
dormant drug-tolerant phenotype . Vilchze C et al
[9]
demonstrated ability of vitamin C to sterilize M.
tuberculosis cultures. Narwadiya SC et al [10] claim
Vitamin C to have similar dose related inhibitory
effect on Mycobacterium tuberculosis. Given this
possibility, the effect of Vitamin C on
Mycobacterium tuberculosis could prove to be a
major breakthrough in Medicine. This highlighted the
need for an in-vitro experimentation of Vitamin C on
various strains of Mycobacterium tuberculosis.
Therefore this experimental pilot study was aimed at
testing the effect of active ingredient of Vitamin C
(Ascorbic Acid) on the sensitive as well as the
resistant strains of Mycobacterium tuberculosis of
routine Tuberculosis patients obtained from the

laboratory stocks at Intermediate Reference


Laboratory (IRL), Department of Microbiology, Goa
Medical College with the following objectives: 1) To
study the in vitro effect of the active ingredient of
vitamin C on the laboratory isolates of
Mycobacterium tuberculosis with known sensitivity
and resistance to the first line Anti tubercular drugs
currently used in DOTS (Directly Observed
Treatment, Short Course) regimen of RNTCP
(Revised National Tuberculosis Control Programme).
2) To compare the dose related response of both
sensitive and resistant strains of Mycobacterium
tuberculosis to varying concentrations of Vitamin C.
METHODOLOGY
Type of study: This is an experimental laboratory
based study.
Ethics approval: The study was conducted after
prior approval from the Institutional Ethics
Committee. Study design: Completely Randomized
Design was used.
Methodology: M. tuberculosis strains used in this
study were obtained from laboratory stocks of year
2011 onwards, isolated from routine TB patients,
provided by IRL at the Department of Microbiology,
Goa Medical College, Goa.
The isolates were first sub cultured on Lowenstein
Jenson (LJ) media to ensure their viability. Thirtyeight strains of Mycobacterium tuberculosis from the
laboratory stocks were first subjected to subcultures,
of which 20 viable strains were further subjected to
DST (Drug Susceptibility Testing). Since three
strains got subsequently contaminated, a total of 17
viable strains, 10 of which were sensitive to all first
line anti-TB drugs (Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol) and seven strains
resistant to all first line Anti-TB drugs, were finally
experimented upon.
Drug susceptibility testing (DST) of Mycobacterium
tuberculosis to Ascorbic acid (active ingredient of
Vitamin C) was done using Proportion Method. [11] .
Drug free/plain LJ media was used as control during
the procedure for DST and the LJ media containing
L-Ascorbic acid (99.7%) AR 2013 served as the drug
containing media. Ascorbic acid solution of varying
concentrations (1, 10 and 100 millimoles) was
sterilised by Membrane filtration. The final LJ media
was sterilised by Serum Inspissation. The cultured
media were incubated at 37oC; the observations for
397

Nikita et al.,

Int J Med Res Health Sci. 2015;4(2)396-400

growth were made on days 28 and 42. [11]. Sensitivity


and resistance pattern was interpreted as per the

Revised National TB Control Programme Training


Manual Guidelines [11].

RESULTS
Table 1: Results of the Drug susceptibility testing

Mycobacterium
tuberculosis strains

Strains sensitive to
all four standard
first line anti-TB
drugs (H, R, Z, E)
Strains resistant to
all four standard
first line anti-TB
drugs (H, R, Z, E)
Total

Ascorbic acid (1 mM)


(n=17)

Ascorbic acid (10 mM)


(n=17)

Ascorbic acid (100 mM)


(n=17)

No growth of
M.tb observed in
drug containing
media
No.

Growth of
M.tb observed in
drug containing
media
No.

No growth of
M.tb observed
in
drug
containing
media
No.

Growth of M.tb
observed in
drug
containing
media
No.

No growth of
M.tb observed
in
drug
containing
media
No.

Growth of M.tb
observed in
drug
containing
media
No.

10

10

10

17

17

17

H=Isoniazid, R=Rifampicin, Z=Pyrazinamide and E=Ethambutol


One mM concentration of Ascorbic acid, permitted
growth of Mycobacterium tuberculosis strains in both
drug - containing as well as control media. Dose of
Ascorbic acid was further increased to 10 mM and
100 mM, to study the dose-dependant response of the
10 sensitive and seven resistant M.tuberculosis
strains. No growth of Mycobacterium tuberculosis
strains was observed with higher concentration of
Ascorbic acid (10 mM and 100mM). The LJ media
with 100 mM concentration of Ascorbic acid
however turned dark green in colour and the reason
could not be ascertained. The observations made on
day 28 and 42 remained unchanged.
DISCUSSION
In this pilot experiment, both the control (Ascorbic
acid free media) as well as Ascorbic acid containing
media, showed growth of Mycobacterium
tuberculosis colonies at lower concentration (1mM)
of Ascorbic acid. However a study done by Vilchze
C et al [9] found the minimum inhibitory concentration
(MIC) of Vitamin C that prevented the growth of M.
tuberculosis was one mM. This difference in the
observations could be attributed to loss of biological
activity of Ascorbic acid at lower concentrations
subsequent to serum inspissation at 80oC for an hour

on consecutive days, which happens to be the


standard sterilisation procedure for preparing LJ
Media.
Another possible explanation to support this could be
found in studies done by Alvarado JD et al [12] and
Munyaka AW [13] which state that at higher
temperatures, conversion of its active ingredient, i.e.
l-ascorbic acid to dehydroascorbic (DHAA) takes
place. DHAA could be easily converted to other
compounds that do not have the biological activity of
Vitamin C. The issue of possible loss of biological
activity due to heat degradation could be addressed
by using a liquid media or any other selective media,
which would have allowed the addition of Vitamin C
after sterilisation.
In our study, we observed a dose related response (no
growth of M. tb strains) with higher concentrations of
Ascorbic acid. The absence of growth of
Mycobacterium tuberculosis (both sensitive and
resistant strains) at higher concentrations of Ascorbic
acid i.e. 10mM and 100 mM, could either be due to
some chemical alteration or shift of pH of LJ medium
that may have possibly lead to inability of M.
tuberculosis to grow in the media, or the lack of
growth may also be due to the unique susceptibility

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Int J Med Res Health Sci. 2015;4(2)396-400

of Mycobacteria to Ascorbic acid as claimed by


similar research studies conducted in the past. [7-10]
CONCLUSION
The objectives with which we started the pilot study
were largely met. With regards to the first objective
the authors found that all 17(100%) of the laboratory
isolates of Mycobacterium tuberculosis which were
sensitive (10 strains) as well as resistant (seven
strains) to first line anti TB drugs used in RNTCP,
showed in-vitro susceptibility to the active ingredient
of Vitamin C at higher concentrations (10mM and
100 mM). Our second objective was to compare the
dose related response of both sensitive and resistant
strains of Mycobacterium tuberculosis to varying
concentrations of Vitamin C. We observed that at
1mM concentration, Vitamin C did not have any
effect on the Mycobacterium isolates, but had effect
only at higher concentrations of 10mM and 100 mM.
Although the findings of this pilot study add to the
supportive evidence of an in- vitro susceptibility of
Mycobacterium tuberculosis to Vitamin C, the

authors recommend that further studies with larger


sample size may be conducted to support the
effectiveness of Ascorbic acid used alone or in
combination with other anti-TB drugs to look for any
drug interactions. Clinical trials in humans using
Vitamin C supplementation to study the in-vivo effect
of Vitamin C in patients who are on DOTS regimen
for treatment of Tuberculosis could also be thought
of. This could revolutionize the current scenario in
relation to treatment of Tuberculosis.
LIMITATIONS OF THE STUDY
1. Use of a selective liquid media would have
allowed the addition of Ascorbic acid after
sterilization, thus ruling out the possibility of loss
of efficacy of Ascorbic acid due to degradation at
higher temperatures (if any) and would probably
have given us results with the lower
concentration (1mM).
2. The reason for the dark-green colouration of LJ
media with 100 mM concentration of Ascorbic
acid could not be ascertained.

Figure 1: Summary

ACKNOWLEDGEMENT
The authors would like to thank the Indian Council of
Medical Research for the research grant awarded to
the first author (undergraduate student from II
MBBS) to conduct this experimental pilot study
through its Short Term Studentship program. The
authors express their sincere thanks to Ms Puja A.
Parulekar (Senior Laboratory Technician at IRL, Goa
Medical College and Dr Cigy C Borges,

Microbiologist at IRL, Goa Medical College for the


immense
guidance,
technical
support
and
cooperation, received while conducting this pilot
experiment in the Microbiology laboratory of Goa
Medical College without whom it would not be
possible to conduct such a study. We also thank the
Institutional Ethics Committee for approving this
pilot research study.
Conflict of interest: NIL
399

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Int J Med Res Health Sci. 2015;4(2)396-400

REFERENCES
1. World Health Organisation (WHO). Global
Tuberculosis Report 2013. Geneva: WHO; 2013.
2. World Health Organisation (WHO). Global
Tuberculosis Report 2014. Geneva: WHO; 2014.
3. World Health Organisation (WHO). Global
Tuberculosis Report 2012. Geneva: WHO; 2012.
4. Colijn C, Cohen T, Ganesh A, Murray M.
Spontaneous Emergence of Multiple Drug
Resistance in Tuberculosis before and during
Therapy. PLoS ONE.2011; 6(3): e18327. Doi:
10.1371/journal.pone.0018327.
5. Selkon JB.. The emergence of isoniazid-resistant
cultures in patients with pulmonary tuberculosis
during treatment with isoniazid alone or isoniazid
plus PAS. Bull. World Health Organ. 1964; 31:
27394.
6. Klenner FR. Massive doses of vitamin C and the
virus diseases. South Med Surg. 1951 Apr; CIII
(4): 101-7.
7. McConkey M, Smith DT. The Relation of
Vitamin C Deficiency to Intestinal Tuberculosis
in the Guinea Pig. J. Exp. Med. 1933; 58: 503
512.
8. Taneja NK, Dhingra S, Mittal A, Naresh M,
Tyagi
JS.
Mycobacterium
tuberculosis
transcriptional adaptation, growth arrest and
dormancy phenotype development is triggered by
vitamin C. PLoS One. 2010; 5: e10860.
9. Vilchze C, Hartman T, Weinrick B, Jacobs W R.
Mycobacterium tuberculosis is extraordinarily
sensitive to killing by a vitamin C-induced
Fenton reaction. Nat Commun.2013; 4: 1881.
10. Narwadiya SC, Sahare KN, Tumane PM,
Dhumne UL, Meshram VG. In vitro
antituberculosis effect of vitamin C contents of
medicinal plants. Asian J. Exp. Biol. Sci. 2011; 2:
15154.
11. Directorate General of Health Services, Ministry
of Heath and Family Welfare, Central TB
Division. Revised National TB Control
Programme Training Manual for Mycobacterium
tuberculosis Culture and Drug Susceptibility
Testing. New Delhi: 2009: 1-76.
12. Alvarado JD, Palacios VN. Effect of temperature
on the aerobic degradation of vitamin C in citric
fruit juices. Arch Latinoam Nutr. 1989 Dec;
39(4): 601-12.

13. Munyaka AW, Makule EE, Oey I, Van Loey A,


Hendrickx M.Thermal stability of L-ascorbic acid
and ascorbic acid oxidase in broccoli (Brassica
oleracea var. italica). J Food Sci. 2010 May;
75(4): C336-40. . doi: 10.1111/j.17503841.2010.01573.x

400

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Int J Med Res Health Sci. 2015;4(2)396-400

DOI: 10.5958/2319-5886.2015.00074.0

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 14 Feb 2015
Research article

Coden: IJMRHS
Revised: 20th Mar 2015

Copyright @2015
ISSN: 2319-5886
Accepted: 30thMar 2015

PREVALENCE AND FACTORS AFFECTING BURNOUT AMONG SECONDARY CARE DOCTORS


IN BAHRAIN- A CROSS SECTIONAL STUDY
Husain Isa Hasan1, Yusuf Nooh1, * Adel Salman Alsayyad2
1

Family Physician, 2Consultant Family Medicine, Public Health & Epidemiology, at Ministry of Health, Bahrain

*Corresponding author email: Asayyad@health.gov.bh


ABSTRACT
Background: Burnout isa type of prolonged response to chronic job-related stress appears as a syndrome of
emotional exhaustion, depersonalization, and reduced personal accomplishment. Objectives: The present study
investigated level of burnout, compare burnout levels in view of demographic factors and to identify the potential
risk factors that lead to high level of burnout among secondary care doctors in Ministry of Health in Bahrain
kingdom. Methods: The study was carried out in 230 doctors. A questionnaire survey was administered: The
level of "burnout" was evaluated using the Maslach Burnout Inventory; socio-demographic variables were
collected as well. Results: the mean response rate was 87.8%. The prevalence of the three dimensions of burn out
was 43.1% with high emotional exhaustion, 26.7% with high depersonalization and 51.5% reported low personal
accomplishment. In general, the profiles of an individual with high burn out were between 30-40 years old
Bahraini married physician with no children. Conclusion: a high level burnout was found among the studied
population. The study results underline significant relations that were found to link burn out with various sociodemographic variables.
Keywords: Prevalence, Factors, Burnout, Secondary care, Doctors, Bahrain
INTRODUCTION
Burnout definition had come long way since its first
definition in 1947. Even though Many Burn out
definitions do existfor this research the definition of
burnout that will be used is adopted from Maslach
and Jackson (1986) because it is the most widely used
across the world [1].This definition stated that:
Burnout is a syndrome of emotional exhaustion,
depersonalization,
and
reduced
personal
accomplishment that can occur among individuals
who do people work of some kind [2].
Burnout have a devastating effect on work force and
hence on work out come. Burnout is associated with
decreased job performance and commitment[3,4] and
lower career satisfaction[5,6] which can lead to
increased incidence of errors in clinical care[7] and
lower quality of care[8,9,10]. People who are
experiencing burnout can have a negative impact on
Hasan et al.,

their colleagues, both by causing personal conflicts


and disrupting job task[11].
There is also some evidence that burnout has a
negative "spill over" effect on both physician's home
life as they experience an increasing family problems
[7, 12, 13, 14]
and the physician's health. Health is highly
affected by burnout as burn out might cause mental
dysfunction such as anxiety[7,15],depression[7,9,15],Low
self-esteem and morale[11], increased use of alcohol
and drugs addiction[7,8,15] eating disorder and massive
weight gain[7,15].
Burnout is not a new phenomenon it has its root in
the past. However, because of a unique constellation
of several factors it was discovered in the early
1970s as a particular type of prolonged occupational
stress that seemed to occur most prominently among
human services professionals [16].
401
Int J Med Res Health Sci. 2015;4(2):401-406

Physicians' burnout is common with rates ranging


from 25% to 76%, depending on the socio-economic
characteristics and working conditions [2, 17, 18, 19, 20].
The level of burnout is higher among employees over
30 years old[18, 21, 22].Some studies show higher
burnout for women[23,24,25], some show higher scores
for men[8,21,26](males often score higher on cynicism
where as women score slightly higher on
exhaustion),and
others
find
no
overall
[3,27,28]
differences
.Singles seem to experience higher
burnout levels[18, 29, 30], even more than those who are
divorced[21]. Being a parent [31] and having a physician
father are protectors from burnout [32].
MATERIALS AND METHODS
Type of study: A cross-sectional design was used in
the main secondary care hospital in Bahrain
Inclusion criteria: The participants were randomly
enrolled from the list of doctors from chief of medical
staff in Salmaniya Medical Complex.
Doctors working in training pool & service pool in
the following SMC departments: medical, surgical,
pediatrics, obstetrics& gynecology, orthopedics,
psychiatry, ophthalmology, emergency, ENT,
radiology, pathology, anesthesia, neuroscience and
oncology. The Training pool doctors were those in
the specialty training residency program (STRP)
which is a recognized program that adapt the training
doctors to pass the Arab Board Medical
Specializations requirements. The total number of
doctors in SMC was obtained from the head of
medical education & training office and was
confirmed by the secretary of each department which
was equal to 675.
Sample size: The sample size was calculated using
the epi-info program version 6.0 to calculate sample
size.The sample size was 230 candidates.
Exclusion criteria: Doctors who were on study leave
(more than 3months) during the period of data
collection were excluded from the study
Ethical approval: Privacy and confidentiality was
ensured during data collection. The questionnaire was
filled anonymously. Ethical approval was received
from Technical research committee in ministry of
health Bahrain.
Methodology: Maslach Burnout Inventory Human
Services questionnaire [2]was used as a tool for
measuring the prevalence of burnout syndrome
among the secondary care doctors in this research. It

was correlated with the participants demographic


data and the job Characteristics.
The Maslach Burnout Inventory (MBI) [2]:The
initial research on the (MBI) was based on data from
the United States and Canada but subsequent studies
had been done in many countries around the world
and the (MBI) had been translated burnout.
Psychometric studies of the (MBI) in these different
settings have into various languages. Nowadays it is
considered as the leading measure of continued to
validate the three-dimensional structure of the
measure.
There are now three versions of the (MBI)[2]:
1. The original measure that was designed for
professionals in the human services (MBI Human
Services Survey or MBI_HSS).
2. An adaptation of the original measure for use
with educators (MBI Educators Survey, or
MBI_ES; formerly known as MBI Form Ed).
3. A new version of the MBI designed for use with
workers in other occupations (MBI General
Survey, or MBI_GS).
For this research, the Maslach Burnout Inventory_
Human services Survey (MBI_HSS) was devised as
an instrument to asses Burnout. It has been found to
be reliable, valid, and easy to administer [2].
Permission obtained from the author of the study to
use the questionnaire and from the chairperson of
secondary care research committee to implement the
study.Each participant was given the questionnaire by
hand and asked to answer it alone without knowing
how the other participants responded to the questions
to insure privacy. An accompanying cover letter was
attached to inform the participants that the purpose of
the study was to explore the job related attitudes of
the residents. The word "Burnout" was not mentioned
in the cover letter as recommended by the Maslach
Burnout Inventory2.No financial or other incentives
were offered for participation. Complete instructions
were provided for the participants and they were
given 10-15 minutes to fill out the questionnaire.
Explanations to some difficult words in the
questionnaire were added. Once the questionnaire
filled, it was collected immediately. Those who were
unable to fill it out were requested to fill it in their
leisure time and were followed up. Statistical
analysis: For data Analysis and interpretation the
authors adopted the methods explained in the
Maslach Burnout Inventory Manual 3rd edition[2].For
402

Hasan et al.,

Int J Med Res Health Sci. 2015;4(2):401-406

our study the Statistical Package for Social Sciences


(SPSS) version 15 was used to enter and analyze the
data collected.

Emotional exhaustion. All these relationships were


statistically not significance. (Table 3)
Table1: Demographic Data of participant of
secondary care doctors in ministry of health of
Bahrain kingdom.

RESULTS

230 full-time doctors were asked to complete a brief


Factors
N
(%)
and simple survey that was specifically designed for
Male
122
60.7
Gender
the purpose of this study. The general response rate
Female
79
39.9
was 87.7%.Total number of participants in this study
Total
201
100.0
was 202. 60.7% (122) were male. The average age for
<30
58
32.0
the participants was 36 years with 9 SD. 41.1 % of
Age
30-40
75
41.4
those who answered the Age question were in the age
>40
48
26.5
group 30-40 years. Almost three quarters of the
Total
181
100.0
participants (72.8%) were married and 79 (76.7%) of
Current Marital Not married 54
26.9
them had children. The majority of the participants
Married
147
73.1
were Bahraini 164 (83.7%). (Table 1).The prevalence
status
Total
201
100.0
of the three dimensions of burn out among our
No
24
23.3
sample was in the high category in emotional
Having
Yes
79
76.7
exhaustion (43.1%) and in the low category for both
children
Total
103
100
depersonalization (DP) and personal accomplishment
Bahraini
164
83.7
(51.5%). (Table 2)In terms of the socio-demographic
Nationality
factors being >40 years old is less likely to
Non
32
16.3
experience a high levels of Emotional exhaustion
Bahraini
(18.8%) and depersonalization (8.3%) but they have a
Total
196
100.0
low level of personal-accomplishment (75%) ,
Table 2: The Prevalence of Burnout dimensions
whereas, being Bahraini was associated with a high
among secondary care doctors in ministry of
levels of Emotional exhaustion (47.6 %). Both
health of Bahrain kingdom.
relationships were statistically significant (Table
Burnout
Low
Average
High
3).On the other hand, males showed lower levels of
dimension
N (%)
N(%)
N(%)
personal accomplishment (54.1%), females showed
Emotional
70(34.7)
45(22.3)
87(43.1)
high levels of Emotional exhaustion (49.4%). Married
Exhaustion
Depersonalization
104(51.5)
44(21.8)
54(26.7)
doctors had a higher score of Emotional exhaustion
Personal
104(51.5)
53(26.2)
45(22.3)
(46.3) and lower levels of personal accomplishment
Accomplishment
(57.8%). The results also showed that those who
N= Number
haveno children (62.5%) had high levels of
Table 3:The relation between Demographic characteristics and burnout dimensions among secondary care
doctors in ministry of health in Bahrain kingdom
Factors
Age

<30

High Emotional Exhaustion


N
%
P value
25
43.1
0.01

Gender

30-40
>40
Male

42
9
48

56.0
18.8
39.3

Female
Not married
Married
No
Yes
Bahraini
Non-Bahraini

39
19
68
15
36
78
7

49.4
35.2
46.3
62.5
45.6
47.6
21.9

Current
marital status
Having
Children
Nationality

0.57
0.33
0.35
0.01

High Depersonalization
N
%
P value
18
31.0
0.01

Low Personal accomplishment


N
%
P value
22
37.9

23
4
35

30.7
8.3
28.7

38
36
66

50.7
75.0
54.1

19
16
38
7
16
50
4

24.1
29.6
25.9
29.2
20.3
30.5
12.5

38
19
85
14
51
83
19

48.1
35.2
57.8
58.3
64.6
35.6
59.4

0.15
0.84
0.21
0.07

0.01
0.28
0.08
0.5
0.91

*P value of Chi Square test


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Int J Med Res Health Sci. 2015;4(2):401-406

DISCUSSION
This study was concerned to demonstrate the interrelationship of the three most important aspects of
Burnout which are: Emotional exhaustion (EE),
Depersonalization (DP) and Personal accomplishment
(PA) among secondary care physicians of the
ministry of health in Bahrain. There are a lot of
factors which have been studied and have proved the
strong association among those aspects.
In this study, it was found that doctors who spent 510 years of practicing medicine whom are mainly
training doctors who carry most of the work load and
decision making have a high levels of
depersonalization
and
emotional
exhaustion.
Moreover, physicians who were in the age group of
(30-40) have shown strong exhibition of burnout
among them with a rate of (41.1%). Both of these
results reflects the fact that older doctors has less
burnout than their younger beers which is similar to
previous literature.[18, 21, 22] This protective effect of
older age of physician might be due to the increase in
financial security and cultural factors that attribute
older age with more respect and trust from patients.
The study found no significant difference in burn out
between males and female participants which is
similar to what had been previously shown in other
studies[3,27,28]. This might be due to equally distributed
work load regardless of gender
It was found that Bahraini doctors have lower levels
of emotional exhaustion in comparison to NonBahraini doctors.
This may be attributed to the fact that non Bahraini
doctors has a lower expectations from the work and
actually for most of them working in Bahrain may
make them feel that they have achieved certain goals
In their careers, especially financial. They are less
involved in argumentation with senior colleagues and
higher authorities, and social and political issues. In
addition, they also have- in general- a good working
deal that include allowances for housing, annual
airline tickets to the home country plus school fees
for their children[18, 29, 30].
Limitations of this study were its cross-sectional
design which creates difficulties in ascertaining
causality. Several factors from in or outside work
might have influenced both the perception of the
work and the level of burnout and therefore might be

confounders. Employees who are currently depressed


or burned out perceive the characteristics of their
work more negatively compared with healthy
employees[31].
The other limitation factor was the nature of the
sample which included physicians from different
specialties, different institutions, different income,
levels and working conditions so it was not possible
to draw conclusions regarding specific physician
group or working conditions [32].
CONCLUSION
A high level burnout was found among the studied
population. The study results underline significant
relations that were found to link burn out with various
socio-demographic variables.
Recommendations: In view of Burnout is prevalence
and its adverse effect on the doctors wellbeing, doctor
patient relationship and quality of care; we
recommend periodically surveying physicians and
organization for Burnout.
Further research is necessary for more comprehensive
understanding of the problem of Burnout and
psychiatric
morbidity
among
physicians,
improvement of medical training and attention to the
psychological implications of working in health care
may facilitate prevention and treatment of possible
emotional problems physicians may encounter during
their career. This might in turn, have positive effect
on the doctor-patient relationship and quality of care.
ACKNOWLEDGMENT
We would like to deeply and greatly Mr. Hasan A.
Albasri for his great assistance in biostatistics
analysis, Mr. Warwick Price for his generous
assistance by providing us with to tools to measure
burnout.
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DOI: 10.5958/2319-5886.2015.00075.2

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
Received: 17th Jan 2015
Revised: 10th Feb 2015
Research article

Copyright @2014
ISSN: 2319-5886
Accepted: 31st Mar 2015

COMPARISON OF INDUCTION, INTUBATION AND RECOVERY CHARACTERISTICS OF


HALOTHANE + PROPOFOL V/S SEVOFLURANE + PROPOFOL IN CHILDREN UNDERGOING
ADENOTONSILLECTOMY
Sarabjit kaur 1, Veena Chatrath 2, Gagandeep Kaur 3, Vishal Jarewal 4, *Kulwinder S Sandhu 5, Sudha6
1, 2

Professor, 3,6Senior Resident, 4Resident, Department of Anaesthesia, 5Senior Resident, Department of ENT,
GMC Amritsar, India.
*Corresponding author: Kulwinder S Sandhu Email: gsandhu2454@gmail.com
ABSTRACT
Purpose: General anaesthesia for oral surgeries in paediatric patients is always challenging for an
anaesthesiologist. Aim was to compare halothane+propofol and sevoflurane+propofol in paediatric patients
undergoing adenotonsillectomy without muscle relaxant. Method: In a double blind manner, eighty patients of 310 years were premedicated with inj. Atropine and randomly divided into two groups of forty each. In Group A,
priming was done with 50% oxygen+50% nitrous oxide+4% halothane for 1 minute, after loss of eye lash reflex
and centralisation of pupil intravenous cannulation done. Inj. midazolom, lignocaine and Propofol were given
and trachea was intubated. Maintenance was done with 1-2% halothane+ nitrous oxide+ oxygen and continuous
propofol infusion. Similar technique was used in group B except for priming done with sevoflurane 7% and
maintenance with 2-3%. Both groups were compared for induction, intubating conditions, haemodynamics and
emergence characteristics. Results: Induction was rapid in group B as time for loss of eye lash reflex and
centralisation of pupil was less in group B (21.8812.6 &114.4028.8 seconds) as compared to group A
(33.054.0 & 140.0512.1 sec) p<0.001. Intubating conditions were excellent but mean intubation time was less
in group B as compared to group A p<0.001. Heart rate and blood pressure remained on lower side in group A.
Emergence was significantly rapid in group B. No side effect or complications were noted. Conclusion: Both
groups provided excellent intubating conditions but sevoflurane+propofol group was better as it provided faster
induction and rapid recovery from anaesthesia with more stable haemodynamics as compared to
Halothane+propofol group.
Keywords: General anaesthesia, Paediatric, Halothane, Sevoflurane, Propofol.
INTRODUCTION
General anaesthesia for adeno-tonsillectomy in
paediatric patients is always challenging for an
anaesthesiologist as there is sharing of the airway
with the surgeon, limited access and risk of soiling
the airway with blood. Children with adenotonsillar
hypertrophy can have nasal obstruction, reactive
airways and sometimes obstructive sleep apnoea.[1]
They are at increased risk of desaturation,
laryngospasm and airway obstruction during
induction of anaesthesia.[2] Hence induction in these
patients is preferred with potent inhalational agents,

which can be used as an alternative to muscle


relaxants to facilitate tracheal intubation and to
further avoid the potential side effects of muscle
relaxants like myalgias, hyperkalemia, masseter
spasm or malignant hyperthermia.[3,4] Halothane with
its sweet odour and minimal effects on airway
reactivity makes it a suitable agent for paediatric
anaesthesia, despite its propensity to cause
bradycardia,
hypotension
and
arrhythmias.[5]
Sevoflurane has nonpungent odour, provides rapid
onset and emergence from anaesthesia and has less

Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

407

cardiovascular side effects, which makes it an


attractive alternative for paediatric anaesthesia.[6]
Induction,
recovery
characteristics
and
haemodynamics of Halothane and Sevoflurane in
paediatric patients have been compared previously
also. But in most of the studies, either muscle
relaxants were used for intubation [7,8] or where
muscle relaxants were omitted, perfect intubating
conditions were not obtained.[9,10,11] Propofol an
intravenous induction agent, can be considered as an
alternative to muscle relaxants as it attenuates
laryngeal and pharyngeal reflexes, provides better
jaw relaxation [3] and also decreases the extubation
related complications.[12] With these considerations
in mind, the present study was done to compare
induction characteristics, intubating conditions,
haemodynamics and recovery profile of Halothane +
propofol and Sevoflurane + propofol without muscle
relaxants in paediatric patients undergoing
adenotonsillectomy.
Aim and objectives
Induction
characteristics
and
intubating
conditions.
Haemodynamic parameters
Recovery characteristics.
Side
effects
and
complications
of
halothane+propofol and sevoflurane+propofol in
paediatric patients.
MATERIAL AND METHODS
After approval from the institutional ethics
committee, this double blind randomised study was
conducted on eighty patients of American Society of
Anaesthesiologist (ASA) grade I and II in the age
group of 3 to 10 years undergoing adenotonsillectomy under general anaesthesia. Patients with
history of acute upper respiratory tract infection,
Hematocrit < 25%, bleeding disorders, hepatic or
renal dysfunction, congenital anomalies, exposure to
general anaesthetic agents in previous seven days,
any contraindication for using study drugs or personal
or family history of malignant hyperthermia were
excluded from the study. A well informed written
consent was taken from the parents or guardians of
the patients included in the study. A day before
surgery, a detailed preanaesthetic checkup was done.
General physical examination and systemic
examination was done. Mallampatti grading was done
to assess the airway. Routine investigations were

noted and if needed special investigations were


ordered. Weight of each patient was recorded.
Patients were randomly divided in to two groups of
forty each, Group A: (Halothane + propofol) and
Group B (Sevoflurane + propofol) is using a
computer-generated randomization technique. On the
day of surgery, patients were reassessed
preoperatively and after confirming overnight fasting,
patients were shifted to operating room and multipara
monitor was attached to monitor baseline heart rate,
respiratory rate, systolic blood pressure (SBP),
diastolic blood pressure (DBP), mean arterial blood
pressure (MAP), SPO2 and electrocardiograph
(ECG). Continuous monitoring of vitals was then
started.
In group a (halothane + propofol), priming of circuit
was done with 4% halothane + 50%: 50% of oxygen
and nitrous oxide for one minute. In group B
(sevoflurane + propofol), priming of the circuit was
done with 7% sevoflurane + 50%: 50% of oxygen
and nitrous oxide for one minute. Face mask of
appropriate size was kept on the face of
spontaneously breathing patient and time taken to
loss of eyelash reflex as a sign of loss of
consciousness was noted. Time taken to complete
induction (centralisation of pupil, no gross bodily
movements) was also recorded. Induction was done
by a senior anaesthesiologist who was unaware of the
inhalation agent used as the vapourisers were
concealed by a screen and dial settings were adjusted
by a separate anaesthesiologist. The anaesthesiologist
doing the induction also recorded all the variables.
After centralisation of pupils, intra venous
cannulation was done and infusion of Isolyte P was
started. Any bodily movements occurring at the time
of cannulation were noted. Injection midazolam 0.04
milligram per kilogram body weight, injection
lignocaine 1 milligram per kilogram body weight
followed by bolus dose of Injection propofol 3 mg/kg
body weight intravenously was given. After giving
propofol concentration of halothane was reduced to
2% in group A and Sevoflurane was reduced to 4% in
group B. Bag and mask ventilation was started and
when adequate jaw relaxation was obtained, trachea
was intubated with appropriate sized endotracheal
tube without using any muscle relaxant. Care was
taken that endotracheal tube does not touch the
carina. Injection Atropine sulphate was given only if
indicated to decrease secretions. The quality of
408

Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

intubating conditions was assessed by using scoring


system devised by Helbo-Hansen, Ravio and TrapAnderson [13] and revised by Styne and colleagues. [14]
Following parameters were noted: Jaw relaxation,
Ease of laryngoscopy, Vocal cord positioning,
Coughing on laryngoscopy or intubation and any
Limb movements. For all variables, score of 1-4 was
taken, where score of 1 was taken as ideal conditions,
therefore total score of five was taken as best possible
score for all parameters. Other variables like
laryngospasm, struggling, oxygen desaturation and
hemodynamic changes occurring during induction
and intubation were also recorded. Immediately after
intubation, paracetamol suppository (20mg/kg body
weight) per rectum was given for analgesia.
Maintenance of anaesthesia was done with 40%
oxygen: 60% nitrous oxide + either 1-2 % halothane
in group A or 2-4% sevoflurane in group B. After
intubation, Continuous intravenous infusion of
propofol was started at the rate of 5-7 milligram per
kilogram body weight per hour. Any of the patients
requiring muscle relaxant during surgery were
excluded from the study. Continuous monitoring of
respiratory rate, systolic and diastolic blood pressure,
mean arterial pressure, heart rate, SPO2,
electrocardiogram was done at 1st minute, 3rd minute,
5th minute and then at every 5 minute interval till the
completion of surgery. If the heart rate or blood
pressure varies more or less than 20% of the baseline
value, then the concentration of inhalational agent
was increased or decreased accordingly. At the
completion of surgery, oropharyngeal and
endotracheal suctioning was done in deep plane of
anaesthesia. Nitrous oxide and inhalational agents
were stopped and 100% oxygen was given.
Intravenous infusion of propofol was continued till
the spontaneous respiration was considered adequate
and patients were extubated. During recovery,
emergence time (time taken from stoppage of all
anaesthetic agent to that when patient responds to
verbal commands) and time taken to shift the patient
to recovery room (time taken from the time when
patient start responding to verbal commands to the
time when patient regained full consciousness) was
noted. Any coughing, laryngospasm and struggling
on emergence were noted. Mental state assessment
(alert, awake, agitated or Drowsy) was done during
shifting the patient to recovery. Any post operative
nausea and vomiting was also noted. In the post

operative period, syrup Ibuprofen + paracetamol were


given as rescue analgesia. Syrup ondansetron was
given for managing postoperative nausea and
vomiting. All patients were observed for any side
effect or complications of the procedure. Statistical
analysis: The data from the present study was
systematically collected, complied and analysed using
SPSS 19.0 evaluation version. Data was expressed as
mean and standard deviation. The patients
characteristics (non parametric data) were analysed
by using the Chi Square tests while the inter group
comparison of the parametric data was done by using
unpaired t test. The p value was determined finally
to evaluate the levels of significance. The p value of
> 0.05 was considered not significant; p value of 0.01
to 0.05 was considered significant and p value < 0.01
was considered highly significant. Power analysis
was done to calculate the power of study by taking
error at 0.05. Effect size was calculated and power
was above 90%.

Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

RESULTS
In the present study both groups were comparable
with respect to age, sex ratio, weight, duration of
surgery and baseline haemodynamic parameters as
shown in table: 1. During induction, time taken for
loss of eye lash reflex and centralisation of pupil was
significantly less in group B as compared to group A
(P=0.00). Mean time taken from induction of
anaesthesia to intubation of trachea (intubation time)
was also significantly less in group B as compared to
group A. (table: 2). However intubating conditions
were excellent and comparable in both the groups.
There was complete jaw relaxation, open vocal cords
on laryngoscopy with no coughing, no laryngospasm,
no limb movements or struggling during intubation in
both the groups. None of the patient had oxygen
desaturation in both groups during induction and
intubation. During maintenance of anaesthesia, none
of the patient required non depolarising muscle
relaxant in both the groups. Total amount of propofol
required during maintenance of anaesthesia in group
A (88.112 34.54 milligram) and group B (98.187
34.02milligram) was also comparable
(P=0.193).Mean heart rate remained on lower side in
group A as compared to group B at all measured
intervals from 2nd to 60th minutes and the difference
between the two groups was highly significant
(p=0.00). But after 60 minutes, heart rate remained
409

stable and comparable in both the groups as shown in


fig: 1. The maximum percentage fall in heart rate was
observed at third minute and that too was
significantly more in group A (21.55% fall) as
compared to group B(9.93% fall) (p<0.01). Mean
systolic blood pressure (SBP) remained stable and
comparable in the two groups during first two
minutes (p>0.05), after that SBP was significantly on
lower side in group A as compared to group B at 3rd,
4th and 5th minute (p<0.001). After 5th minute, mean
SBP was comparable in both groups (p>0.05) at all
measured intervals upto 60 minutes.(fig: 2). However
maximum percentage fall in SBP was significantly
more in group A (20.492.64%) as compared to
group B (13.65 2.85%) at third minute and the
difference was highly significant (p<0.001). Mean
diastolic blood pressure (DBP) remained comparable
(p>0.05) in both groups at all measured intervals
from 0-60 minutes.(fig: 2). Maximum percentage fall
in DBP was also more in group A (20.45 4.20%) as
compared to group B (18 3.5%) and that too at third
minute but the difference was non significant. Mean
arterial pressure (MAP) also remained comparable in
both groups (p>0.05) at all measured intervals. (Fig:
2). Difference in the percentage fall in MAP was
statistically non-significant at first five minutes with

maximum fall noticed at third minute which was


20.45 4.20% in group A and 18.00 3.5% in group
B. Later on MAP remained stable in both groups as
shown in fig: 3. Mean heart rate, Systolic blood
pressure, Diastolic blood pressure and mean arterial
pressure remained stable and comparable in both
groups from 60 minutes onwards till the end of study.
Mean Respiratory rate and saturation of O2 in
peripheral blood remained stable and comparable in
both groups at all measured intervals till the end of
study. None of the patient had any ECG changes from
induction to recovery in both the groups. After
completion of surgery, emergence from anaesthesia
was significantly more rapid in group B (15.78
3.886 minutes) as compared to group A (19.08
4.492 minutes) (p=0.001). But the mean time taken to
shift the patients to recovery room was comparable in
both groups (p=0.233) as shown in Table: 2. None of
the patient had coughing, laryngospasm, oxygen
desaturation or struggling during emergence from
anaesthesia in both the groups. Patients in both the
groups were drowsy but were responding to verbal
commands at the time of shifting to the recovery
room. None of the patient developed nausea and
vomiting in both the groups during immediate
postoperative period.

Table1: Demographic profile of patients in Group A and Group B.


Group
A Group
Parameters
(Halothane
B(Sevoflurane+
p value
+propofol)
propofol)
No. of patients
40
40
Age in years
6.80 2.235
7.175 2.312
0.445
Weight in kg
16.68 5.622
18.93 6.439
0.100
Sex
Male
21(52.5%)
22 (55%)
ratio
0.823
Female
19 (47.5%)
18 (45%)
Duration of surgery
Baseline Heart rate
Baseline
Systolic
blood pressure
Baseline
Diastolic
blood pressure

Significance
NS
NS
NS

52.23 8.163
118.35 6.747

51.85 5.304
122.85 9.638

0.808
0.068

NS
NS

117.08 8.337

113.23 9.449

0.058

NS

72.85 5.811

71.73 8.608

0.495

NS

Values are expressed as mean and standard deviation


or number and percentage. P >0.05 is no significant
(NS). Number of patient in both group were
comparable. Mean age, mean weight, sex ratio and
duration of surgery in minutes was comparable in
both groups (p>0.05). Inter group comparison of age,

weight and duration of surgery was done with


unpaired t test and sex ratio was compared with
Chi- Square test. Mean baseline heart rate per minute,
systolic blood pressure and diastolic blood pressure in
mm of Hg were also comparable in both the groups

Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

410

while using unpaired t test for statistical analysis.


(p>0.05).
Table2: Induction, Intubating and Emergence parameters in Group A and Group B.

Loss of eye lash reflex in seconds


Centralisation of pupil in seconds

Group A
(Halothane+ propofol) n=40
33.05 4.015
140.05 12.106

Group B(Sevoflurane+
propofol) n=40
21.88 12.652
114.40 28.811

Mean Intubation time in seconds

211.8811.305

189.3033.087

No cyanosis
No pain on I/v access
No laryngospasm
No body movement
Jaw relaxation complete 1
Vocal cord position open 1
No Cough- 1
No limb movement 1
No laryngospasm 1
Total score 5
19.084.492

No cyanosis
No pain on i/v access
No laryngospasm
No body movement
Jaw relaxation complete 1
Vocal cord position open 1
No Cough- 1
No limb movement 1
No laryngospasm 1
Total score 5
15.783.886

11.782.516

10.754.776

Parameters

Quality of induction

Intubation parameters
(total score)

Emergence time in minutes


Mean time taken to shift
patient to recovery room in
minutes

Values are expressed as mean and standard deviation.


P>0.05 is non significant (NS), p<0.01 is significant
(S), p<0.001 is highly significant. In group B
(sevoflurane +propofol) loss of eye lash reflex,
centralisation of pupil and intubation time was
significantly less as compared to group A (halothane
+propofol) p<0.001. However quality of induction
and intubating conditions were comparable in both
groups. Emergence was also earlier in group B as
compared to group A. P<0.001. Time taken to shift
the patient to recovery room was again comparable in
both groups.(p>0.05) Statistical analysis was
performed for various parameters of induction and
recovery using unpaired t test.

Fig1: Mean Heart Rate in group A


(Halothane+propofol)
and
group
B
(Sevoflurane+propofol) at various time intervals.
Line diagram showing comparison of Mean heart rate
at various time intervals in both groups. It remained
on lower side in group A from 3rd to 60th minute of
Sandhu et al.,

p value

Significance

0.000
0.000

HS
HS

0.000

HS

---

---

---

---

0.001

0.233

NS

induction as compared to group B. Maximum fall in


heart rate was at 4th, 5th, 6th minute of induction in
both group and that too was more in group A as
compared to group B when unpaired t test was
applied. (P<0.001)
Fig2: Mean Systolic Blood Pressure, Diastolic

Blood Pressure and Mean Arterial Pressure at


various
time
intervals
in
Group
A
(Halothane+propofol)
and
Group
B
(Sevoflurane+propofol).
Line diagram showing the comparison of systolic
blood pressure (SBP), Diastolic blood pressure (DBP)
and mean arterial pressure (MAP) from first minute
to 60 minute of induction in group A and group B.
There was maximum fall in SBP, DBP and MAP in
both groups at 2, 3 and 4 minute of induction. SBP
remained on lower side in group A as compared to
Group B. DBP and MAP remained comparable in
411
Int J Med Res Health Sci. 2015;4(2):407-414

both groups. Unpaired t test was used for


intergroup comparison of MAP, SBP and DBP.

Fig3: Line diagram showing percentage changes


in mean arterial pressure (MAP) in group A
(Halothane+propofol) and group B (sevoflurane
+propofol) at various time intervals.
Line diagram showing percentage change in mean
arterial pressure (MAP) in both groups. Percentage
fall in MAP was more in group A as compared to
group B from second to fifth minute. P was less than
0.001 on applying unpaired t test.
DISCUSSION
Goals of anaesthesia for paediatric patients are fast
emergence and short recovery with low incidence of
post operative side effects, permitting a rapid and safe
discharge.[13] Continuous research for an ideal
inhalation agent which has all the induction
properties of halothane but with minimal cardiac side
effects led to the introduction of sevoflurane. It
provides rapid induction and emergence due to its
low blood gas solubility.[14] With the advent of potent
and short acting intravenous induction agent
Propofol, intubating the trachea without using
muscle relaxant has been under evaluation. Propofol
has faster onset, provides good intubating conditions
by decreasing muscle tone and depressing airway
reflexes, allows smooth transition to emergence and
rapid recovery from anaesthesia.[15] In the present
study, both groups were comparable with respect to
demographic profile and duration of surgery.
Induction of anaesthesia was more rapid in
sevoflurane group, as the time taken to loss of eye
lash reflex and centralisation of pupil was
significantly less in sevoflurane group as compared to
halothane group (p<0.01). Previous studies also
reported that time taken for loss of eye lash reflex and

centralisation of pupil was less with sevoflurane than


with halothane induction, but in these studies
induction time was slightly more than the present
study.[6,7,9,16,17] This difference might be due to fact
that either no priming of the circuit was done [6,16] or
step wise increased concentration technique, starting
with low concentration of inhalational agent was used
for induction in these studies.[7,9,17] However in the
present study, quality of induction was good and
comparable in both the groups as none of the patient
had any cyanosis, laryngospasm, breath holding or
pain during intravenous cannulation. Batra Y K et al
[10]
used graded inhalational technique for
bronchoscopic removal of foreign body in children.
Induction was done with either Halothane or
sevoflurane in oxygen only. Slight incidence of
coughing, breath holding, layngospasm and
excitement was observed during induction in both
groups. In a study done by Abdel-Halem et al [16]
induction was done with either 5% halothane or 8%
sevoflurane in oxygen only. Struggling, bodily
movements and laryngospasm during induction was
observed in both the groups. In the present study, use
of nitrous oxide during priming of the circuit for
induction might be helpful for smooth induction.
Addition of nitrous oxide to oxygen, decreases the
MAC of sevoflurane and halothane [18] and also
minimises the adverse airway reactions and
struggling associated with use of high concentration
of inhalational agents.[19]Similarly time taken for
intubation was significantly less in sevoflurane group
as compared to halothane group but intubating
conditions were excellent in both groups. Less
intubation time taken during sevoflurane induction
was documented by previous studies also.[18,20] O
Brien et al [11], in their study observed coughing,
vocal cord movements, laryngospasm and oxygen
desaturation during intubation, when halothane and
sevoflurane was used with O2 and N2O for induction
without using muscle relaxants. In the present study,
I/V lignocaine and propofol [15] given just before
intubation might have improved the intubating
conditions. I/V lignocaine abolish the injection pain
of propofol, improve intubation scores by its
antitussive effects and also attenuate the pressor
response to tracheal intubation. [21]In Halothane +
propofol group, mean heart rate remained on lower
side as compared to sevoflurane + propofol group
from first minute to sixty minutes and the maximum
412

Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

fall at third minute was also more in halothane group.


Previous studies also observed that heart rate
remained on lower side in halothane group and it
remained on higher side in sevoflurane group during
induction and maintenance of anaesthesia.[5,17,18,20] In
the present study, heart rate did not increased from
baseline values in sevoflurane group at all measured
intervals and no stress response was noted in either of
the two groups at the time of intubation as reported
by Paris S T et al [17] and Dedhia KN and Kudalkar A.
Intravenous lignocaine [21] and propofol [15] given just
before intubation, effectively attenuates the
haemodynamic stress response to intubation. Blood
pressure remained on lower side and maximum fall in
blood pressure was also more in halothane + propofol
group as compared to sevoflurane + propofol group.
Both sevoflurane and halothane decreases myocardial
contractility, but effect of halothane is more. In stable
conditions, blood pressure is better maintained with
sevoflurane than with halothane as documented by
Piat V et al [20], Dedhia KN and Kudalkar A [5] and
Paris S T et al.[17]After completion of surgery,
emergence was significantly faster in Group B as
compared to Group A. Emergence from anaesthesia
depends on the blood gas solubility of inhalational
agents.
Blood gas- partition coefficient of
sevoflurane is low, hence provides rapid
emergence.[18] Previous studies also reported faster
emergence with sevoflurane as compared to
halothane.[9,10,16,17,20] In the present study, none of the
patient had cough, laryngospasm, struggling or
oxygen desaturation during extubation and
emergence from anaesthesia. Children were drowsy
but were responding to verbal commands at the time
of shifting to recovery room, in both the groups. No
emergence agitation was noted in both groups and the
time taken for shifting the patients to recovery room
was comparable. In the postoperative period none of
patient developed nausea and vomiting. Propofol
depresses the airway reflexes and thus decreases the
incidence of coughing and laryngospasm during
extubation.[12] Previous studies found that rapid
emergence from sevoflurane as compared to
halothane was associated with increased incidence of
struggling and excitement.[7,8,10,17] Moore JK et al [22]
concluded that emergence agitation was observed
more when sevoflurane alone was used for
maintenance and addition of propofol decreases the
emergence agitation. Propofol also decreases the

incidence of postoperative nausea and vomiting if


used for maintenance of anaesthesia.[22,23]
CONCLUSION

Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

Hence it was concluded that both groups provided


excellent intubating conditions without using muscle
relaxants, with no stress response. But Sevoflurane +
propofol group was better as it provided faster
induction and rapid recovery from anaesthesia with
more stable haemodynamics as compared to
Halothane + propofol group.
ACKNOWLEDGEMENT
We are highly thankful to Dr. Ranjana kheterpal and
Dr. JP attri, Associate professor, Department of
anaesthesia for their whole hearted support and
encouragement in completing this project.
Conflict of Interest: Nil
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Sandhu et al.,

Int J Med Res Health Sci. 2015;4(2):407-414

DOI: 10.5958/2319-5886.2015.00076.4

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 25 Feb 2015
Letter to editor

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 7 Mar 2015
Accepted: 17th Mar 2015

RETAINED STONE PIECE IN ANTERIOR CHAMBER


*ZvornicaninJasmin, Nadarevic-VodencarevicAmra
Eye Clinic, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina
*Corresponding author email: zvornicanin_jasmin@hotmail.com
Dear Editor,
We read with interest the article by Surekha et al.
regarding the retained stone piece in anterior
chamber.[1]Similar to the results of previous studies,
the authors found that delayed intraocular foreign
body (IOFB) management can result in good visual
outcome without an apparent increased risk of
endophthalmitis or other deleterious side effects.[2]
However, the authors failed to explain the exact
reason for the diminution of vision in patients left
eye. It is unclear what the uncorrected visual acuity
was and what kind of correction was used, more
precisely type and amount of cylinder, given the
presence of the corneal opacity. Since the size of the
IOFB is approximately 4x4x1mm, significant iridocorneal angle changes resulting in intraocular
pressure raise and optic nerve head damage can be
expected. Traumatic glaucoma following open globe
injury can occur in 2.7 to 19% of cases, with several
risk factors associated with glaucoma development
(advanced
age,
poor
visual
acuity
at
presentation,perforating rather than penetrating ocular
injury,lens injury, presence of vitreous hemorrhage
and presence of an IOFB).[3] Earlier reportsof
latetraumaticoptic neuropathy onset, even after
several years, indicate that this possibility cannot be
completely ruled out too.[4] Therefore, repeated
intraocular pressure measurements, gonioscopy,
pupillary reaction assessment, together with through
posterior segment examination including visual field
and optical coherence tomography examinations can
be useful in determining the possible optic nerve

damage as one of the possible reasons for visual


acuity reduction.
The authors did not suggest any operative treatment
at this time. However, it should bear in mind that the
inert anterior chamber IOFB could be a risk factor for
non-infectious endophthalmitis development even
after many years.[5]Also, long term retained anterior
chamber foreign body leads to permanent endothelial
cell loss and can even result in a corneal ulcer
formation.[6] On the other side, it is not clear what
was the grade and morphology of the lens opacity,
especially if it is known that visual acuity in right
healthy eye is 6/12 with presence of immature senile
cataract. Retained IOFB is a risk factor for prolonged
postoperative inflammation and endophthalmitis after
cataract surgery.[7,8] Therefore, surgical intervention
including cataract extraction, foreign body removal
with possible toric intraocular lens implantation could
be therapy of choice for this patient.
For these reasons, we would kindly ask the authors to
present the data regarding the uncorrected visual
acuity, required spherical and cylindrical correction,
keratometry and refractometry readings, intraocular
pressure values, grade and morphology of the lens
opacification, state of the iridocorneal angle, possible
changes in the vitreous, retina and optic nerve head.
Without this informations it would be difficult to
hypothesize that the IOFB in the anterior chamber
was completely inactive forthe past twenty years and
it did not produce any adverse effect in patients eye.
These findings will significantly contribute to the
papers scientific value and contribution.
415

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Int J Med Res Health Sci. 2015;4(2):415-416

Overall we agree with Surekha et al. that IOFBs can


be variable in presentation and outcome. There is still
signicant controversy in the management of IOFBs,
particularly the timing and method of surgery.[9]
Conflict of interest: Nil
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Retained stone piece in anterior chamber: a case
report. Int J Med Res Health Sci.2015; 4: 236-8.
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Bower KS, Ward TP, Haller JA.Delayed
intraocular foreign body removal without
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4. Yu-Wai-Man P, Griffiths PG. Steroids for
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5. Ahn M. Noninfectious endophthalmitis caused by
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6. JastaneiahSS.Long-term corneal complication of
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7. Stangos AN, Pournaras CJ, Petropoulos IK.
Occult anterior-chamber metallic fragment postphacoemulsification masquerading as chronic
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DOI: 10.5958/2319-5886.2015.00077.6

International Journal of Medical Research


&
Health Sciences

www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
th
Received: 20 Jan 2015
Revised: 28th Feb 2015
Review article

Copyright @2015 ISSN: 2319-5886


Accepted: 19th Mar 2015

EVOLUTION OF AUTOMATICITY OF HEART PACEMAKER STUDIED FROM A THEORETICAL


PERSPECTIVE
3

Vijay Kumar Konuri1, Mohammed Abdul Hannan Hazari2, Ravi Kumar K , Chandrasekhar M ,
5

Ambareesha K , Ram Reddy B


1

Associate Professor, Department of Anatomy, All India Institute of Medical Sciences, Raipur, Chhattisgarh,
India
2
Associate Professor, Department of Physiology, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad,
Telangana, India
3

Assistant Professor of Anatomy, Govt Medical College, Jagdalpur, Chhattisgarh


Professor and HOD, 5Tutor, Department of Physiology, Meenakshi Medical College, Kanchipuram,
Tamil Nadu
4

Professor & HOD, Department of Physiology, Apollo Institute of Medical Sciences and Research, Jubilee Hills,
Hyderabad, Telangana, India.
*Corresponding author email: vkkonuri@gmail.com
ABSTRACT
The pacemaker of the mammalian heart had developed a robust and yet a flexible system in the course of
evolution whose function is based on multiple interactions at the sub-cellular, cellular and finally at the tissue
level. These, in turn, should respond to extrinsic signals. Cardiac action potentials were explained for a long time
based on the changes that occur at the cell surface. New hypothesis was put forward at the turn of the century that
pointed to the role of intracellular calcium clock. Discovery of ryanodine receptors, fluorescence labeling
techniques, confocal imaging and finally computer modeling of physiological processes had brought about a
noticeable change that allowed development of a new concept of pacemaker automaticity. Reviewing all these
developments we hereby put forward a few theoretical formulations that can turn out to be new instruments in
advancing our knowledge of cardiac physiology. We had theorized that cardiac muscle is an emergent property of
smooth muscle in the course of evolution, and that pacemaker activity of the cardiac muscle underwent a phase
transition that finally led to the evolution of a structural pacemaker.
Keywords: Heart, Pacemaker, Automaticity, Evolution
INTRODUCTION
The sino-atrial node (SAN) pacemaker cells produce
billions of incessant and uninterrupted beats in the
course of the life time of an individual. It is evident
that the pacemaker of the mammalian heart has
developed a robust and yet a flexible system in the
course of evolution [1]. Robustness indicates the failsafe properties and flexibility signifies the
adaptability to changes in the demands made on it.
The pacemaker function is based on multiple

interactions at the level of sub-cellular, cellular and


finally at the level of tissue architecture, which in turn
should react to extrinsic signals like stretch, electrical
and chemical signals that act on the cell surface
receptors.
The generation of action potentials in the
myocardium was explained for a long time,
predominantly, basing on the changes that occur on
the cell surface and its ion channels [2]. However, the

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turn of the century has brought new evidence pointing


to the role of an intracellular clock. This turned out to
be the cyclical rhythm of cytosolic Ca2+
concentration. Sarcoplasmic reticulum (SR) has
proved to be having the capacity to operate another
physiologic clock of calcium cycles[3]. Recent
developments in experimentation like confocal
imaging have revealed the presence of multiple
spontaneous, rhythmic, local calcium releases[4].
These tightly regulated processes begin to occur
beneath the cell surface during the later part of
diastolic depolarization. This activates the Na+-Ca2+
exchanger that causes an explosive increase in
diastolic depolarization and leads to the activation of
L-type calcium channels[5].

Fig 1. Interplay between intracellular and membrane


surface Ca2+ clock.
The existing understanding of cardiac action
potentials
The explanation of action potentials in the working
myocardium is as follows. Phase 0 or the rapid
depolarization results from the opening of the fast
Na+ channels. Phase 1 of the action potential starts
the repolarization process and is attributed to the
closing of Na+ channels and inward movement of Clions. Phase 2, the so-called "plateau" phase of the
action potential results from several mechanisms but
could be mainly because of slow inward movement of
Ca2+ and Na+. Phase 3 involves relative rapid
repolarization, commencing with inactivation of slow
Ca2+ and Na+ channels and rapid outward movement
of K+ ions. Phase 4 restores the ionic composition
back to the resting state by Na+-K+ ATPase which
pump Na+ ions out and K+ ions inside the cell[6].
Membrane
potential
of
pacemaker
cells
spontaneously declines to the firing level and is
known as prepotential or pacemaker potential which

triggers the next action potential. At the peak of each


action potential, conductance of potassium (IK+)
begins and repolarization occurs. IK+ then declines
and the membrane potential reaches slight
hyperpolarization. At this instance an "h" or "f"
channel which allows both Na+ and K+ is activated.
As conductance through "h" channel (Ih) increases,
the membrane begins to depolarize forming the initial
part of the prepotential. T-type Ca2+ channels then
open and its conductance (ICa2+T) completes the
prepotential. At this juncture L-type Ca2+ channels
open and ICa2+L produce action potential.
The measurements of calcium concentrations
The finding that oscillations in Ca2+ concentrations
were inhibited by calcium channel blockers (CCBs)
had brought to the fore the idea that Ca2+
concentration represents a two-way interaction
between the intracellular Ca2+ stores and the
membrane surface potential changes[7]. But due to the
rapidity of changes; spontaneous, localized
oscillations of the calcium clock could not be
measured within the individual SA nodal cells and
hence the concept that initiators of the normal
automaticity of pacemaker cells are internal calcium
oscillations could not be established.
The membrane surface processes was disconnected
from that of intracellular oscillations, for a long time,
by the employment of Ca2+ overload conditions to
voltage clamp studies[8]. Studies have gradually
demonstrated that the intracellular oscillations could,
in fact, produce spontaneous membrane currents. It is
now considered that the intracellular oscillations
involve the cycling of Ca2+ ions between SR and
cytosol[9].
Discovery of ryanodine receptors
Then came the discovery that the drug named
ryanodine can have a profound negative chronotropic
effect on the automaticity of cardiac pacemaker cells.
By studying the effect of ryanodine on the contour of
the action potential it was suggested that Ca2+
released from the SR contributes to diastolic
depolarization[10].
It is now possible to measure the intracellular calcium
levels in spontaneously firing pacemaker cells of
SAN which made it clear that each spontaneous
action potential evokes a calcium gradient in the
cytosol and that the influx of calcium through L-type
calcium channels affects the calcium loading of the

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Int J Med Res Health Sci. 2015;4(2):417-421

SR. Intracellular buffering of calcium has the potency


to block the generation of spontaneous action
potentials[11]. This constitutes a strong evidence in
favor of the idea that normal automaticity of
pacemaker cells is strongly linked with the dynamics
of intracellular calcium.
Modern techniques
Fluorescence imaging of intracellular calcium is
made possible in the last decade that enabled to
document not only the global transients of cytosolic
calcium but also of many localized calcium releases
beneath the cell surface during late diastolic
depolarization[12]. Such local calcium releases are
observed in SA nodal cells in the absence of changes
in the membrane potentials, i.e. in voltage clamped
SA node pacemaker cells. There is evidence that local
Ca2+ release from the sarcoplasmic reticulation (Ca2+
sparks) occurs during the prepotential. Local calcium
releases (LCRs) during the late diastolic
depolarization begin to boil and then explode into an
action potential[13].
A tiny change in the current to the degree of 3 pA is
enough to explode into an action potential during the
critical diastolic depolarization phase of rabbit SA
node cells. Although the individual local release of
calcium during the diastolic depolarization of
pacemaker cells is relatively small and stochastic in
nature, the synchronized and cumulative effects of
LCRs imparts and impacts the rising phase of
diastolic depolarization leading to the next action
potential. A failure to generate an exponential phase
in diastolic depolarization is the consequence of a
failure to generate diastolic INCX[14].

Structurally SA node is heterogeneous


Till now we discussed the mechanisms of
automaticity and spontaneous calcium cycles in
individual pacemaker cells. But cardiac pacemaker
function cannot be understood completely by the
study of the intrinsic properties of the pacemaker
cells. Advanced histological studies had revealed that
SA node is a highly heterogeneous structure with
small pacemaker cells predominantly located in the
centre[15]. The SA nodal tissue is characterized by
complex cell-to-cell interactions in generating the
highly robust impulses with a fail-safe mechanism[16].
The function of the pacemaker tissue within the SA
node is determined by the intrinsic properties of
individual cells that are being modulated by several
factors of the local environment within the SA
node[17]. The pacemaker tissue is at the same time
being influenced by extrinsic modulators that include
the electrical and mechanical forces as well as the
autonomic milieu. These modulatory factors are
heterogeneous throughout the SA node which could
explain the differences in the shape of the action
potential curves of different cells in the same
locality[18]. This could be the result of mutual
interaction between the depolarizing charges
generated by individual SA node cells and the
structural properties of the surrounding non-excitable
tissue[19].
Extensive amounts of connective tissue and numerous
fibroblasts occupy from 25% to almost 90% of the
area of SA node[20].

Fig 2: Phase transition and emergence of cardiac muscle from smooth muscle with maintenance of legacy
in some aspects

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Int J Med Res Health Sci. 2015;4(2):417-421

In addition to bands of connective tissue, the gap


junction proteins are also found to be located in
various types and with varying densities in near
vicinities. The myofilament density decreases from
periphery to the centre of the SA node[21]. The nerve
endings and autonomic receptors on pacemaker cells
are found to be at the highest density in the central
area of SA node[22]. All these structural features make
the SA node a highly heterogeneous structure that can
generate not only flexible but also a robust action
potential[23].Intracellular calcium cycling plays a
major role in the generation of automaticity in
embryonic cardio myocytes and so could be used to
generate stem cell derived spontaneously beating
myoblast cells[24].
Discussion: A theoretical approach is needed to
interpret physiology at an advanced level
We have seen how our concepts of pacemaker
potentials transformed over time, from the more or
less simplified notions that membrane currents
explain everything to developing a more and more
complex picture of mutual entrainment of the
cytosolic and the membrane clocks and of their
different mechanisms in generating automaticity.
We understand the vertebrate circulatory system as a
closed canal system comprised of network of smooth
muscle and other cells, the proximal part of which
has been transformed into cardiac muscle due to
increased circulatory load imposed on the
system[25].This can be visualized as a type of phase
transition during evolution of smooth muscle there by
transforming phase maker activity from a network of
molecules to a network of cells and tissues, which can
justify the existence of special conducting system in
myocardium. So this can be generalized as an
emergent property of smooth muscle. Pacemaker
properties of the smooth muscle is well preserved
but is now regulated by pacemaker system of cardiac
muscle. Even in smooth muscle the initiation of
pacemaker activity is due to the oscillations of
intracellular calcium that are being modulated by
external conditions. It is our endeavor to elucidate
how function is translated into structure through the
alteration of the genetic program.
CONCLUSION

Pacemaker in mammalian heart is the phase shift


transformation of the smooth muscle through cardiac
muscle during the evolutionary process. In the course
of development of highly evolved forms of
organisms, the metabolic necessities of the complex
tissues and organs demanded continuous supply of
nutrients and gases for sustenance of life. Hence, the
smooth muscle underwent structural and functional
adaptations to develop into cardiac muscle which
further acquired autonomy at the expense of losing
the contractility to form pacemaker tissue. This aptly
describes the proverb "Necessity is the mother of
invention".
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missing link in the mystery of normal
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2. Mangoni ME and Nargeot J. Genesis and
regulation of the heart automaticity. Physiol Rev.
2008; 88:919982.
3. Lakatta EG, Vinogradova T, Lyashkov A,
Sirenko S, Zhu W, Ruknudin A, Maltsev VA.
The integration of spontaneous intracellular Ca2+
cycling and surface membrane ion channel
activation entrains normal automaticity in cells of
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1080:178206.
4. Maltsev VA and Lakatta EG. Synergism of
coupled sub-sarcolemmal Ca2+ clocks and
sarcolemmal voltage clocks confers robust and
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interactions of an intracellular Ca2+ clock and
membrane ion channel clock underlie robust
initiation and regulation of cardiac pacemaker
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6. Sanders L, Rakovic S, Lowe M, Mattick PA,
Terrar DA. Fundamental importance of Na-Ca2+
exchange for the pacemaking mechanism in
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7. Vinogradova TM and Lakatta EG. Regulation of
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Stucky M, Jones LR, Fishbein MC, Weiss JN,
Chen PS, Lin SF. Intracellular calcium dynamics
and acceleration of sinus rhythm by betaadrenergic stimulation. Circulation. 2009;
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Rigg L, Heath BM, Cui Y, Terrar DA.
Localisation and functional significance of
ryanodine receptors during beta-adrenoceptor
stimulation in the guinea-pig sino-atrial node.
Cardiovasc Res. 2000; 48:254264.
Li J, Qu J, Nathan RD. Ionic basis of ryanodines
negative chronotropic effect on pacemaker cells
isolated from the sinoatrial node. Am J Physiol.
1997; 273:H2481H2489.
Bogdanov KY, Vinogradova TM, Lakatta EG.
Sinoatrial nodal cell ryanodine receptor and Na+Ca2+ exchanger: molecular partners in pacemaker
regulation. Circ Res. 2001; 88:12541258.
Vinogradova TM, Lyashkov AE, Zhu W,
Ruknudin AM, Sirenko S, Yang D, Deo S,
Barlow M, Johnson S, Caffrey JL. Zhou YY,
Xiao RP, Cheng H, Stern MD, Maltsev VA,
Lakatta EG. High basal protein kinase Adependent phosphorylation drives rhythmic
internal Ca2+ store oscillations and spontaneous
beating of cardiac pacemaker cells. Circ Res.
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Maltsev VA and Lakatta EG. Cardiac pacemaker
cell failure with preserved If, ICaL, and IKr: a
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Cardiol. 2007; 42:289294.
Vinogradova TM, Zhou YY, Maltsev V,
Lyashkov A, Stern M, Lakatta EG. Rhythmic
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Lancaster MK, Jones SA, Harrison SM, Boyett
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Lakatta EG, Stern MD. Diastolic calcium release
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OWJ, de Gier-de Vries C, Wiese C, Clout DEW,
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DOI: 10.5958/2319-5886.2015.00078.8

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 14 Feb 2015
Review article

Coden: IJMRHS
Revised: 7th Mar 2015

Copyright @2015
ISSN: 2319-5886
Accepted: 25th Mar 2015

COMPLIMENT RECEPTOR TYPE - 1 (CD35) GENE POLYMORPHISM AND PLASMODIUM


FALCIPERUM MALERIA
Rishabh Dev Saket*, Shrikant Kol, Arvind Kumar Tripathi, Sher Singh Parihar, Jitendra Kumar Tipathi, Ugam
Kumari Chauhan.
Department: Centre for Biotechnology studies, Awadhesh Pratap Singh University, Rewa (M.P.), India.
*Corresponding author email: rdev47@gmail.com
ABSTRACT:
Malaria is a most causative agent for worldwide death. Plasmodium falciperum infected malaria most dangerous
than other plasmodium species. It has closely association to compliment receptor type -1 (CD35) gene
polymorphism. CD35 (CR1) is a cell surface receptor for plasmodium falciperum containing PfEMP-1 as a
legend. Density of CD35 on erythrocyte can be determined by CR1 allele (HH, HL, and LL). HH allele of CR1
gene express high density of CD35 whereas LL in low density. High density of CD35 is more susceptible to
falciperum infection. CD35 is also responsible for sever malaria. During plasmodium infection, pro-inflammatory
cytokine like TNF-, IFN- levels are increased. The elevated ratio of TNF-/IL10 indicates falciperum infection.
Cell adhesion protein like VCAM, ICAM also mediate the malarial infection.
Keyword: Plasmodium falciperum, CD35, CR1 allele, TNF-, IL10, ICAM.
INTRODUCTION:
Malaria is the most infectious and dangerous disease
in the world. The World Health Organization (WHO)
estimated 225 million malaria cases worldwide with
781,000 deaths due to Plasmodium infection per year.
Four types of Plasmodium species (P. falciparum, P.
vivax, P. malariae, and P. ovale) are responsible for
almost all human infections. Plasmodium falciparum
malaria is responsible for more than one million
deaths that occur each year from malaria infection in
Africa. Most of these deaths occur as a result of
complications such as severe malaria associated
anaemia (SMA) and cerebral malaria (CM) [1].
Compliment Receptor 1 (CR1), a protein on RBC
cells that having role in immune complex clearance.
Its also known as C3b/C4b receptor or CD35. In
humans this protein is encoded by CR1 gene is
located at on the long arm of chromosome 1 at band
32 (1q32) and lies within a complex of

immunoregulatory genes. The Compliment Receptor


1 (CR1) gene polymorphism conform density of
CD35 on RBC cells. The human CR1 binds to a
major malarial adhesion, the P. falciparum
erythrocyte membrane protein-one (PfEMP-1). High
density of CR1 on erythrocyte indicates high risk of
falciparum infection [2- 5].
PREVALENCE AND EPIDEMIOLOGY OF P.
FALCIPARUM: Malaria affects the 300-500 million
people each year in which 1-3 million people leading
cause of death worldwide annually. There are five
Plasmodium species that infect humans; Plasmodium
falciparum, Plasmodium vivax, Plasmodium ovale,
Plasmodium malariae, and Plasmodium knowlesi.
These species differ in their morphology,
immunology, and geographic distribution. Among the
five species that cause malaria in humans,
Plasmodium falciparum (P. falciparum) is the most
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Int J Med Res Health Sci. 2015;4(2):422-431

virulent resulting in the greatest number of


complications and the great majority of malariarelated deaths in children under the age of five. The
evolutionary history and geographical distribution of
P. falciparum reflects a three-way interaction
between the parasite, the host, and the Anopheles sp.
mosquito (the vector for transmission). Circa, 1900
prior to the widespread use of anti-malarials, the
distribution of malaria reached the geographic
latitudes of 64 north and 32 south [6-7].
However, genetic history and the coevolution of P. falciparum with humans suggest this
has not always been the geographic model. The
closest relative to the modern day P. falciparum is the
chimpanzee
malaria
parasite,
Plasmodium
reichenowi. It has been argued that P. falciparum is
of African origin because P. reichenowi is a parasite
that infects African chimpanzees. Despite some
controversy, it is generally accepted that the
divergence of these two species of malaria occurred
approximately 9-10 million years ago, prior to the
divergence of humans from non-human primate
relatives such as the chimpanzees. It is believed that
the major spread of P. falciparum in Africa occurred
during the Agrarian Revolution (4000-5000 years
ago) when small nomadic groups began to establish
larger settled communities; this lifestyle change
provided ideal conditions for sustained P. falciparum
transmission [8-9].

Fig 1: Geographic distribution of Plasmodium


falciparum malaria [6].
Life cycle of Plasmodium falciparum malaria: The
P. falciparum infection begins when a human host is
bitten by an infected female Anopheles mosquito, and
the mosquito injects sporozoites into the
subcutaneous tissue of the human host. The
sporozoites, within one hour reach to the liver and
infect hepatocytes. The duration of the asymptomatic

liver (exo-erythrocytic cycle) stage of the infection is


approximately one-two weeks. During this stage,
each sporozoite may yield thousands of merozoites
[10]
.
Invasion: The hepatocytes rupture releasing the
merozoites into the blood stream (the beginning of
clinical disease) where they are able to enter into
RBCs by a complex invasion process comprised of
four phases: (a) initial recognition and reversible
attachment of the merozoite to the RBC membrane.
(b) Reorientation. (c) Invagination of the RBC
membrane around the merozoite. (d) Resealing of the
RBC membrane after completion of merozoite
invasion. RBC invasion is a rapid process that is
governed by molecular interactions between the
merozoites and the host cell surface [11-12].
Primary contact is initiated by a surface coat of
proteins
that
is
largely
comprised
of
glycosylphosphatidylinositol
(GPI)-anchored
membrane proteins. There are at least nine recognized
GPI anchored proteins that are predicted to be
potential RBC ligands. Merozoite surface protein-1
(MSP-1) is the dominant antigen and is essential for
parasite survival. MSP-1 is involved in the initial
recognition of the RBC via sialic acid residues found
on the RBC membrane. Other important proteins are
MSP-2, -3 and -4. P. falciparum apical membrane
antigen-1 (PfAMA-1) is also essential for successful
invasion as it is translocated to the merozoites surface
before invasion of the RBCs, and is also present on
the sporozoite for invasion into hepatocytes [13-14].

Fig 2: Life cycle of Plasmodium falciparum malaria


[11]
.
Maturation : Initially, the merozoites develop into

an early trophozoite stage known as the ring


form. The ring form persists for 24 hours and
matures inside the RBC through a highly active
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metabolic state. The P. falciparum ring feeds from


the host cytoplasm, importing glucose and breaking
down hemoglobin into constituent amino acids.
Following the ring stage, P. falciparum matures and
develops to a late stage trophozite. The mature
trophozoite stage parasite replicates by nuclear
division resulting in schizont stage parasites. Each
schizont is comprised of 20-24 merozoites, which are
released upon rupture of the infected RBC. When the
infected RBCs rupture, merozoites and parasite
metabolic waste products such as hemozoin,
degradation of hemoglobin, and parasite toxins are
released. The majority of the merozoites will invade
other RBCs continuing the asexual cycle; however,
some parasites will form sexual stage forms called
gametocytes which are then transmitted to new hosts
by the Anopheles vector [11-17].
Pathophysiology of Plasmodium falciparum
malaria: Infection with P. falciparum results in
considerable morbidity and without treatment may be
fatal. The clinical outcome of malaria depends on
many contributing factors including the parasites
virulence, the hosts response, geographical, and
socio-economic factors (Table 1).
Table 1. Factors contributing to the clinical
outcome of P. falciparum infection [11].
Parasite Factors
Host Factors
Geographic and
Social factors
-Drug Resistance
Immunity
-Transmission
-Multiplication rate
Genetics: Sickle intensity
-Invasion Pathways cell,
-Culture and
-Cytoadherence
thalassaemia,
economic factors
-Rosetting
ABO blood type -Access to
-Malaria
toxins Age
treatment
(hemozoin)
Pregnancy
-Antigenic Variation Proinflammatory
(PfEMP1)
cytokines

The combination of these factors result in a range of


possible outcomes for the host, including
asymptomatic infection, uncomplicated malaria
infection, severe infection (severe malaria anemia and
cerebral malaria) and death.
Clinical stages of malaria pathogenesis: There are
three defined clinical stages of malaria pathogenesis:
uncomplicated malaria, severe malaria, and cerebral
malaria. Uncomplicated malaria initially presents

with fever and chills, nausea and headache,


sometimes associated with diarrhea and vomiting.
Unfortunately, because of the similarity in symptoms,
malarial infection is often mistaken for many other
infections including influenza or gastro-intestinal
infection and is therefore not properly treated [18]. In
1990, the World Health Organization (WHO)
established criteria for the diagnosis of severe
malaria. The major criteria include neurological
involvement (cerebral malaria), pulmonary edema,
acute renal failure, and severe anemia. Severe anemia
is the second most common symptom of P.
falciparum infection and is caused by the destruction
of RBCs and overall decreased erythropoiesis.
Acidosis and hypoglycemia are the most common
metabolic complications [4,19].
Cerebral malaria is the most common cause
of death in adults and children with severe malaria.
According to the WHO, the strict definition of
cerebral malaria requires the presence of P.
falciparum parasitemia and unarousable coma with a
Glasgow Coma score of 9 or less; all other causes of
coma, such as hypoglycemia, bacterial meningitis and
viral encephalitis, need to be excluded. Typical
neurological symptoms include coma, seizures,
edema, and brainstem damage. Engorgement of
cerebral capillaries and venules filled with infected
RBCs and non-infected RBCs are typical
histopathological findings in cerebral malaria. As the
infection progresses, the increasingly detrimental
pathogenesis of P. falciparum malaria is believed to
be caused by two main factors: (a) an imbalance of
cytokine production; and (b) the sequestration of
infected RBCs in the microvasculature of vital organs
[20-21]
.
Inflammatory response:
P. falciparum infection results in an increase
of both pro-inflammatory cytokines and antiinflammatory cytokines. However, in cerebral
malaria, there is an unbalanced and excessive
production of the pro-inflammatory response. Blood
concentrations of pro-inflammatory cytokines,
especially tumor necrosis factor (TNF), interferon
gamma (IFN-), and IL-6, have been shown to be
raised in cerebral malaria. TNF may contribute to
malaria pathogenesis including cerebral malaria. TNF
up regulates endothelial cytoadherence receptors such
as intercellular adhesion molecule-1 (ICAM-1),
vascular cell adhesion molecule-1 (VCAM-1), and E424

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selectin. TNF may cause hypoglycemia and


dyserthryopoesis, and has been shown to induce the
release of nitric oxide (NO) which interferes with
synaptic transmission [22-23].
Parasite sequestration:
P. falciparum has a unique ability to adhere to host
microvasculature endothelium, a process known as
sequestration. Sequestration causes microvascular
obstruction and compromises the blood flow through
tissues such as the liver, spleen, lung, and brain. The
effects of sequestration include mechanical
obstruction (which can lead to hypoxia), metabolic
disturbances and is a central point where parasite
toxins and inflammatory mediators concentrate [24].
Increased expression of cytoadherence
receptors enhances infected RBC sequestration to the
endothelium via parasite derived proteins (expressed
on the surface of the infected RBC), such as PfEMP1. The principal parasite surface protein and
sequestration ligand known as P. falciparum
erythrocyte membrane protein 1 (PfEMP-1), encoded
by var genes, is expressed. It is predominantly mature
stage parasites (trophozoites and schizonts) that
adhere to the microvasculature [25].

Fig 3: The PfEMP-1 molecule and associated host


receptors [26].

The PfEMP-1 molecule has a pivotal role in the


pathogenesis of P. falciparum as a number of host
receptors are recognized by the various extracellular
binding domains of PfEMP-1. Thus, permitting the
infected RBCs to adhere to host endothelium. In the
case of cerebral malaria, PfEMP-1 may mediate
adhesion to several adhesion molecules, in particular
ICAM-1 which is unregulated on the cerebral
vascular endothelium [26].
Innate immunity to P. falciparum malaria:
The innate immune response is crucial to the
outcome during a P .falciparum infection. Innate

immune responses take effect immediately and


provide an early defence until the adaptive immune
response is engaged. In some cases, an infection by P.
falciparum may be controlled by the innate immune
system. 61 Parasite burdens observed in non-immune
individuals with acute P. falciparum malaria are
lower than expected based on parasite replication
rates observed in vitro, suggesting that the innate
immune system can contribute to effective control of
acute parasite replication before the adaptive immune
response develops [27].
The innate immune system functions to limit the
maximum parasite density, but gradually acquired
adaptive mechanisms complete parasite elimination.
The innate immune system is essential for most
inflammatory responses that are triggered by
monocytic cells, other leukocytes and mast cells
through their innate sensing receptors. Macrophages
are important in innate immunity as they are able to
clear parasitized RBCs in the absence of opsonizing
malaria-specific antibodies. It is hypothesized that
there are two methods of infected RBC uptake by
macrophages. The predominant method of uptake
involves the binding of non-specific IgG and
complement to the surface of infected RBCs, and
increased exposure of senescent RBC markers such
as exposure of phosphatidylserine (PS). This method
induces the release of pro-inflammatory cytokines.
The second method of uptake is CD36 mediated,
which involves the binding of CD36 on the
macrophage to PfEMP-1 on the infected RBCs. This
method does not involve the release of proinflammatory cytokines [28-29].
There are three main biochemical pathways
that result in activation of the complement system:
the classical complement binding pathway; the
mannose-binding lectin pathway; and the alternative
pathway. All three lead to the formation of C3 and C5
convertase which results in the cleavage of C3 and
C5 into C3a, C3b, C5a and C5b, respectively. RBCs
opsonized by IgG and complement (C3b) are
recognized by the Fc receptor (FcR) and CR1
(respectively),
and
phagocytosed
by
macrophages.This method of clearance is effective in
senescent and damaged RBCs, and also in P.
falciparum infected RBCs [30].
COMPLEMENT RECEPTOR 1(CD35):
CR1 is a 200-kDa single chain membrane bound
glycoprotein and a member of the regulators of
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Int J Med Res Health Sci. 2015;4(2):422-431

complement activation (RCA) gene cluster. CR1


possesses complex tri and tetra N-linked
oligosaccharides in its mature form and the gene for
this protein is located on the q32 arm of chromosome
1. It is composed of a number of repeated domains
called short consensus repeats (SCRs) each of which
is composed of 60 amino acids containing four
invariant cysteines. The extracellular domain of the
CR1 is composed of 30 SCRs, the first 28 of which
are arranged in tandem repeats in homologous groups
of 7, with each group known as long homologous
repeat (LHR). SCRs 8-12 and SCRs 15-18
preferentially bind to C3b and SCRs 1-4
preferentially bind to C4b. The region of CR1 that
interacts with infected erythrocytes to form rosettes
has been mapped to LHRB and first three SCRs of
LHR-C, SCR 10 and 17 have been particularly found
to play an important role in this interaction [31-32].
Effect of differential CR1 expression on malarial
pathogenesis; Differences in the expression of CR1
on erythrocytes might determine susceptibility of an
individual towards development of cerebral malaria
and severe malaria-associated anemia. In one of the
studies it was suggested that young children may be
more susceptible to SMA because of their lower
levels of RBC complement regulatory proteins, which
make them less equipped to handle IC formation and
complement activation. Previously same group of
researchers had proved that a decline in levels of CR1
and increase in immune complex levels significantly
associates with SMA. The mechanism for the loss of
CR1 from the surface of erythrocytes is being
investigated. A series of experiments indicated that
CR1 present in the form of clusters on RBC surface
undergoes unclustering due to the binding of IgM C3b complexes to glycophorin A. Unclustering might
promote rapid loss of CR1 from the surface of
erythrocytes infected with the malaria parasite [33].
CR1 polymorphisms; CR1 is a highly polymorphic
glycoprotein. Three different polymorphic forms of
CR1 have been identified, namely structural (size
variation 160-250 kDa), density (high and low
expression on RBCs controlled by alleles H and L)
and knops blood group (McC (a+)/McC (b+); Sl
(a+)/Sl (a-); Kna/ Knb).
a) Structural polymorphism:
Four different structural polymorphic forms of CR1
are known, namely A, B, C and D (CR1*1, CR1*2,
CR1*3, CR1*4) with respective molecular weights of

190, 220, 160 and 250 kDa (under non-reducing


conditions). This polymorphism is regulated by four
autosomal co-dominant alleles. A polymorphism in
the CR1 transcripts with incremental differences of
1.4 kb in mRNA was present in donors expressing the
various polymorphic forms. This difference
corresponds to the size of one LHR and 40 kDa
difference, seen among allotypic forms of CR1.
Therefore on the basis of this observation it was
suggested that the insertion or deletion forms the
basis of structural polymorphism. Analysis of
restriction fragment length polymorphism (RFLP)
suggested that intragenic duplication rather than
alternate mRNA splicing is responsible for the
allotypic differences [34-35].
b) Density polymorphism:
Second type of polymorphism is a Hind III RFLP,
which in Caucasians but not in Africans,
correlates with CR1 copy number on erythrocytes.
Homozygotes for the L (low expression) allele
usually express fewer than 200 copies of CR1,
homozygotes for the H (high expression) allele
express several times this number and heterozygotes
are intermediate. This polymorphism arises due to a
single base change in the intron of d1d2 segment
within the LHR-D (Long homologous repeat) region
resulting in the generation of a polymorphic Hind III
site within this region [36].
Genotypic frequencies of HH, HL and LL forms have
also been studied in the malaria endemic and nonendemic groups in different populations. In
nonendemic Caucasian and Choctaw population
groups in USA, the gene frequencies for H and L
alleles were found to be 0.82, 0.18 and 0.84, 0.16
respectively. In endemic Black Africans the gene
frequencies for H and L alleles were 0.85 and 0.15; in
S. Chinese-Taiwanese 0.71 and 0.29; in Pacifi c
Asians 0.42 and 0.58 and in Cambodians 0.53 and
0.47 respectively [37].
c) Knops polymorphism:
The third type of polymorphism represented by
Knops blood group system is of particular interest. In
this system, Mca and Mcb is one allelic antigen pair
and Sla and Vil is another pair. The corresponding
phenotypes for the fi rst pair are McC (a+) and McC
(b+) and for the second pair are Sl (a+) and Sl (a-).
Studies have now established the molecular basis for
Knops polymorphism. These antigens have been
localized on the LHR-D segment of CR1. Single
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Int J Med Res Health Sci. 2015;4(2):422-431

nucleotide polymorphisms occurring in SCR 25,


which lead to amino acid substitutions, result in
generation of these polymorphic forms Population
based studies have been carried out to determine the
distribution of different types of Knops polymorphic
forms in different populations. The gene frequencies
for Sl (a+) and Sl (a-) in African American persons are
almost equal (0.48 vs. 0.52) wheras Sl (a-) is greatly
increased in Africa [38-39].
Out of the three polymorphic forms, size
polymorphism has not been found to play a role in
determining susceptibility to severe malaria. With
regard to density polymorphism, some studies
suggest that low-density allele confers protection
against malaria, whereas another suggested that lowdensity allele might be a risk factor for severe forms
of malaria. Erythrocytes with low CR1 expression
(because of the homozygous LL genotype of CR1)
have been shown to form reduced number of rosettes
with Plasmodium falciparum infected cells [40-42].
CYTOKINES AND MALARIAL INFECTION:
The study of immune response against Plasmodium is
based on murine experimental systems. Both cell
mediated and antibody-dependent immunity is
required for adequate protection against malarial
infection in different mechanisms. In addition, innate
immunity is thought to play a crucial role in clearing
Plasmodium from parasitized hosts [43]. In splenic
response, tissular changes that provoke alterations in
blood flow through the organ. These changes prevent
the access of infected erythrocytes to splenic tissues
in which the immune response is going on until
armed effector cells are produced. In general, most of
the evidence supports the hypothesis that cells from
the monocyte-macrophage lineage are more effective
than neutrophils at phagocytosing parasitized
erythrocytes [44].
P. chabaudi infection in / T-cell-deficient mice has
exacerbated early and chronic parasitemias. Resulting
early production of gamma interferon (IFN-) and
tumor necrosis factor alpha (TNF-) both to spleenic
/ T lymphocytes and to natural killer (NK) cells [4546]
.
Both the cellular and humoral responses are pivotal
elements in the eradication of Plasmodium from the
body, and both are critically dependent on / CD4+
lymphocytes. It has been firmly established that CD4+
T cells are comprised of at least two functionally
different subsets, distinguished on the basis of

lymphokine secretion in Th1 (IFN--producing) and


Th2 (interleukin-4 [IL-4]/IL-5-producing) cells. CD4+
T cells of either Th1 or Th2 type also have regulatory
functions in human P. falciparum malaria. Both Th1
and Th2 responses seem to be required to control the
infection, but they need to be adequately tuned in
intensity and time [47-48].
Cytokines in Early Protection; The early production
of IFN- is responsible for resistance against
infection. In support of this point, analysis of IFN-
R-/- mice infected with P. chabaudi chabaudi showes
a critical role of IFN- in immunity against this
pathogen. Interestingly, Tan et. al.[50] reported that
IFN responsive factor (IRF-1)-/- mice infected with P.
berghei revealed that lower mortality than wild-type
mice, although they produced no IFN- or NO [51-53].
There are mechanisms of resistance independent for
IFN- and NO. In which treatment in vivo with antiIFN- exacerbates P. yoelii 17XL infection in
C57BL/6 because mice treated with antibody die
earlier. In contrast, treatment with aminoguanidine,
an irreversible inhibitor of NO production, has no
effect. Consistently, mice lacking inducible nitric
oxide synthase (iNOS-/-) cleared P. berghei XAT (an
attenuated variant of P. berghei NK65) as effectively
as did wild-type animals. In this case, resistance was
dependent on IFN- , since its in vivo, blocking
provoked progression of parasitemia and death [54].
The overall conclusion that can be drawn
from this is that the role of a particular cytokine is
likely to be different at different stages of the
infectious process. A prominent role in switching
from Th1 to Th2 responses is attributed to IL-10.
Therefore, it is probably involved in controlling the
adequate timing of antiparasitic responses. Early IL10 production has been associated with susceptibility
to infection, and it is thought that this cytokine has a
prominent anti-inflammatory effect, limiting in some
way the damage inflicted on normal tissues by an
excessive Th1 response [55-56].
Cytokines in the Immunopathology of Malaria;
The pathogenesis of malaria is complex and
containing immunologic and non-immunologic
mechanisms. In general, it is now accepted that
severe malaria is the consequence of alterations in
many tissues and organs. These dys-functions often
lead to metabolic acidosis and localized ischemia. It
is evident that parasite factors can contribute to the
severity of disease, as is clear from their ability to
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infect a high percentage of erythrocytes or to induce


production of proinflammatory cytokines. In
particular, much evidence has been accumulated that
glycosylphosphatidylinositols from Plasmodium as an
important pathogenic factors due to their ability to
induce TNF- and IL-1 [57-58]. This view is strongly
supported by the fact that the toxicity of malaria
parasite extracts can be neutralized with monoclonal
antibodies against this moiety in experimental models
[59]
. It is noteworthy that recent work suggests that the
presence of anti-glycosyl phosphatidyl inositol
antibodies in the serum of patients may provide
protection against clinical symptoms of malaria.
Therefore, cytokines, viewed as potential pathogenic
elements, can contribute either directly or indirectly
to many pathological processes [60-61].
Cytokines in the Diagnosis of Malaria; The Th2
profiles have been reported in humans, with elevated
levels of IgE being found in the blood of malaria
patients, presumably due to the predominance of Th2
cells over Th1 helper cells. This polarization was
significantly higher in the case of patients suffering
from severe malaria [62]. Th1 responses are important
for clearance of P. falciparum malaria. In nonimmune children with severe P. falciparum malaria
showed lower levels of IL-12 and IFN- in serum and
had a reduced capacity to produce them after in vitro
stimulation. It is interesting that children with severe
anemia had the highest levels of TNF- [63]. It has
been reported that children with prior mild malaria
showed an enhanced ability to express iNOS in vitro
over children with prior severe malaria. Furthermore,
Luty et. al. [64] found that peripheral blood
mononuclear cells of patients with mild malaria
produced IFN- in response to malarial antigens,
whereas those with severe malaria did not. However,
no associations were found with TNF- production.
The studies on Ghanaian children showed that only
patients with uncomplicated malaria had a positive
correlation with levels of TNF- and soluble TNF-
R1 and TNF- R2 in serum. In the same study,
children with CM had high levels of TNF- , and
although TNF- level were associated with fever no
differences were observed in soluble TNF-
receptors. Interestingly, children with fever and
detectable parasitemia, but not afebrile parasitized
patients, had elevated levels of TNF- [65]. Patients
who died from P. falciparum malaria had higher

amounts of IL-6, IL-10, and TNF- in serum than


did the patients who survived.
CONCLUSION
Malaria is a worldwide spreaded disease due to
plasmodium species (P. falciparum, P. vivax, P.
malariae, and P. ovale). It affects 300-500 million
people in which 1-3 million going to death. All of
plasmodium species, P. falciparum is very dangerous
leads to cerebral malaria. For completing, his life
cycle, plasmodium having two host first mosquito (as
a vector) and second human. When plasmodium is
introduced in blood by mosquito, it attached with
RBCs through CD35 (CR1) which act as a receptor
for PfEMP-1 (present in plasmodium) and circulate in
blood stream. CD35 is a cell surface receptor and its
gene present in chromosome no. 1. It is also known as
Complement Receptor Type 1 (CR1). Density of
CD35, in cell surface is determined by CR1 gene
polymorphism. There are types of CR1
polymorphism (a) Structural polymorphism (b)
density polymorphism (c) knops polymorphism. High
density of CD35 is more susceptible to plasmodium
infection. ICAM-1 and VCAM-1 are also play
important role in malarial pathogenesis. Cytokine
profiling
indicates
malarial
severity.
Proinflammatory cytokine TNF- and INF- level is
increased during malarial infection where as IL10,
IL4, and IL6 are anti-inflammatory cytokine.
Conflict of interest: Nil
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The course of Plasmodium chabaudi chabaudi
infections in interferon- receptor deficient mice.
Parasite Immunol. 1997:19:37533.
Tan RS, Feng C, Asano Y, and Kara AU. Altered
immune response of interferon regulatory factor
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52. Sam H, and Stevenson MM. Early IL-12 p70, but
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53. Kobayashi F, Ishida H, Matsui T, and Tsuji M.
Effects of in vivo administration of anti-IL-10 or
anti-IFN- monoclonal antibody on the host
defense mechanism against Plasmodium yoelii
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54. Yoneto T, Yoshimoto T, Wang CR, Takahama Y,
Tsuji M, Waki S, and Nariuchi H. Gammainterferon production is critical for protective
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55. Yoshida A, Maruyama H, Kumagai T, Amano T,
Kobayashi F, Zhang M, Himeno K, and Ohta N.
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56. Linke A, Kuhn R, Muller W, Honarvar N, Li C,
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Blomberg MT. IgE and tumor necrosis factor in
malaria infection. Immunol. Lett. 1999:65:2933
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Lehman LG, Luckner D, etal. Low interleukin-12
activity in severe Plasmodium falciparum
malaria. Infect. Immun;2000: 68:390915.
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Luckner D, Greve B, etal. Interferon- responses
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McGuire W, DAlessandro U, Stephens S,
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Int J Med Res Health Sci. 2015;4(2):422-431

DOI: 10.5958/2319-5886.2015.00079.X

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 14 Dec 2014
Case report

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 16 Jan 2015
Accepted: 26th Jan 2015

A UNIQUE CASE OF PHEOCHROMOCYTOMA PRESENTING WITH HYPERTENSIVE


RETINOPATHY
*Maji.S1, Saha. ML2, Kanwar KS3, Das S4, Bhagat P5, Bhar P6
1,3

Resident, 2Professor,
Kolkata, India

4,6

Assistant Professor, 5RMO, Department of General Surgery, I.P.G.M.E&R, SSKM&H,

*Corresponding author email: drsuvendumaji@rediffmail.com


ABSTRACT
Pheochromocytoma is an extremely uncommon tumor of childhood and there are several features that distinguish
its presentation between adults and children. The incidence of pheochromocytoma in childhood is 10% of the
adult incidence, occurring in approximately 1 in 500,000 children compared with 1 in 50,000 adults. Around 10%
of childhood tumors are familial which is 4times the frequency in adults. Whereas only 7% of
pheochromocytomas are bilateral in adults, the reported incidence of the same in children range from 24 % to as
high as &70%.These tumors are known for their great diversity in clinical presentation. Greater than 50% of
children present with headaches, fever, palpitation, thirst, polyuria, sweating, nausea and weight loss. However
the commonest mode of presentation is sustained hypertension. Pheochromocytoma accounts for 0.5% of children
with hypertension and must be considered once other causes have been eliminated. We here in report a unique
case of a 13 year old girl who initially presented with bilateral hypertensive retinopathy and later found to have a
pheochromocytoma on subsequent workup. Hypertensive retinopathy secondary to pheochromocytoma is itself a
rare entity whose exact incidence in children is still unknown. This case highlights the importance of routine
history, physical examination and measurement of bp. Prompt surgery can reverse the effect of hypertension and
lead to good outcome as was evident in our case.
Keywords: Pheochromocytoma, Hypertensive retinopathy, Metanephrines, Normetanephrines, Zellballen
INTRODUCTION
Pheochromocytomas are rare tumors with prevalence
rates ranging from 0.3 to 0.95% in autopsy series, and
approximately 1.9% in series using biochemical
screening. Recent advances in molecular genetics
have shown presence of germline mutation in up to
59% of apparently sporadic pheochromocytomas
presenting at 18 years or younger and in 70% of those
presenting before 10 years of age[1].They can occur at
any age with a peak incidence in the fourth and fifth
decades of life, and have no gender predilection[2].
Pheochromocytoma is rare in children1.It is a
catecholamine producing tumor of the sympathetic
nervous system9. The presentation varies from vague
Saha et al.,

symptoms to hypertensive emergencies. Headache,


palpitations, and diaphoresis constitute the "classic
triad" of pheochromocytomas. The hypertension
related to this tumor may be paroxysmal with
intervening normotension, sustained with paroxysms,
or sustained hypertension alone. In children however
hypertension often remains sustained. Presentation
may not be always with the above classic triad and
unique presentation as in our case needs to be kept in
mind! The treatment of pheochromocytoma remains
surgical excision although medical management of
hypertension is an essential part of preoperative
preparation[3].
432
Int J Med Res Health Sci. 2015;4(2):432-434

Case report
A 13 year old girl presented with blurring of vision
since a week .She underwent ophthalmic assessment
in a private eye clinic where she was found to have
bilateral hypertensive retinopathy. She was then
admitted to our SSKM hospital, initially in the
general medicine ward where she underwent full
work up and physical examination. She was later
transferred to the surgical unit. Her history revealed
that she had complaints of palpitation, throbbing
headache and occasional sweating for the last 7
month. She also had associated weight loss. However
her appetite, bowel and bladder habits were normal.
On admission she had a bp of 180/110 mm of Hg and
a pulse rate of 130/mint. On abdominal examination
no lump was found. On USG a large (3.92x 4.21) cms
hetrogenous mass with cystic degeneration above
superior pole of left kidney was found. CECT
abdomen revealed (4.5 x 3.9) cms cystic sol with
enhancing thick walled mass in the left adrenal gland.
Biochemical tests showed high value of 24 hour
urinary metanephrine level (14.36) microgram/litre
and elevated level of normetanephrine (1445.1)
microgram/litre. There was no drug history of
ephedrine, amphetamines, methlxanthines etc use in
this patient which could have lead to false elevated
metanephrine level. Serum levels of Ca2+,PTH,
phosphate, calcitonin were all normal. Preoperatively
she received prazosin & propnanolol. She underwent
left adrenalectomy under GA following which she
was shifted to ICU where constant monitoring of her
vitals was undertaken. She was hypotensive and had
to be put on noradrenaline drip for 3 days. She was
started on oral diet by 5th postop. day and was
discharged on the 7th day. She was followed up with a
repeat test of serum and urinary markers which
showed normal results. Her pathological report
showed a well encapsulated tumor composed of large
polygonal cells, vesicular nuclei, small nucleoli and
abundant eosinophilic granular cytoplasm, arranged
in Zellballen, surrounded by elaborate vascular
network which was consistent with a diagnosis of
benign pheochromocytoma [fig 1&2]. On 6 months
follow up she has been healthy and enjoying a good
quality of life without any visual problem.

Fig1: Pathology specimen showing the cystic


adrenal tumor.

Fig 2: Microscopic appearance showing tumor


cells arranged in Zellballen
DISCUSSION
Pheochromocytomas are catecholamine-secreting
neoplasms. Due to its variable presentation, they have
been called the masquerader .The clinical spectrum,
ranges from completely asymptomatic (10%) to a
sustained stable hypertension (50%), or to frequent
life-threatening hypertensive crises (30%). Majority
of the patients present with the classical triad of
episodic headache, palpitations, diaphoresis, and a
feeling of impending doom. Several series have
reported that 19-76% of pheochromocytomas are not
diagnosed until after death2 & the incidence of
asymptomatic tumors being is 4.4 to 17 %[3]. Atypical
symptoms described in literature include abdominal
pain, vomiting, polyuria, polydipsia, heart failure,
cerebrovascular hemorrhage. A pheochromocytoma
presenting initially with hypertensive retinopathy is
rare and its incidence is unknown. About 10% of
pediatric pheochromocytoma is thought to be
familial4. Studies of families with pheochromocytoma
occurring across several generations suggest a
dominant autosomal mode of inheritance with high
433

Saha et al.,

Int J Med Res Health Sci. 2015;4(2):432-434

penetration[4,5].Familial cases of pheochromocytoma


also carry a higher risk of malignancy than
sporadically occurring varieties[6].The diagnosis of
this tumor relies on the demonstration of blood and
urinary catecholamines and their metabolites. A 24
hr urine measurement of catecholamines,
metanephrine and vanillyl mandelic acid is the best
diagnostic test. Once the chemical diagnosis is
established the tumor must be localized. Radiological
imaging modalities like USG, Contrast Enhanced CT
scan and MRI are useful in determining the origin
and extent of tumour. Prompt diagnosis and complete
excision are the most important treatment for
childhood
pheochromocytoma[7,8].Pre-intra-and
postoperative medical management is as important as
the surgical procedure itself. All patients should
undergo follow up to confirm normalization of
catecholamine levels. [9,10]
This case was unique and interesting due to following
reasons:
1. Hypertensive retinopathy as an initial presentation
of pheochromocytoma is extremely rare. Data about
this is limited and is mainly in form of few case
reports. Most of these are from western literature9,10
and very few from the Indian subcontinent.
2. Though childhood pheochromocytomas are
frequently multiple, bilateral and frequently have
familial associations our case was unique being
unilateral, single lesion and sporadic in presentation.
3. It highlights the importance of blood pressure
measurement in the clinical diagnosis of this rare
condition. Early diagnosis is crucial not only because
it is a curable cause of severe hypertension but also
since unrecognized tumor may provoke fatal
hypertension crisis during surgery, some diagnostic
procedures or other stresses.

REFERENCES
1. Armstrong R, Sridhar M, Greenhalgh KL, Howell
L, Jones C, Landes C, McPartland JL, Moores C,
Losty PD & Didi M. . Phaeochromocytoma in
children. Archives of Disease in Childhood2008
;93(10):899 -04.
2. Kloos RT, Gross MD, Francis IR, Korobkin M,
Shapiro B. Incidentally Discovered Adrenal
Masses. Endoc Rev 1995; 16:460-84
3. Jain SK, Agarwal N. Asymptomatic Giant
Pheochromocytoma. J Assoc Physic India
2002;50:842-4.
4. Michael G. Caty, Arnold G. Coran, Michael
Geagen,et al. Current diagnosis and treatment of
pheochromocytoma in children: experience with
22 con-secutive tumors in 14 patients. Arch Surg,
1990,125: 978- 81.
5. Sawin RS. Functioning adrenal neoplasm. Semin
Pediatr Surg, 1997; 6:156-63
6. Levine C, Skimmine J, Levine E. Familial
pheochromocytomas with unusual associations. J
Pediatr Surg,1992,27: 447-51,
7. Caty MG, Coran AG, Geagen M, Thompson NW.
Current diagnosis and management of
pheochromocytoma in children. Arch Surg 1990;
125: 978-81.
8. Chen TY, Liang CD, Shieh CS, Ko SF, Kao ML.
Reversible hypertensive retinopathy in a child
with bilateral pheochromocytoma after tumor
resection. J Formos Med Assoc 2000; 99: 945-47.
9. McClellan MW. Pheochromocytoma: evaluation,
diagnosis, and treatment. World Journal of
Urology. 1999; 17(1):3539.
10. Barontini M, Levin G, Sanso G Characteristics of
pheochromocytoma in a 4- to 20-year-old
population. Ann NY Acad Sci2006; 1073:307.

CONCLUSION
A high index of suspicion and early diagnosis is key
to successful management in pheochromocytomas .A
high blood pressure in a child should prompt
thorough search for this condition. Preoperative
stabilization of blood pressure is crucial in preventing
intraoperative
catastrophe
of
uncontrolled
hemorrhage.
Conflict of Interest: Nil

434
Saha et al.,

Int J Med Res Health Sci. 2015;4(2):432-434

DOI: 10.5958/2319-5886.2015.00080.6

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 26 Dec 2014
Case report

Coden: IJMRHS
Revised: 20th Jan 2015

Copyright @2014

ISSN: 2319-5886
Accepted: 4th Feb 2015

NECROLYTIC ACRAL ERYTHEMA: HIGH DEGREE OF SUSPICION FOR DIAGNOSIS


* Shumez H 1, Prasad PVS 2, Kaviarasan PK 3, Viswanathan P 4
1

Junior Resident, 2Professor, 3Professor & Head, Department of Dermatology, Venerology and Leprosy,
4
Professor & Head, Department of Pathology, Rajah Muthiah Medical College and Hospital, Annamalai
University, Tamil Nadu, India.
*Corresponding author email: shumezh@gmail.com
ABSTRACT
Necrolytic Acral Erythema (NAE) is a recently described, poorly understood, rare dermatological entity, which is
frequently associated with Hepatitis C Virus (HCV) infection. This report describes a 53 year old male with a 6
month history of well demarcated, reddish brown to hyperpigmented, scaly skin over dorsum of both hands and
feet. Investigations revealed hypothyroidism and low serum zinc levels. Patient also tested seropositive for HCV.
Histopathological examination revealed hyperkeratosis and subcorneal clefting along with areas of necrosis.
Patient was started on oral zinc along with treatment for hypothyroidism, and improved symptomatically in 2
weeks. Early recognition of NAE is of prime importance to dermatologists as it allows diagnosis of HCV in
previously unaware patients and gives way for efficacious treatment.
Keywords: Necrolytic erythema, Hepatitis C, HCV
INTRODUCTION
Necrolytic acral erythema (NAE) belongs to the
group of necrolytic erythemas which include
acrodermatitis
enteropathica, pellagra, biotin
deficiency, essential fatty acid deficiency and
necrolytic migratory erythema. These conditions are
both histologically and clinically similar but differ in
their etiology. [1] NAE is a recently described, poorly
understood, rare dermatological entity. NAE is
characterised by erythematous to violaceous, scaly
plaques on the acral sites. It is frequently associated
with Hepatitis C Virus (HCV) infection and is now
considered a diagnostic cutaneous marker for the
disease. Recognition of NAE requires clinicopathological correlation and a high degree of
suspicion. NAE responds well to oral zinc therapy
and treatment of the underlying HCV infection with
interferon alpha. We report a case of NAE from
Southern India.

Shumez et al.,

CASE REPORT
A 53 yr old man, farmer by profession, presented to
the dermatology department with dry, rough,
thickened skin over the hands and legs for the past 6
months. The lesions initially started on the legs and
then progressed to involve the hands in about 2
weeks. It was associated with itching and burning
sensation on sun exposure. Patient also gave history
of loose stools since 3 weeks. Stools were watery in
consistency, about 4-5 episodes per day, not
associated with blood or mucus. It was associated
with pain abdomen. Patient was not an alcoholic or
on any medications. Family and personal history were
non-contributory in our case.
Cutaneous examination showed well demarcated,
reddish brown to hyperpigmented, rough, thick, scaly
skin with cracks over both lower limbs extending up
to the knee and both upper limbs extending just above
the elbow joints (Figures 1a and b).
435
Int J Med Res Health Sci. 2015;4(2):435-438

Diffuse, erythematous patches were present over the


face (Figure 2) and V region of neck with
hyperpigmentation and a few papules, suggestive of
casals necklace. Rest of the examination including
that of oral cavity and genitalia did not show any
abnormality. Deep tendon reflexes were sluggish.
A skin biopsy specimen taken from the lesions over
the forearm demonstrated hyperkeratosis and clefting
present subcorneally, extending up to subepidermal
levels (Figure 3). Areas of epidermis showed
necrosis. Dermis showed sparse inflammatory
infiltrate along with congested blood vessels.
Liver function tests were altered - Alkaline
phosphatise was elevated (332 IU/L) but Aspartate
transaminase and Alanine transaminase were normal.
Electrocardiogram showed low voltage complexes.
ECHO revealed mild pericardial effusion with no
ischaemic changes. Thyroid hormone levels were
suggestive of hypothyroidism (free T3 0.15 pg/ml,
free T4 0.07 ng/dl, serum TSH 57 IU/ml).
Serum zinc levels were low (47.3g/dl). Patient
tested seropositive for Hepatitis C virus. Other
routine investigations were normal.
Patient was started on oral Zinc sulphate 440 mg/day
in two divided doses, as the mainstay treatment. He
was also put on Thyroxine 100 g once a day. Patient
improved symptomatically in about 2 weeks (Figures
5a and 5b). Patient was continued on low doses of
zinc sulphate for a period of one year and followed up
at regular intervals. There was no recurrence of
lesions.

Fig 2: Diffuse, erythematous patches were present


over the face

Fig 3: Hyperkeratosis with sparse inflammatory


infiltrate seen around blood vessel and adnexae.

Fig 1a and b: Well demarcated, reddish brown,


rough, hyperpigmented, thick, scaly skin with
cracks over both upper limbs extending just above
the elbow joints.

Fig 4a and b: Resolution of lesions with oral zinc


in about 2 weeks

Shumez et al.,

Int J Med Res Health Sci. 2015;4(2):435-438

436

DISCUSSION
NAE is an infrequently described dermatologic
entity. [2] It was first described by El Darouti et al in a
case series of 7 Egyptian patients in 1996. [3] It
belongs to the group of necrolytic erythemas. This
group of dermatoses also includes acrodermatitis
enteropathica, pellagra, biotin deficiency, essential
fatty acid deficiency, and necrolytic migratory
erythema. These conditions share many histological
and clinical similarities but have diverse etiologies.
NAE is often associated with HCV infection.
The initial lesion is often erythema with vesicles and
flaccid bullae, especially around the periphery of
plaques.[3,4,5] Chronic lesions appear as erythematous
to violaceous plaques with thick scale, erosions and
crusting, and often have a dark red rim.[1,3,4,5,6]
Lesions are predominantly found on acral sites.[1,4.7,8]
The most common site of NAE plaques is the dorsal
aspect of feet.[1,3,4,7,8,9] However, absence of lesions
over feet is not critical for diagnosis.
Scaly, erythematous lesions on acral locations can be
observed in both psoriasis and NAE. NAE has dark,
verrucous scales as opposed to the silvery white
scales of psoriasis. Furthermore, NAE can present
with flaccid blisters and it typically spares the palms
and soles. Histologically, the lesions of psoriasis do
not possess the necrotic keratinocytes seen with NAE.
[5, 9]

zinc deficiency in a subset of patients with the disease


and the clinical response to zinc supplementation
substantiates this theory. According to Najarian et al,
even patients with normal serum zinc levels may
harbour occult cutaneous zinc deficiency. [12]
Treatment of NAE is initiated with oral zinc sulphate
supplementation, and response is often noted within
several weeks of beginning therapy. The
recommended dose is 440 mg/day in 2 divided
doses.[1,4,9] In many patients, including ours, complete
or near-complete resolution of skin lesions is attained
with zinc treatment alone.4,5,9,12 Other modalities of
treatment like oral amino acid supplementation,
topical corticosteroids and intralesional triamcinolone
have been tried, but efficacy in skin disease has been
minimal.[1,3,4,5,7,9]
Treatment of underlying hepatitis C (with interferonalpha with or without ribavirin) is the definitive
treatment and has led to improvement of skin disease
in a majority of patients. [1, 3, 4, 6, 8]
CONCLUSION
The incidence of Hepatitis C infection worldwide is
rising and NAE is a diagnostic cutaneous marker.
Early recognition of NAE is of prime importance to
dermatologists as it allows diagnosis of HCV in
previously unaware patients and gives way for
efficacious treatment.

Histologically, NAE resembles findings of other


necrolytic erythemas. Abdallah et al found that in the
early stages, NAE shows acanthosis, epidermal
spongiosis and superficial perivascular dermatitis. In
the late stages, it shows psoriasiform hyperplasia and
prominent papillomatosis with parakeratosis,
subcorneal pustules, epidermal pallor and necrotic
keratinocytes.[4,10] Confluent necrosis of the
keratinocytes in the upper parts of the epidermis may
lead to cleft formation.[4,5] Since there are no specific
histopathological features, correct diagnosis requires
clinico-pathologic correlations and a high degree of
suspicion.[4,11]
The exact pathogenesis of NAE is not known, but the
etiology of NAE seems to be multifactorial. Several
mechanisms have been put forward, including zinc
deficiency, hypoaminoacidemia, hypoalbuminemia,
hepatocellular dysfunction, hyperglucagonemia and
diabetes. [4, 5] Zinc deficiency has been suggested as
an etiologic factor in the skin lesions. The presence of

ACKNOWLEDGEMENT: None

Shumez et al.,

Int J Med Res Health Sci. 2015;4(2):435-438

Conflict of Interest: None


REFERENCES
1. Khanna VJ, Shieh S, Benjamin J, Somach S,
Zaim MT, Dorner W, Jr, Shill M, Wood GS.
Necrolytic acral erythema associated with
hepatitis C: effective treatment with interferon
alfa and zinc. Arch Dermatol 2000;136:7557.
2. Liu A, Erickson CP, Cockerell CJ, et al.
Necrolytic acral erythema: a case not associated
with hepatitis C infection. Dermatol Online J
2008;14:10.
3. El Darouti M, Abu el Ela M. Necrolytic acral
erythema: a cutaneous marker of viral hepatitis
C. Int J Dermatol 1996;35:2526.
4. Bentley D, Andea A, Holzer A, et al. Lack of
classic histology should not prevent diagnosis of
necrolytic acral erythema. J Am Acad Dermatol
2009;60:504-7.
437

5. Nofal AA, Nofal E, Attwa E, El-Assar O, Assaf


M. Necrolytic acral erythema: a variant of
necrolytic migratory erythema or a distinct
entity? Int J Dermatol 2005;44:91621.
6. Hivnor CM, Yan AC, Junkins-Hopkins JM,
Honig PJ. Necrolytic acral erythema: response to
combination therapy with interferon and
ribavirin. J Am Acad Dermatol 2004;50:12124.
7. Abdallah MA, Ghozzi MY, Monib HA, Hafez
AM, Hiatt KM, Smoller BR, Horn TD.
Necrolytic acral erythema: a cutaneous sign of
hepatitis C virus infection. J Am Acad
Dermatol 2005;53:24751.
8. El-Ghandour TM, Sakr MA, El-Sebai H, ElGammal TF, El-Sayed MH. Necrolytic acral
erythema in Egyptian patients with hepatitis C
virus
infection. J
Gastroenterol
Hepatol 2006;21:12006.
9. Abdallah MA, Hull C, Horn TD. Necrolytic acral
erythema: a patient from the United States
successfully treated with oral zinc. Arch
Dermatol 2005;141:857.
10. Abdallah MA, Ghozzi MY, Monib HA, Hafez
AM, Hiatt KM, Smoller BR, Horn TD.
Histological study of necrolytic acral erythema. J
Ark Med Soc 2004;100:3545.
11. Fielder LM, Harvey VM, Kishor SI. Necrolytic
acral erythema: case report and review of the
literature. Int J Dermatol 2005;44:91621.
12. Najarian DJ, Lefkowitz I, Balfour E, Pappert AS,
Rao BK. Zinc deficiency associated with
necrolytic acral erythema. J Am Acad
Dermatol 2006;55:10810.

Shumez et al.,

438
Int J Med Res Health Sci. 2015;4(2):435-438

DOI: 10.5958/2319-5886.2015.00081.8

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Nov 2014
Case report

Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 10 Dec 2014
Accepted: 22nd Feb 2015

DOUBLE SUPRASCAPULAR FORAMINA: AN ANATOMICAL VARIATION


Taqdees Fatima1, *Vanitha2, H.S. Kadlimatti3
1

Dept. of Anatomy, Khaja Bandanawaz Institute of Medical Sciences, Gulbarga, Karnataka, India
Dept. of Anatomy, ESIC Medical College, Gulbarga, Karnataka, India

2, 3

*Corresponding author email: vanithasanjeev@gmail.com


ABSTRACT
Suprascapular notch transmit supra scapular nerve to the supraspinous fossa. Transverse scapular ligament
bridges the notch to form a supra scapular foramen. This region is the most common location of supra scapular
nerve injury & compression. Most important predisposing factor of supra scapular neuropathy is an ossified
superior transverse scapular ligament. We report here a case of double supra scapular foramen found during our
routine osteology demonstrations. The etiopathogenesis and clinical implications of such variations are discussed.
Keywords: Compression, Ossification, Suprascapular nerve, Transverse scapula ligament.
INTRODUCTION
Scapula is a triangular, flat bone situated in the
postero-lateral part of chest wall [1].Its superior border
presents a supra scapular notch near the root of the
coracoid process. Superior transverse scapular
ligament bridges the notch to form a supra scapular
foramen which transmits supra scapular nerve to the
supraspinous fossa [2].This region is the most common
location of supra scapular nerve injury &
compression. Most important predisposing factor of
supra scapular neuropathy is an ossified superior
transverse scapular ligament [3].

Inferior band: Length-1cm, Thickness: Medially9mm, Centre-6mm & Laterally-10mm.


Superior Foramen: Transversely-10mm, Vertically4mm.
Inferior Foramen: Transversely-7mm, Vertically
3mm. Both the foramina were transversely oval.

CASE REPORT
During the routine osteology class for the MBBS I
phase students, in the department of anatomy, ESIC
Medical College, Gulbarga, an anatomical variation
of the supra scapular notch where two bony bridges
converting it into a double supra scapular foramina
was found in one left scapula. Dimensions of bony
bridges and foramina were as follows:
Superior band: Length- 1.2cm, Thickness:
Medially-4mm, Centre-3mm & Laterally-3mm

Fig1: Shows double suprascapular foramen .SBSuperior band, SF-Superior foramen, IB-Inferior
band, IF-Inferior foramen
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Int J Med Res Health Sci. 2015;4(2):439-441

DISCUSSION
Suprascapular neuropathy is infrequent condition that
occurs in only 1-2% cases of shoulder pain [4]. Causes
includes trauma caused by repetitive over head
abduction in athletes and in volley ball players,
rotator cuff tear, compression of the nerve at the
suprascapular notch or spinoglenoid notch or by
supraglenoid and paralabral cysts [4]. The incidence of
complete ossification of the STSL (superior
transverse scapular ligament ) depends on population
and has been found to vary from 4 to 12.5% [5] . A
familial case of the ossification of the STSL causing
entrapment neuropathy of the Suprascapular nerve
affecting both father & son has also been described,
suggesting that the ossification may have a genetic
basis [6].
Ticker et al., studied anatomy of Suprascapular nerve
and demonstrated partial and complete ossification of
supra scapular ligament and multiple bands including
the first report of a trifid superior transverse scapular
ligament [7]. Alon et al., reported a case of bilateral
Suprascapular nerve entrapment due to ossification of
bifid Transverse scapular ligament in a female patient
[8]
. Rengachary et al., classified Suprascapular notch
into 6 types [9].
Very few cases of double supra scapular foramen has
been reported in literature till now. Michal P et al.,
studied 610 scapulae by 3D CT scan and found one
case of double suprascapular foramen on left side in
56-year-old Caucasian female [10]. Probable cause for
the formation of double suprascapular foramen was
also explained in their study which could be because
of ossification of STSL & ACSL [11], ossification of
the bifid STSL, partial ossification of the trifid STSL
or ossification of the bifid ACSL. The entrapment of
the supra scapular nerve by the ossified STSL may
result in symptoms like pain in the shoulder region
and also result in wasting and weakness of
supraspinatus & infraspinatus muscles. [12]
CONCLUSION
Suprascapular neuropathy is an uncommon cause of
shoulder pain and weakness and therefore is
frequently misdiagnosed. As a consequence,
misdiagnosis can lead to inappropriate conservative
treatment or unsuccessful surgical procedure. It has to
be differentiated from other conditions like rotator
cuff tears. Knowledge of such an anatomical variation
Vanitha et al.,

will be helpful in arthroscopic & open procedures at


the supra scapular region & also confirms safety of
operative decompression for the supra scapular nerve.
Conflict of Interest: Nil
REFERENCES
1. Harold Ellis, Patricia Collins, David Johnson,
skeletal system, Grays Anatomy; The anatomical
basis of clinical practice. Churchill Living stone,
38th edn London. 1995;615.
2. Asim Kumar Dutta. Essentials of Human
Anatomy, Part III.: 4th Ed. Kolkatta: Current
Books International;2009, 5-7.
3. Gargi Soni, Lovesh Shukla, Neha Gaur.
Complete Ossification Of Superior Transverse
Ligament: A Case Report. The Internet Journal of
Human Anatomy. 2011; 2 (1):12
4. Boykin RE, Friedman DJ, Higgin LD and Warner
JP. Suprascapular Neuropathy. The journal of
bone and joint surgery. 2010; 929(13), 2348-64.
5. Rengachary SS, Burr D, Lucas S, Brackett CE.
Suprascapular entrapment neuropathy: A clinical,
anatomical, and comparative study. Part 3:
Comparative study. Neurosurgery 1979; 5: 45255.
6. Cohen SB, Dines DM, Moorman CT. Familial
calcification of the superior transverse scapular
ligament
causing
neuropathy.
Clinical
Orthopaedics and Related Research. 2007;
334:131-5.
7. Ticker JB, Djurasovic M, Strauch RJ, April
EW, Pollock RG, Flatow EL, Bigliani LU. The
incidence of ganglion cysts and other variations
in anatomy along the course of the suprascapular
nerve. J Shoulder Elbow Surg. 1998; (5):472-8.
8. M Alon, S Weiss, B Fishel, S Dekel. Bilateral
suprascapular nerve entrapment syndrome due to
an anomalous transverse scapular ligament.
Clinical Orthopaedics and Related Research.
1998; 234: 3133.
9. Polguj M, Podgrski M, Jedrzejewski K , Topol
M. The double suprascapular foramen: unique
anatomical variation and the new hypothesis of
its formation. Skeletal Radiol. 2012; 41(12):
163136.
10. Avery BW, Pilon FM, Barclay JK. Anterior
coracoscapular ligament and supra scapular nerve
entrapment. Clin Anat. 2002; 15 (6):3836.
440
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11. Srijit Das, Rajesh Suri and Vijay Kapur.


Ossification of Superior Transverse Scapular
Ligament and its Clinical Implications. Sultan
Qaboos Univ Med J. 2007; 7(2): 15760.
12. Sergides NN, Nikolopoulos DD, Boukoros E,
Papagiannopoulos G. Arthroscopic decompression of an entrapped supra scapular nerve due to
an ossified superior transverse scapular ligament:
a case report. Cases J. 2009; 2: 8200.

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Int J Med Res Health Sci. 2015;4(2):439-441

DOI: 10.5958/2319-5886.2015.00082.X

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
th
Received: 4 Dec 2014
Revised: 20th Jan 2015
Case report

Copyright @2014
ISSN: 2319-5886
Accepted: 12th Feb 2015

A RARE PRESENTATION OF A CONCOMITANT LUMBAR SPINE BURST FRACTURE WITH A


DISTAL CORPUS STERNI FRACTURE DUE TO A FLEXION DISTRACTION INJURY
Ravi Kumar TV1, *GadiDaksh2, Jain Vinay3, Rangaswamy BT4
1

Assistant Professor, 2 Resident, 3,4 Resident, Department of Orthopaedics, M S Ramaiah Medical College &
Hospitals, Bengaluru, Karnataka, India
*Corresponding author email: dr_daksh@yahoo.com
ABSTRACT
Sternum fractures are a rare entity and occur either due to direct trauma or indirectly associated to a flexion
compression injury. Earlier literatures used to describe the association of sternum fractures with upper thoracic
vertebral fractures. To the best of our knowledge very few cases have been described in literature with
concomitant lumbar vertebral fracture with associated sternum fracture. We hereby report a rare presentation of a
flexion distraction injury leading to a concomitant sternum fracture with a L1 vertebral burst fracture.
Keywords: Lumbar spine burst fracture, Corpus sterna fracture, Flexion distraction injury
INTRODUCTION
Sternum fractures in the literature has been described
as a marker for a high velocity trauma with many
associated injuries [1].Other than cases with a direct
trauma to sternum, rarely an isolated sternal fracture
is seen. In the literature the rib sternum complex has
been described as a fourth column to the spine
suggesting a high chances of associated spine injury
with a sternum fracture[2,3]. But most of the cases
described in the literature involve only the upper
thoracic vertebrae. According to a study done by
Fowler[4], flexion compression force leads to
displaced fractures of sternum with the distal
fragment displaced anterior to the proximal fragment
and opposite for distraction injuries. Such injuries are
more commonly seen during high velocity road
traffic accidents.
The level of sternum involvement with the associated
level of vertebral involvement was described by Max
J. Scheyerer et al in their study with statistically
significant association of manubrium sterni i.e. upper
sternum involvement with upper thoracic and lower

sternum i.e corpus sterni part 3 (distal one third) with


lumbar spine fractures[5].
In our study we hereby describe a rare case with a
distal one third corpus sterni fracture with L1
vertebral burst fracture suggesting a flexion
distraction injury following a fall from height and
landing on both feet sustaining associated bilateral
talus fractures, right bimalleolar and calcaneum
fractures.
CASE REPORT
A 28yr old male patient presented to us following a
fall from a height of around 12metres. According to
the patient, he slipped while working on a
construction site and had a fall; he landed on the
ground on both feet. Patient was not able to stand/
bear weight following fall. On presentation, he
complained of severe pain in feet, ankle and back. He
had no breathing difficulty or pain in the chest. He
had sustained no open injuries, head injury (GCS:
15/15)and was haemodynamically stable. On clinical
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Int J Med Res Health Sci. 2015;4(2):442-445

examination, swelling was noted over ankle, range of


movement in the ankle was tender bilaterally with
severe tenderness over the heel of right foot.
No distal neurological deficits were present but
tenderness was elicited in lumbar spine and the chest.
Full evaluation using plain radiographs[Fig 1a,
Fig1b] and CT scans[Fig 2, Fig3] was done initially
and bilateral talus fracture, right bimalleolar fracture,
L1 vertebral burst fracture with distal one third
corpus sterni fracture was noted. Further MRI was
done[Fig 5a, 5b,5c,5d] for evaluating the lumbar
spinal injury and association of posterior elements
with the L1 fracture.
As the right talus had a comminuted fracture with
bimalleolar fracture, it was initially fixed using
contoured talus locking plate and cancellous screws,
one third tubular plate was applied for the lateral
malleolus and cancellous screw and K-wiring for
medial malleolus. Left talus and right calcaneal
fractures were undisplaced and so were planned to be
managed conservatively.
Patient was explained for need for surgical

Fig 1a, 1b: Plain radiographs showing L1


vertebral burst fracture

Fig 2: Sagittal CT image showing L1 burst


fracture with sternum fracture

intervention for the lumbar spinal injury but patient


wanted to undergo conservative management and so
was advicedabsolute bed rest for 2 months.
Fig 3: Axial CT scan of L1 vertebra
Fig: 1a

Fig 4: 3D CT image of L1 vertebral body


Fig: 1b

Fig: 5a

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Int J Med Res Health Sci. 2015;4(2):442-445

Fig: 5b

Fig: 5c

Most fractures are secondary to a flexion


compression injury and are associated with a spine
injury. Upper thoracic vertebrae may be involved in
such cases but rarely lumbar spine involvement may
also be seen.
But literature suggests that the site of sternal
fracture[10] and the displacement pattern2 can suggest
the mechanism of injury.
In our case patient was diagnosed a concomitant
lumbar spine burst fracture with a distal corpus sterni
fracture following fall from height. The fracture
pattern in L1 vertebral body with fracture extension
into lamina and spinous process suggests a flexion
distraction mechanism which also coincides with
Fowlers study on mechanism of concomitant
sternum and spinal injury.
Also the sternum fracture involves the distal 1/3rd
with posterior displacement of distal fragment
confirming the mechanism of injury.
Although the incidence of such injuries is less but a
high index of suspicion for such fractures must be
there when such patients are being evaluated. Delay
in diagnosis may lead to increase morbidity and
mortality in these patients.

Fig: 5d
CONCLUSION
A concomitant lumbar spine injury with a sternum
fracture is a rare entity, but it is essential for all
orthopaedic surgeons to be aware of such injury
patterns and its associated complications. Such rare
injuries also help us to understand the mechanism of
trauma. Missing or delay in diagnosing such fractures
may lead to undue complications and increase
mortality.
Fig 5a, 5b,5c,5d: MRI Lumbosacral spine showing
L1 compression fracture

ACKNOWLEDGEMENT:Nil

DISCUSSION

REFERENCES

Sternum fracture is a rare fracture and is usually


associated with multiple injuries[6,7]. Isolated sternal
fracture may occur in direct traumatic injuries[8]. The
sternal fracture component is commonly missed
because of it being comparatively less symptomatic
compared to the other associated injuries. Thus
making it essential to examine and investigate for an
associated sternum fracture with a spine injury[9].

1. B. C elik, E. Sahin, A. Nadir, and M.


Kaptanoglu. Sternum fractures and effects of
associated injuries. Thoracic and Cardiovascular
Surgeon2009;57(8):46871.
2. E. E. Berg. The sternal-rib complex: a possible
fourth column in thoracic spine fractures. Spine,
1993; 18(13):191619.
3. Mihai H. Vioreanu, John F. Quinlan, Ian
Robertson, John M. OByrne Vertebral fractures

Conflict of Interest: Nil

444
Daksh etal.,

Int J Med Res Health Sci. 2015;4(2):442-445

4.
5.

6.

7.

8.

9.

10.

and concomitant fractures of the sternum.


International Orthopaedics (SICOT) 2005; 29:
33942
Fowler AW. Flexion/compression injury of the
sternum. J Bone Joint Surg 1957;39:48797.
Max J. Scheyerer et al. Location of Sternal
Fractures as a Possible Marker for Associated
Injuries. Hindawi Publishing Corporation
Emergency Medicine International Volume 2013,
407589, 1-7
D. P. Harley and I. Mena, Cardiac and vascular
sequelae of sternal fractures, Journal of Trauma,
1986;26(6): 55355
Gopalakrishnan KC, el Masri WS Fractures of
the sternum associated with spinal injury. J Bone
Joint Surg Br1986; 68(2):17881
B. C elik, E. Sahin, A. Nadir, M. Kaptanoglu.
Sternum
fractures
and
effects
of
associatedInjuries.Thoracic and Cardiovascular
Surgeon,2009; 57(8):46871
R. Singh, D. M. Taylor, D. DSouza, A. Gorelik,
P. Page, P. Phal. Injuries significantlyassociated
with thoracic spine fractures: a case-control
study.
Emergency
Medicine
Australasia,2009;21(5): 41923,
J. Inamasu, B. H. Guiot, Thoracolumbar
junction injuries after rollover crashes:
differencebetween belted and unbelted front seat
occupants.European Spine Journal 2009; 18(10);
146468.

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Int J Med Res Health Sci. 2015;4(2):442-445

DOI: 10.5958/2319-5886.2015.00083.1

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2 Coden: IJMRHS
Copyright @2015
th
th
Received: 7 Jan 2015
Revised: 20 Feb 2015
Case report

ISSN: 2319-5886
Accepted: 4th Mar 2015

SURGICAL MANAGEMENT OF EPIBULBAR DERMOID CYST: A CASE REPORT


*Shubhangi Nigwekar P1, Chaitanya Gupte P2, Prajakta Kharche M2, Akshay Beedkar U2, Neeta Misra S1,
ParagTupe N3
1

Professor, 2Post Graduate Student, 3Associate Professor, Department of Ophthalmology, Rural Medical College,
Loni, Ahmednagar, Maharashtra

*Corresponding author: Shubhangi Nigwekar P Email: shubhangi2501@yahoo.in


ABSTRACT
Dermoids are congenital lesions representing normal tissue in abnormal location. Orbital dermoid cysts are
divided into superficial and deep dermoids. Depending on type and location, superficial ocular dermoid cysts are
divided into limbal, dermoid cyst and epibulbar dermoid cyst or dermolipoma. The most common location for the
epibulbar dermoid cyst is inferotemporal region of eye. They are usually asymptomatic or may present with
inflammatory response due to leakage of cyst contents or may cause local irritation due to protruding hair and do
cause cosmetic blemish to a school going child. For local irritation and cosmetic reasons, complete surgical
excision with intact capsule of epibulbar dermoid cyst is mandatory to prevent acute inflammatory response and
its recurrence. In this article we are presenting the clinical features and surgical management of an inferotemporal
epibulbar dermoid in a male patient.
Key words: Epibulbar dermoid, Dermoid cyst.
INTRODUCTION
Dermoid cysts are choristomas, and are often evident
soon after birth [1]. They are lined with epithelium and
filled with keratinized material and usually contain
hair and other skin structures[2, 3].Superficial epibulbar
dermoid cyst is most commonly located in
inferotemporal region of eye. Epibulbar dermoid
cysts are most commonly unilateral. They can be
asymptomatic or may present mass in eye or fullness
of eyelid depending upon the size of cyst. Leakage of
its contents may lead to inflammatory response and
fibrosis around cyst. Epibulbar dermoid cyst needs
surgical excision for cosmetic reasons and when it is
symptomatic due to local irritation [4]. Here we are
describing the clinical presentation and management
of an epibulbar dermoid located in the inferotemporal
region in 14 years old male.
CASE REPORT

Hospital, Loni with painless mass in the inner side of


the right lower eyelid, situated laterally, which was
present since childhood. Patient had complaints of
local irritation, watering. Patient himself noticed
growing hair from lower fornix of right eye. Apart
from cosmetic blemish, there were no other
symptoms like pain or diplopia.
General and systemic examination of the patient was
normal. Family history was not significant. Slit lamp
examination and direct ophthalmoscopy showed
normal anterior and posterior segments in both eyes.
Visual acuity in both eyes was 6/6(Snellens chart).
Extraocular movements were full and free in all
directions of gaze. Local examination revealed a
swelling measuring 1.510.5cm in inferotemporal
region in right eye (fig 1). It was soft, non-tender,
freely mobile, and non-adherent to the sclera or
conjunctiva and with single protruding hair. There

A fourteen years old male came to Pravara Rural


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Int J Med Res Health Sci. 2015;4(2):446-449

was no corneal involvement. Clinical diagnosis was


an epibulbar dermoid cyst.
Patient had normal haemogram and normal chest Xray. The X-ray orbit and CT ruled out deeper
extension. With proper consent and anaesthetic
fitness complete excision of intact epibulbar dermoid
cyst was carried out under general anaesthesia (fig 2,
3). The intact cyst was sent for histopathological
examination which showed lining of stratified
squamous epithelium with fibrous stroma containing
few hair follicles and sebaceous glands which
confirmed the diagnosis of epibulbar dermoid cyst
(fig 5). Post-operatively antibiotic and steroid drops
were instilled in tapering dose (fig 4). One year
follow up examination showed no recurrence and any
inflammatory response too.

Fig 4: 1st post-operative day with conjunctival


sutures in situ.
Pilosebaceous Unit

Fluid Filled Cyst

Hair Follicles

Fig 1: Mass in Inferotemporal quadrant

Fig 5: Histopathology showing contents


dermoid cyst

of

DISCUSSION

Fig 2: Raised Mass during dissection

Fig 3: Removal of epibulbar mass in toto

A dermoid is a choristoma, representing overgrowth


of normal, non-cancerous tissue in an abnormal
location. It consists of ectodermal and mesodermal
elements combined in different proportions. It is
made up of cutaneous and subcutaneous tissue and
contains hair and other skin structures and may occur
anywhere in the body [5, 6].
There are two main dermoid types that occur on or
around the eyes. First, a deep Orbital Dermoids
typically found in association with the bony socket.
Second, superficial an Epibulbar Dermoids found on
the surface of the eye which gradually increases in
size through epithelial desquamation and glandular
secretions.
It has two typical locations. One is at the junction of
the cornea and sclera called Limbal Dermoid which
causes astigmatism. The second location of epibulbar
dermoid is on the surface of the eye where the lids
meet in the temporal corner (towards the ear) which
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Int J Med Res Health Sci. 2015;4(2):446-449

is often called a Dermolipoma or Lipodermoid. These


are more commonly found in the superotemporal
quadrant extending to orbit or the lacrimal gland can
lead to dry eye due to disturbance of lacrimal gland
involvement. They are typically unilateral but can be
bilateral. Rarely, they may affect the cornea or the
bulbar conjunctiva only as occurred in our case.
Epibulbar dermoid may not present at birth but can
develop soon after birth. Most patients present before
age 16 years. The most frequent site of Epibulbar
dermoids believed to be infero-temporal segment
(85%).They can range from several millimetres to a
centimetre or more in size.
Epibulbar dermoid has no symptoms unless hair or
other dermal structures cause local irritation. The
lesion does cause a cosmetic defect. Patients may
present with decreased vision, foreign body sensation,
cosmetic disfigurement, or an enlarging ocular mass.
Epibulbar dermoid is typically fleshy, yellow and
soft. It gets moulded as per the curve of the eye and
has a dome shape. Hair follicles or cilia may be
visible on its surface. Overlying conjunctiva may be
thickened and may have fine superficial
vascularisation and or keratinisation.
Associated systemic abnormalities include preauricular appendages and auricular fistulae more
common with limbal dermoids constituting
Goldenhar
syndrome[7]
also
known
as
oculoauriculovertebral spectrum (OAVS) is a
developmental anomaly involving structures derived
from first and second branchial arches. Limbal
Dermoids or dermolipomas are more likely to be
associated with Goldenhar's Syndrome if they are
multiple or bilateral.
Diagnosis of Epibulbar dermoid though clinical,
ultrasound and radiographic imaging may be required
to investigate the extent of the tumour however
excisional biopsy confirms the diagnosis [8, 9].
Histologically aberrant tissues, including epidermal
appendages, connective tissue, skin, fat, sweat gland,
lacrimal gland, muscle, teeth, cartilage, bone,
vascular structures, and neurologic tissue, including
the brain may be seen [10]. Malignant transformation
is extremely rare.
Complications of an epibulbar dermoid cyst include
thinning of sclera, astigmatism due to corneal
involvement and cosmetic disfigurement. Rupture of
cyst or leakage of cyst contents can cause local
inflammatory response [11].

Hence complete excision of intact cyst in toto is


necessary to prevent recurrence, granuloma
formation, fibrosis and malignant transformation.
In our case since the epibulbar dermoid cyst was
localised, non-adherent to underlying sclera or
overlying conjunctiva, complete excision with intact
wall of the epibulbar dermoid cyst was carried out,
which gave good post-operative cosmetic result. Two
years postoperative follow up showed no
postoperative inflammation or recurrence.
CONCLUSION
Total surgical excision of intact epibulbar dermoid
cyst relieves symptoms, gives good cosmetic and
surgical results without its recurrence.
ACKNOWLEDGEMENT
We are thankful to HOD (Professor) Dr.Dongre and
Professor
Dr.
Karle
for
providing
the
histopathological report and slide.
Conflict of Interest: Nil
REFERENCES
1. Ahuja R. Orbital Dermoids in Children. Semin
Ophthalmol. 2006; 21:207-11.
2. Shields J and Shields C. Orbital Cysts of
Childhood Classification, Clinical Features and
Management. Surv Ophthalmol. 2004; 49(3):28199.
3. Jakobiec FA, Bonanno PA, Sigelman J.
Conjunctival adnexal cysts and dermoids. Arch
Ophthalmol 1978; 96:1404-9.
4. Ramesh Venkatesh HLT. Limbal Dermoid on
Clinical Presentation, but on Histology was
Epidermal Cyst. Bombay Hospital Journal. 2008;
50(2): 295-98.
5. Yeola M, Joharapurkar SR, Bhole AM, Chawla
M, Chopra S, Paliwal A. Orbital floor dermoid:
An unusual presentation. Indian J Ophthalmol
2009; 57:51-2.
6. Srikanth R, Meenakshi S, Chaterjee R,
Mukherjee B. Orbital dermoid mimicking a
monocular elevation deficiency. Oman Journal of
Ophthalmology 2012; 5(2):118-20.
7. Gharehbaghi MM, Ghaemi MR. Goldenhar
Syndrome in an Infant of Diabetic Mother.
Iranian Journal of Pediatrics 2010; 20(1):131-34.
448

Nigwekar et al.,

Int J Med Res Health Sci. 2015;4(2):446-449

8. Yanoff M, Fine BS. Ocular pathology. 3rd ed.


Philadelphia: Harper and Row; 1988; 520
9. Sherman RP, Rootman J, Lapoint JS. Dermoids clinical presentation and management. Br J
Ophthalmol 1984; 68:642-52.
10. Abou-Rayyah Y, Rose GE, Konrad H, Chawla
SJ, Moseley IF. Clinical, radiological and
pathological examination of periocular dermoid
cysts: evidence of inflammation from an early
age. Eye. 2002; 16 (5): 507-12.
11. Karatza EC, Shields CL, Shields JA, Eagle RC.,
Jr Calcified orbital cyst simulating a malignant
lacrimal
gland
tumor
in
an
adult.
OphthalPlastReconstr Surg. 2004; 20:3979

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Int J Med Res Health Sci. 2015;4(2):446-449

DOI: 10.5958/2319-5886.2015.00084.3

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 19 Jan 2015
Case report

Coden: IJMRHS
Revised: 7th Feb 2015

Copyright @2015
ISSN: 2319-5886
Accepted: 17th Feb 2015

DESMOPLASTIC FIBROMA OF RAMUS OF MANDIBLE A RARE CASE REPORT


*Nehru Anand1, R.Kanmani2, MS Anandi3, C. L. Krithika4, A. Kannan5, P.H.Raghuram6
1

Post Graduate Student, 2,3,4Senior lecturer, 5Reader, 6Professor, Department of Oral Medicine & Radiology, SRM
Dental College & Hospital, Chennai, Tamil Nadu, India

*Corresponding author email: dockrk05@gmail.com


ABSTRACT
Desmoplastic fibroma (DF) is a rare, benign fibrous tumor of the bone which is locally aggressive. Desmoplastic
fibroma forms 0.3% of the benign osseous tumors, which most commonly occurs in the tibia, scapula, and femur.
Most commonly affected site in the head and neck region is Mandible. Desmoplastic fibroma causes bone
destruction and has a high tendency for local recurrence. In this case report, we present desmoplastic fibroma of
mandible of 5year old female patient with imaging, histopathology, treatment and discussion about prognosis.
Key words: Locally aggressive, Fibroma, Non metastatic, Desmoplastic, Recurrence
INTRODUCTION
Desmoplastic fibroma is a rare locally aggressive non
metastatic benign fibrogenic tumor of the bone [1].
Desmoplastic fibroma of the bone is considered to be
the intraosseous counterpart of the common softtissue desmoid or fibromatoses[2]. In 1958 Jaffe
reported five cases occurring in the tibia, scapula and
femur. This tumor constitutes less than 1% of the
bone tumors and 0.3% of benign osseous tumors,
which usually involve the tibia, scapula, and femur.
Desmoplastic fibroma causes bone destruction with a
propensity to invade the soft tissues if untreated and
has a high tendency for local recurrence if
inadequately treated was reported in the year 2013
[3]
. In the head and neck region, the most commonly
affected site is the mandible [4].Desomplastic fibroma
of the mandible was first reported by Griffith and
Irby in 1965[5]
CASE REPORT
A female patient aged about 5 years reported to the
outpatient Department of Oral medicine and
radiology, with a complaint of swelling in right side
of face for past 6 months. Patient gives history of

painful swelling in the same region two years back


which subsided spontaneously within two days
without taking any medications. Presently the patient
noticed swelling recurred on the same site which was
initially smaller in size and gradually increased to
present size within 6 months period. On extra oral
examination a diffuse swelling seen in the right side
of lower part of face approximately measuring about
43cm in size which is extending superiorly 4 cm
from lower eyelid, inferiorly it crosses the inferior
border of the mandible and extends to submandibular
region, anteriorly 2.5 cm away from the commissure
of the lip and posteriorly 1 cm anterior to tragus of
the ear. On palpation the inspectory findings were
confirmed. The swelling is non tender, firm to hard in
consistency. On intra oral examination a single
diffuse swelling seen in relation to 85 obliterating
buccal vestibular region, which is approximately
measuring about 3x3 cm in size. Overlying mucosa
appeared to be normal in color. On palpation it was
firm to hard in consistency with mild tenderness and
no secondary changes noted. Correlating the patient
history and clinical findings a differential diagnosis
450

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Int J Med Res Health Sci. 2015;4(2):450-453

of ameloblastoma, odontogenic keratocyst, and


aneurysmal bone cyst was given. Further
investigations like complete hematological and
radiographical evaluation were performed.
OPG revealed multilocular radiolucency involving
right ramus and body of mandible and the
radiolucency extended superiorly upto sigmoid notch,
inferiorly it extended to the angle of mandible, also
revealed break in the continuity of inferior border
mandible.Tooth crypt of 47 displaced superiorly.
Root resorption of erupting 46 evident (Fig-1).CT
revealed 4.42.93.7cm expansile, multiloculated
soft tissue density evident in right ramus with cortical
bone discontinuity involving the inferior, buccal and
lingual cortex (Fig-2). 3D reformatted image showed
buccal cortical expansion with buccal and inferior
cortical breach (fig-3).Working diagnosis of
ameloblastoma was arrived and considering age of
patient curettage of the lesion was performed under
G.A and the specimen was sent for histopathological
evaluation (fig-4).

Fig3: CT 3D Reformatting

Fig 4: Photograph of surgical specimen


On Histological examination revealed the lesion
showed plump spindle shaped fibroblasts cells
arranged in short and long fascicles, focal storiform
pattern and intervening bands of collagen bundles,
there is no atypia or increase in mitosis suggestive of
Desmoplastic fibroma (fig-5).
Fig 1: Preoperative orthopantomogram

Fig 2: Contrast enhanced Computed Tomography


showing expansile, soft tissue density lesion in
right ramus with cortical bone discontinuity in
lingual side

Fig 5:Photomicrograph showing plump spindle


shaped fibroblasts cells (40X)

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Int J Med Res Health Sci. 2015;4(2):450-453

Fig 6: Postoperative orthopantomogram


DISCUSSION
In greek the term desmos means band or ligament. In
1938, the German physiologist and anatomist
Johannes Muller characterized the term desmoids.
Desmoid tumors were localized in the abdominal wall
and the intraosseus variant is the desmoplastic
fibroma. Jaffe in 1958 reported a similarity between
the intraosseous lesions and the desmoid tumor of the
abdominal wall [6]. Desmoplastic Fibroma is a nonmetastasizing, often locally aggressive neoplasm with
normal appearing fibroblasts. In 2002 Desmoplastic
Fibroma was defined as a rare benign bone tumor
consisting of spindle-shaped cells along with minimal
cytological
atypia
and
excess
collagen
production[7].Possible etiologies were related to
endocrine [8], genetic factors [9] and trauma[10,8]. Dahlin
and Unni recorded only 9 case of Desmoplastic
Fibroma in a series of 8542 primary bone tumours.
Bohmet al reviewed191 cases of Desmoplastic
Fibroma reported in 80 publications. In their review,
the age of patients ranged from 15 months to75 years,
with a reported mean age around 23 years[11,12].The
age incidence is in the first, second or third decade.
There is no specific gender predilection [13].In jaw
bones desmoplastic fibroma occurs predominantly in
the mandible and the maxilla is rarely affected. The
ramus, angle and molar area of the posterior mandible
are frequently involved. Less frequently affectedareas
are the premolar area and the anterior segments [14].
Radiographically, the tumor presents as a welldefined, expanding, osteolytic, radiolucency, either
unilocular or multilocular, and the cortex is
perforated in some areas, with an associated soft
tissue mass. Our patient had similar features of a
multilocular osteolytic lesion with corticated borders

with cortical perforation in the inferior, Buccal and


lingual cortex [15].The differential diagnosis of an
osteolytic lesion in the mandible includes
ameloblastoma, odontogenic keratocyst and fibrous
dysplasia, aneurysmal bone cyst, Ameloblastoma
occur at 40 years of age, radiographically may appear
as soap bubble, honey comb or tennisracket pattern.
Odontogenic keratocyst is usually centrally placed,
with a scalloped border and thin marginal sclerosis.
Aneurysmal bone cyst is a false cyst which occurs
as unilocular or multilocular radiolucency which
frequently balloons out of the cortex as opposed to
the fusiform expansion usually seen with
desmoplastic fibroma [16].Fibrous dysplasia is similar
but would also show typical patterns of woven bone
and contains a mineralized matrix and often has a
sclerotic rim[6].Low-grade fibrosarcoma is a main
concern to be ruled out, because of its aggressive,
malignant nature with spindle cells, increased mitotic
activity and pleomorphism[17]. Desmoplastic fibroma
can be diagnosed only from tissue evaluation. If
cortical expansion is present, a few other lesions can
be included such as eosinophilic granuloma,
arteriovenous malformations and hemangiomas.
Central hemangioma may cause loosening and
migration of teeth and teeth demonstrate rebound
mobility when depressed into sockets.
Diverse medical and surgical treatment options have
been recommended for desmoplastic fibroma, which
are simple curettage, segmental resection, en block
Resection, radiotherapy, and chemotherapy, with or
without additional surgical procedures (4).The major
characteristic of desmoplastic fibroma is increased
rate of local recurrence. Recurrence rate is at least
40% if treated by curettage or intralesional resection
[18,19]
.Depending on the affected area and its
aggressive nature,the management is decided. In
cases of intraosseus lesions without any evidence of
extension to the adjacent soft tissue and also when
there is high risk associated with resection because of
anatomical conditions, risk-benefit-analysis can
becarried out and curettage is considered as adequate
management because it reduces operation time along
with lower risk of infection and hence facilitates
faster
recovery.Radiation
therapy
is
not
recommended
because
of
its
potentialfor
transformation of this lesion into fibrosarcoma[6].
In our case, treatment options were discussed and
curettage was decided. Due to higher risk of
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Int J Med Res Health Sci. 2015;4(2):450-453

recurrence, postoperative observation is mandatory,


including clinical and radiographic examinations,
considering the childs age and also as the condyle is
one of the main sites in post natal growth of
mandiblecurettage was performed and the patient was
kept under observation. Patient reviewed 2months
after surgery and also 6 months once regular follow
up was done (fig-6).
CONCLUSION

10.

11.

12.

Desmoplastic fibroma is a rare, benign, locally


aggressive, intraosseous lesion, with a high local
recurrence rate. The tumor should be resected when
ever feasible or curettage done with regular
postoperative follow up.

13.

Conflict of Interest: Nil

15.

14.

REFERRENCES
1.

2.

3.
4.

5.

6.
7.
8.

9.

Harsha Vardhan Talla et al Desmoplastic fi


broma of the mandible: A rarecase report Journal
of Indian Academy of Oral Medicine &
Radiology 2014 ; 2:26
Fornasico V, Pritzker KPH, Bridge JA.
Desmoplasticfibroma of bone. In: Fletcher CDM,
Unni KK, MertenSF, Eds. The World Health
Organization classificationof tumours. Pathology
and genetics of tumours ofsoft tissue and bone.
Lyon: IARC Press, 2002:288
Yadavalli Guruprasad et al, Journal of CranioMaxillary Diseases 2013;2 (1):26
Dhaif G, Satir AA, Sharif S. Desmoplastic
fibroma of the mandible:A 5 year
follow-up.
Bahrain Med Bull 2008; 30:251-4.
Griffith JG, Irby WB. Desmoplastic fibroma.
Oral Surg OralMed Oral Pathol 1965; 20:26975.
Majid Jamali, D.M.D. The New York State
Dental Journal 2013
Alexander Nedopil et al The Open Orthopaedics
Journal, 2013; 7, 40-46
Triantafyllou NM, Triantafyllou DN, Antonados
DN. Desmoid tumors of the bone. Int Surg1972;
57:79397Jaffe HL. Tumors and Tumorous
Conditions of the Bones and Joints. Philadelphia,
PA: Lea and Febiger, 1958, 298-03.
Bridge JA, Swarts SJ, Buresh C, Nelson M,
Degenhardt JM, Spanier S, et al. Trisomies
8and20 characterize a subgroup of benign fibrous

16.
17.

18.

19.

lesions arising in both soft tissue and bone. Am J


Pathol 1999; 154:72933
Jaffe HL. Tumors and Tumorous Conditions of
the Bones and Joints. Philadelphia, PA: Lea and
Febiger, 1958, 298-03
Dahlin DC, Unni KK. Bone tumors: general
aspects and dataon 8542 cases (4th
edn).
Springfield, IL: Thomas, 1986, 37576.
Bohm P, Krober S, Greschniok A. et al.
Desmoplastic fibromaof the bone: a report of two
patients, review of the literature,and therapeutic
implications. Cancer 1996; 78: 101123.
Journal of Indian Academy of Oral Medicine &
Radiology 2014; 2:26
Lt Col VK Shukul et al MJAFI 2004; 60 : 307309
Chang JJ, Hu C, Chang PC, Liu HY, Tu CN.
Juvenile desmoplastic fi broma of mandible: A
case report. Zhonghua Ya Yi Xue Hui Za Zhi
1988; 7:35-40.
H Shi et al Dentomaxillofacial Radiology (2008)
37, 40811
Said-Al-Naif N, Fernandes R, Louis P, Bell W,
Siegal GP. Desmoplastic fibroma of the jaw: a
case report and review of literature. Oral Surg
Oral Med Oral Path 2006; 101:8294
Inwards CY, Unni KK, Beabout JW, Sim FH.
Desmoplastic fibroma of bone. Cancer 1991; 68:
197883.
Gebhardt MC, Campbell CJ, Schiller AL, Mankin
HJ Desmoplastic fibroma of bone: a report of 8
cases and review of the literature. J Bone Joint
Surg Am 1985; 67: 73247.

453

Nehru et al.,

Int J Med Res Health Sci. 2015;4(2):450-453

DOI: 10.5958/2319-5886.2015.00085.5

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 20 Jan 2015
Case report

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 20 Feb 2015
Accepted: 6th Mar 2015

GIANT FIBROEPITHELIAL STROMAL POLYP OF VULVA IN A YOUNG GIRL


Khumanthem Pratima D1, Sarkar Sabyasachi2,*Kumari Suman2, Nabakishore Singh N3, BimolChandra Singh L4,
Reeta Devi M5
1

Senior Registrar, 2Postgraduate student, 3Professor & Head,4Associate Professor, Department of Obstetrics and
Gynaecology, Regional Institute of Medical Sciences Imphal, Manipur, India
5
Assistant Professor Department of Pathology Regional Institute of Medical Sciences Imphal, Manipur, India
* Corresponding author email: drsumankatewa@gmail.com
ABSTRACT
Fibroepithelial stromal polyps are site-specific mesenchymal lesions that typically occur in women of
reproductive age group and present more commonly in vagina than cervix or vulva. These polyps usually do not
grow larger than 5 cm in diameter and are most commonly identified during routine gynecological examination.
Although benign, sometimes their clinical features may overlap with those of malignant neoplasms so
histopathological examination of the polyp is often necessary to make a definitive diagnosis.
Key words: Fibroepithelial stromal polyps, cervix, vulva.
INTRODUCTION
Fibroepithelial stromal polyps (FEPs) are also known
as Acrochordons or skin tags. These are site specific
mesenchymal lesions which show a predilection for
the neck, axilla, and groin and are typically seen in
adult obese women. FEPs of the lower genital tract
often develop in young to middle-aged women and
are more common in the vagina than vulva and rarely
seen in cervix. [1]These polyps are thought to be
hormone sensitive and are usually seen in
reproductive age group. however they can also be
seen in postmenopausal women who are on hormone
replacement therapy. These lesions display a wide
range of morphologic appearances and usually
present as polypoid or pendunculated growth. Mostly
the size of lesions is 1x2 cm but rarely it can reach an
extremely large size up to 15- 20 cm.[2] Small lesions
are usually asymptomatic and are detected during
routine
gynaecological
examination.
Symptomatology of large lesions includes general
discomfort with sensation of a mass as well as
bleeding and discharge due to secondary infection of

the lesion. Their clinical features may overlap with


the malignant lesions of vulvovaginal region so
biopsy is often necessary for confirmatory diagnosis.
[3]
We present a case of 8x7 cm large fibroepithelial
stromal polyp of the vulva in 22 years old unmarried
girl with a brief review of literature.
CASE REPORT
A 22 year old unmarried girl presented to
gynaecology department of our institute with swelling
in the right labia which was first noticed around 6
year back. Initially the swelling was around 1-2 cm
and was static in size. The swelling increased in size
over the course of the last 8 months until its current
size on presentation. The girl was extremely
embarrassed and this was the reason why she had not
consulted so far to any health care provider. But
polyps rapid growth and ulceration over the surface
forced her to present for evaluation. She complained
of itching and discharge from the swelling
454

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Int J Med Res Health Sci. 2015;4(2):454-456

accompanied with fever since last 5 days. The general


physical examination and systemic examination was
unremarkable except the swelling. Her menstrual
history was normal. The patient denied any
significantpast medical or surgical history. No history
of sexually transmitted disease or gynaecologyrelated surgery was present. Local examination
revealed a large 8 7 cm pendunculated, globular
mass arising from the right labia majora. The
proximal end was connected to the right labia majora
by 3.5x1.5 cm pedicle. The skin over the growth was
ulcerated with signs of inflammation (Figure 1).

Fig 2:Fibrovascular tissue having myxoid stroma( Big


arrow) with few stellate cells(small arrow) [40x]

These histopathological features were suggestive of


fibroepithelial stromal polyp. The patient was
discharged and was advised for monthly follow up
visit. On follow up the pedicle site was healed and
she did not manifest any signs of recurrence
following excision.
DISCUSSION

Fig 1: Large pendunculated globular mass arising from


the right labia majora with signs of inflammation.

The growth was soft and warm on palpation with


mild tenderness. No lymph nodes were palpable in
the vulvar and inguinal regions. There was no
increase in the size of the mass with coughing and
valsalva manure.
Blood investigations showed
polymorphonuclear leucocytosis (Total WBC counts14000/mm3 with 78% neutrophils) with raised ESR
(65 mm in first hour). Other laboratory investigations
were within normal limit including random blood
sugar. She was treated initially with antibiotics and
local antiseptic ointment. Later on total surgical
excision of the mass was performed under local
anaesthesia. Grossly the cut section of the specimen
revealed a solid greyish white mass with yellow
brownish area in the centre. Microscopic examination
of the tissue showed fibrovascular tissue having
myxoid to fibrous stroma with reactive stromal cells.
Few stellate cells and multinucleated cells were noted
near the epithelial-stromal interface (Figure 2).

Fibroepithelial stromal polyps of the vulvovaginal


region are rare benign tumours which exhibit a wide
range of morphological appearances and can be
misinterpreted as malignant. Differential diagnosis of
fibroepithelial stromal polyp includes cellular
angiofibroma,
angiomyofibroblastoma,
embryonalrabdomyosarcoma
and
aggressive
[4]
angiomyxoma. So histopathological examination is
necessary for confirmatory diagnosis. Histologically
fibroepithelial polyps are classified in two types: (1)
Predominantly epithelial (2) Primarily stromal.
Microscopically the most characteristic feature of a
fibroepithelial stromal polyp is the presence of
stellate and multinucleate stromal cells which are
usually identified near the epithelial-stromal
interface.[5] Immunohistochemically FEPs are often
positive for desmin, vimentin, oestrogen, and
progesterone receptors and less frequent for actin.
[3]
The pathogenesis of FEPs has not been completely
understood yet. Frequent irritation seems to be an
important causative factor, especially in persons who
are obese. Skin aging with many other factors may
also be the predisposing factor for genesis and
development of fibroepithelial polyp. FEPs are
extremely uncommon before the menarche and after
menopause. Presence of oestrogen and progesterone
receptors in the stromal cells of FEPs, occurrence of
these lesions during reproductive age group
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Int J Med Res Health Sci. 2015;4(2):454-456

especially during pregnancy, spontaneous regression


after delivery and presence of FEPs in
postmenopausal women on harmone replacement
therapy, all these indicate an association between
hormonal changes and pathogenesis of fibroepithelial
polyp.[6] Association of FEPs have also
been
observed with type 2 diabetes mellitus and obesity.[7]
Giant FEPs have also been reported in association
with other dermatoses.[8]
Although polygonal and multinucleate stromal cells
are characteristics of FEPs, they can also be seen in
normal vulva, vagina and cervix suggesting that these
polyps may represent a proliferation of cells normally
found in this region. Thus FEPs represent a
hyperplastic process involving the subepithelial
myxoidstroma of the lower female genital tract rather
than a true neoplasm. Beside histopathological
examination, imaging is also important in the
diagnostic work up of fibroepithelial stromal polyps.
It allows for evaluation of blood supply and flow and
demonstrates the origin and extent of the lesion.
Ultrasonography is preferred over CT and MRI as
first line imaging tool.
The small asymptomatic FEPs do not require
excision, unless concerns exist about the final tissue
diagnosis. Excision is the treatment of choice for
symptomatic FEPs. Large FEPs may cause local
discomfort, mass sensation and may be secondarily
infected after traumatic surface erosion. The
inflammation seen in our case was secondary to
infection over the eroded surface due to repeated
friction between the polyp, thigh and undergarments
of the patient.
Local recurrence after excision is rare but has been
reported in literature. [9] Recurrence may be either
related to incomplete excision or if there is
continuous hormonal stimulation (e.g. pregnancy,
tamoxifen).[3][10]As a result, all patients with this
diagnosis should be followed for long term and
managed appropriately after initial treatment.
However our patient showed no evidence of
recurrence during one year follow-up period.
CONCLUSION
FEPs are relatively site-specific mesenchymal lesions
of the vulvovaginal region that typically occur in
women of child-bearing age. Large FEPs of the
vulval region are rare benign tumours. Due to their
wide range of morphological appearances, they may

be diagnostically challenging and need expert


pathological interpretation to exclude other site
specific lesions such as deep aggressive
angiomyxoma, angiomyofibroblastoma, cellular
angiofibroma and embryonalrabdomyosarcoma.
DECLARATIONS:
interest: None

Funding:

Nil,

Conflict

of

REFERENCES
1. Carter
PE,
Russell
P.
Bilateral
fibroepithelialpolypi of labium minus with
atypical stromal cells. Pathology, 1992;24(1):37
39
2. Bozgeyik Z. Giant fibroepithelial stromal polyp
of the vulva:extended field-of-view ultrasound
and computed tomographic findings. Ultrasound
Obstet Gynecol 2007, 30(5):79192.
3. Nucci MR, Young RH, Fletcher CD. Cellular
pseudo sarcomatous fibroepithelial stromal
polyps of the lower female genital tract: an under
recognized lesion often misdiagnosed as sarcoma.
Am J SurgPathol 2000; 24(2):231-40
4. Laskin WB, Fetsch JF, Tavassoli FA. Superficial
cervicovaginal myofibroblastoma: fourteen cases
of a distinctive mesenchymal tumor arising from
the specialized subepithelialstroma of the lower
female genital tract. Hum Pathol 2001;
32(7):715-25.
5. Nucci MR, Olivia E: Gynecologic Pathology: A
Volume in Foundations in Diagnostic Pathology
Series. Elsevier/Churchill Livingstone; 2009:31
32.
6. Sharma S, Albertazzi P, Richmond I. Vaginal
polyps and hormones--is there a link? A case
series. Maturitas 2006; 53(3):351-55
7. Thappa DM. Skin tags as markers of diabetes
mellitus: An epidemiological study in India. J
Dermatol. 1995;22(10):729-31
8. Dane C, Dane B, Cetin A, Erginbas M, Tatar Z.
Association of psoriasis and vulva fibroepithelial
polyp. Am J ClinDermatol. 2008;9(5):333-5
9. Han X. Giant cell fibroblastoma of the vulva at
the site of a previous fibroepithelial stromal
polyp: a case report. J Low Genit Tract Dis2007,
11(2):112117.
10. Pearl Crombleholme WR, Green JR, Bottles K.
Fibroepithelial polyps of the vagina in pregnancy,
Am J Perinatol 1991;8:236-8
456

Pratima et al.,

Int J Med Res Health Sci. 2015;4(2):454-456

DOI: 10.5958/2319-5886.2015.00086.7

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
st
Received: 21 Jan 2015
Case report

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 27 Jan 2015
Accepted: 1st Mar 2015

PLASMACYTOID MYOEPITHELIOMA OF MINOR SALIVARY GLANDS: A RARE CASE REPORT


*Jha Rohit Kumar1, Sinkar Prachi2, Karadi RN3
1

Post Graduate, 3Professor& Head, Department of Otorhinolaryngology, Shri B.M. Patil Medical College,
Hospital &Research Centre, BLDE University, Vijayapur, Karnataka, India
2
Post Graduate in the Department of Pathology, Shri B.M. Patil Medical College, Hospital &Research Centre,
BLDE University, Vijayapur, Karnataka, India
*Corresponding author email: rohitjhagnh1@gmail.com
ABSTRACT
Myoepithelioma of the salivary glands is a rare benign neoplasm with incidence of less than 1% of all salivary
gland neoplasms. The most common site is the parotid gland followed by minor salivary glands. These tumors
occur at any age with peak incidence in the third & fourth decade. Here we report a case of plasmacytoid
myoepithelioma of the minor salivary glands of soft palate which was conclusively diagnosed on FNAC and
further confirmed by histopathological studies. The rarity of the tumor and the site has been emphasized.
Key words: Myoepithelioma, Minor salivary gland, Plasmacytoid variant, Soft palate.
INTRODUCTION
Myoepithelioma is believed to be rare entity in the
tumours of salivary glands with less than 100 cases
reported in the literature. It was first described by
Sheldon in 1943 and was considered as variant of
pleomorphic adenoma. [1] But now-a-days most
authors consider myoepithelioma as a distinct
pathological
entity,
composed
entirely
of
myoepithelial cells behaving much more aggressively
than pleomorphic adenoma. Myoepithelioma arises
from myoepithelial cells which are usually present in
ductal epithelium of secretary glands like salivary,
sweat and mammary glands. [2] Myoepithelial cells are
characterised by intracytoplasmic myofilaments,
intercellular desmosomes and myogenic markers. [3]
Histopathologically there are five variants; spindle
cell, plasmacytoid, epithelioid, clear cell and mixed
variant. Spindle cell variant is the most common
followed by plasmacytoid variant.
Majority of myoepitheliomas present as painless,
slow growing, well circumscribed, smooth surfaced

tumors. They are well capsulated and rarely


metastasize. However recurrences have been
described. [3]
CASE REPORT
A 60 year old male patient came to the OPD of ENT
department with swelling in the oral cavity since 2
years. On examination swelling was noticed on the
left side of soft palate, measuring about 4 x 3.5cm,
well circumscribed, smooth surfaced. Overlying
mucosa was intact and not traumatized (Fig-1). There
was no evidence of cranial nerve and lymph nodal
involvement. The past history and family history
were not relevant. Routine blood and biochemical
investigations of patient were within normal limits.
Patient was advised FNAC which showed high
cellularity consisting of plasmacytoid cells in sheets,
clusters and singles on a background of myoxid
stromal fragments (Fig-2). Surgical excision was
done (Fig-3) and surgical specimen was sent for
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Int J Med Res Health Sci. 2015;4(2):457-459

histopathological examination. Histopathological


examination revealed a solid tumor consisting of
plasmacytoid cells in nests, islands and cords
separated by scanty myxoid stroma. There were no
ductal or glandular elements, as well as no atypia or
necrosis in the sections studied. Thus, confirming the
diagnosis of plasmacytoid myoepithelioma. (Fig-4)

Fig 1: Tumour measuring 4x3.5cm on the soft


palate.

Fig 2: FNAC Tumour cells arranged in sheets.


Plasmacytoid myoepithelial cells with rounded nuclei
eccentrically placed with eosinophilic hyaline
cytoplasm. Background showing myoxid stromal
elements (H&E; 100x).

Fig 3: Intra-operative tumour mass removed along with


capsule from soft palate

Fig 4: Histopathological study (H&E,100x)


showing tumour tissue arragned in diffuse
sheets.Most of the tumour cells have eccentrically
placed nuclei with hyaline eosinophilic cytoplasm
(i.e. plasmacytoid cells).Also seen spindle shaped
cells and few foci of clear cell change.Stroma
shows hyalinised collagen fibres.
DISCUSSION
Myoepithelioma is rare benign neoplasm of salivary
glands. Among its four sub-types spindle cell type is
most common (seen in 70% cases) where as
plasmacytoid cell type is seen in only 20%cases.
Plasmacytoid cell type is more common in major
salivary
glands.[4]
Therefore
plasmacytoid
myoepithelioma in minor salivary glands is a rare
entity.
The
biggest series
published on
myoepithelioma is by Scuibba and Brannon who
presented 23 cases of myoepithelioma of salivary
glands (both major and minor).[3]According to
literature review only 14 cases of plasmacytoid
variant of myoepithelioma affecting minor salivary
glands of palate have been reported.[5] Age
distribution ranged from 3rd decade to 9th decade,
with mean age of 53 years. No sex predilection has
been
described.[2]Myoepithelioma
must
be
differentiated from pleomorphic adenoma by absence
of chondroid or osteoid changes in the matrix and
absence of inconspicuous ductal differentiation.[1]
Benign myoepithelioma can be differentiated from
malignant myoepithelioma by absence of solid
pattern, infiltrating growth, necrotic areas, mitotic
figures, hyperkeratotic nuclei, cellular polymorphism,
cellular atypia and metastases.[6] Malignant
myoepithelioma has also been identified by cell
proliferation index(>10% highly suggestive of
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Int J Med Res Health Sci. 2015;4(2):457-459

malignant behavior). Basal membrane globule


surrounded by hyperkeratotic myoepithelial cells
goes in favor of malignant myoepithelioma.[1]
Differential diagnoses of plasmacytoid myoepithelioma include myoepithelial cell predominant
pleomorphic adenoma, plasmacytoma, lymphoma,
skeletal muscle and rhabdoid tumors. Presence of
myxohyaline stroma and cohesive clusters of
plasmacytoid cells favor myoepithelioma over other
diagnosis. Absence or less than 5% of epithelial cells
showing ductal or acinar formation and absence of
chondroid stroma helps in differentiating it from
pleomorphic adenoma. In our case myxohaline
stromal fragments were noted and inconspicuous
ductal or acinar pattern helped us to distinguish it
from pleomorphic adenoma. [7]
In immuno histochemical study myogenic markers
like CK-14, CK-18 & 19 is expected to be positive in
plasmacytoid variant. Surgical excision with margin
(few mm) of normal tissue is the treatment of choice.
Recurrences are rare. According to Sciubba &
Brannon, who followed-up 16 cases out of 23 over a
period of 1 year, found recurrence only in one case.[3]
Recurrences can be picked up by regular follow up.
In our case, the patient did well postoperatively and
no recurrence was noted till date.

2. Peel L, Diseases of the Salivary Glands Leon


Barnes(ed), Surgical Pathology of the Head
&Neck, 2nd edtn Marshal-Dekker, Inc., New
York-Basel, 2001;667-70.
3. Shafer G, Hine K, Levy M, Tumors of the
Salivary Glands Text book of Oral pathology,
Elsevier, 4th edtn.Philadelphia,2003;239-40
4. Regezi A, Sciubba j, Jordan K, Salivary Gland
Diseases, Oral Pathology, Elsevier, 5th edition.
St.Louis, 2008; 316-17
5. Rivera Q. Plasmacytoid myoepithelioma of the
palate, Research Gate, http: //www. Research
gate.net/publication/5789445_Plasmacytoid_myo
epithelioma
6. Gnepp R, El-Mofty K, Salivary Glands
(1996),Ivan Damjonov,James Linder(ed), Ander
sons Pathology, Patterson S, St.Louis, 1996;
2:1623-24.
7. Gore CR, Panicker NK, Chandanwale SS, Singh
BK. Myoepithelioma of minor salivary glands A diagnostic challenge: Report of three cases
with varied histomorphology. J Oral Maxillo
facPathol 2013; 17: 257-60.

CONCLUSION
Myoepithelioma- plasmacytoid variant of the palatal minor salivary glands is a rare entity. It is relatively
more aggressive than other benign neoplasms of
salivary glands. Management is surgical excision
which should include margins of normal tissue and
long term follow up for recurrence.
To conclude, myoepithelioma should be kept in mind
as differential diagnosis when dealing with an
intraoral sub mucosal mass inspite of their rarity at
that location.

:
:
:

Conflict of Interest: Nil


REFERENCES
1. Santos P, Cavalcante RR, MeloUC,et al.
Plasmacytoid myoepithelioma of salivary glands:
report of case with emphasis in the
immunohistochemical findings. Head & Face
Medicine2011; 7:24;1-6
459
Rohit et al.,

Int J Med Res Health Sci. 2015;4(2):457-459

DOI: 10.5958/2319-5886.2015.00087.9

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
th
Received: 25 Jan 2015
Revised: 20th Feb 2015
Case report

Copyright @2015
ISSN: 2319-5886
Accepted: 22nd Feb 2015

SILENT UTERINE RUPTURE OF UNSCARRED UTERUS- AN UNUSUAL PRESENTATION.


*Nishi Garg1, Grover Seema2, Simmi Aggarwal3
1

Assistant Professor, 2Professor, Department of Gynecology, Guru Gobind Singh Medical College &Hospital,
Faridkot, Punjab, India
3
Professor, Department of Radiology, Guru Gobind Singh Medical College &Hospital, Faridkot, Punjab, India
*Corresponding author email: nishigargdr@yahoo.co.in
ABSTRACT
It is very rare to see rupture of uterus in an unscarred uterus. But in cases of previous abortions or cesarean
section or scarred uterus, uterine rupture is seen in few cases. Silent uterine rupture is very rare. If there is fetal
demise & presenting part is very high up in pelvis not responding to routine induction, possibility of rupture
uterus should be kept in mind. Ultrasound has an important role in the diagnosis of silent uterine rupture. A case
of silent uterine rupture of unscarred uterus with fetal demise, that remained undiagnosed for many weeks, is
described.
Keywords: Uterine rupture, Unscarred, Silent, Fetal demise
INTRODUCTION
Rupture of the unscarred pregnant uterus is a rare
event, estimated to occur in 1/5700 to 1/20,000
pregnancies.[1-4].In one series, there were 25 uterine
ruptures in women with unscarred uteruses and these
events accounted for 13 percent of ruptures in this
study.[4] The incidence of rupture in unscarred and
scarred uteruses was 0.7 and 5.1 per 10,000
deliveries, respectively. The pathogenesis of rupture
of the unscarred uterus is not well-defined. Rupture in
these cases has been attributed to inherent or acquired
weakness of the myometrium, disorders of the
collagen matrix (Ehlers-Danlos type IV)[5-8], and
abnormal architecture of the uterine cavity
(bicornuate uteri, uterus didelphys, blind uterine
horns). [9-11] Over distension of the uterine cavity,
whether absolute or relative to the size of the cavity,
may be the major physical factor associated with
rupture in such cases. Over distension has even been
reported as a cause of rupture of the non gravid
uterus. [12] Uterine rupture is an uncommon but is a

Nishi et al.,

fatal complication of pregnancy. The difficulty in


diagnosis and management arises in cases of chronic
and silent uterine rupture. Silent ruptures have also
been reported after D&E and hysteroscopic
procedures.[13-14] Normal cardiotocographs (CTG) can
be obtained in silent uterine rupture hence it is not a
useful tool in the diagnosis. [15] Obstetricians should
be aware of the possibility of silent rupture of Uterus.
Ultrasound has an important role in the diagnosis of
silent uterine rupture. [16 ] We present a case of silent
uterine rupture that remained undiagnosed for many
weeks.
CASE REPORT
A patient G2 P0 A1 presented in emergency with
H/O amenorrhea 31wks with paralytic ileus. She was
referred from periphery on 20.9.2014. Her general
parameters were maintained. Blood Pressure & Pulse
was in normal range. The investigations done in civil
hospital were all normal but her HB was 7.0gm %.

Int J Med Res Health Sci. 2015;4(2):460-463

460

She gave H/O vomiting, constipation & mild


abdominal Pain. She was calm, conscious and
cooperative .On P/A examination Uterus Height was
30Wks with Fetal parts palpable & FHS -146 / min
and regular. Surgical Consultation was taken in view
of abdominal distension as abdomen was distended
& tense. No guarding or rigidity was there. Bowel
sounds were absent. Ultrasonography & Ryles tube
aspiration was advised.
She was having regular Antenatal care at Moga Civil
hospital, her previous Ultrasound done there on
2/8/14 showed 25-26 wks pregnancy with 34x23mm
hypoechoic Collection (Retroplacental Collection)
Placenta was anterior & in upper segment. [Fig. 1]
After admission U/S done 22/9/14 showed her upper
abdominal Scan to be normal .Cortical echogenicity
was increased of Right Kidney. Also Right Pelvi
Calayceal system showed hydronephrosis. There was
moderate amount of free fluid in abdomen. Fetal
condition was normal & gestation was 31wks. [Fig.
2] .There was no comment on uterine contour. She
was given I/V fluids, antibiotics & Continuous Ryles
tube aspiration was done. Two Blood transfusions
were given on 22nd Sep. 2014. Distension was still
there but uterus was relaxed& FHS was 136 /mt reg.
She did not complain of any pain and any loss of fetal
movements. On 23rd Sep. fetal heart sound was not
heard but her bowel movements were normal &
abdomen was relaxed. U/S done to see fetal Cardiac
activity, where it was declared to be Intra Uterine
Death. Comment on the contour of the uterus again
was not made. So plan for induction of labor was to
be made & in view of that pervaginum exam was
done. On P/V Exam. Cervix was found to be
unfavourable admitting 1 F & presenting part was
very high. A suspicion of rupture was made & repeats
U/S was done which showed a rent in the anterior
wall of the uterus. Placenta was anterior & free fluid
was seen in all the peritoneal recesses. During all
these days her general parameters were maintained.
Her BP Was 110/70 & there was no tachycardia..
After this decision of laparotomy was made .One unit
of blood was given preoperatively. On opening the
abdomen there was haemoperitoneum and baby was
lying outside the uterus in the amniotic sac .There
was a huge vertical rent in the midline of the uterus &
placenta was partially attatched to the uterus &
partially to the omentum. [Fig. 3] Repair of the
uterus was impossible so hysterectomy done after
Nishi et al.,

taking consent. Also removal of omentum where


placenta was adherent was done.
This Case presented with intestinal Obstruction so
diagnosis of pregnancy with peritonitis & intestinal
pathology was made. Her obstruction got relived with
treatment & abdomen became soft. Also fetal Cardiac
activity was normal. Her general parameters were
normal. So Diagnosis of uterine rupture was missed.
As the rupture progresses and ended up in IUD, led
on to the reaching of diagnosis. In this case as there is
history of previous abortion, so at that time silent
perforation could have led on to scarred uterus. So in
this pregnancy that scar gave way & progressed in
silent rupture. Probably starting asretroplacental clot
which slowly progressed into complete rupture in one
and a half month time resulting in IUD with
haemorrhage.

Fig 1: Ultrasound at 25-26 wks

Fig2: Ultrasound at 31 wks

Fig3: Ultrasound after rupture

Int J Med Res Health Sci. 2015;4(2):460-463

461

Fig 4 : Hemoperitoneum

reported where they conservatively managed prenatal


uterine rupture, diagnosed first at 17 and 19 weeks
respectively on ultrasound. [17-19] Silent rupture can
occur in previous scars as well as in unscarred uterus.
[20-21]
These ruptures remain silent for days and
weeks. Another case is reported where two large 5
Cm and 10 Cm complete ruptures were incidentally
discovered on third postnatal day during tubal
ligation [22]. An unusual presentation of prenatal silent
rupture is reported as anhydramnios and lung
hypoplasia at 31 weeks. Further investigation
revealed foetal leg protruding through uterine wall[23].
CONCLUSION

Fig 5: Ruptured uterus


DISCUSSION
The silent rupture of uterus is encountered when the
patient is asymptomatic and rupture or rent in the
uterus is discovered incidentally on ultrasound or at
surgery. Risk factors are previous scar or other
surgeries upon uterus, induction of labour by
prostaglandins and augmentation of labour by
oxytocin in a multiparous woman. [13-14]
The dilemma in diagnosis arises when uterine rupture
remains asymptomatic or presents with non-specific
symptoms, e.g., vague abdominal pain or discomfort
for many weeks. There is difficulty in diagnosis due
to lack of resources, expertise and ultrasound skills.
CTG is not a useful tool in the diagnosis of silent
uterine rupture. [15]
In our case, the woman sought medical advice outside
at Moga at 25-26 weeks, she had a small rent in the
uterus which was interpreted as a retroplacental clot .
During subsequent one and a half month, the whole
of the anterior surface gave way, resulting in
extrusion of fetus into the peritoneal cavity in sac and
ultimately fetal demise occurred. Also Placenta got
attached to omentum .
A case similar to this is reported where a lady
presented at 29 weeks with abdominal pain for
several weeks and ultrasound revealed foetal parts
outside the uterine cavity. [16] Two other cases are
Nishi et al.,

High index of suspicion should arise for uterine


rupture in cases of previous scar or procedures upon
uterus, when they present with unusual features and
suspicious ultrasonography findings like bands, cysts
, free fluid and unexplained anhydramnios.
Ultrasonography has an important role in diagnosing
silent and old ruptures. Every effort should be made
to seek expertise to define uterine wall integrity.
Conflict of Interest: Nil
REFERENCES
1. Dow M, Wax JR, Pinette MG, et al. Thirdtrimester uterine rupture without previous
cesarean: a case series and review of the
literature. Am J Perinatol 2009; 26:739.
2. Porreco RP, Clark SL, Belfort MA, et al. The
changing specter of uterine rupture. Am J Obstet
Gynecol 2009; 200:269.
3. Miller DA, Goodwin TM, Gherman RB, Paul
RH. Intrapartum rupture of the unscarred uterus.
Obstet Gynecol 1997; 89:671.
4. Zwart JJ, Richters JM, Ory F, et al. Uterine
rupture in The Netherlands: a nationwide
population-based cohort study. BJOG 2009;
116:1069.
5. Walsh, CA, Reardon, W, Foley, ME.
Unexplained prelabor uterine rupture in a term
primigravida: letter to the editor. Obstet Gynecol
2007; 109:455
6. Taylor DJ, Wilcox I, Russell JK. Ehlers-Danlos
syndrome during pregnancy: a case report and
review of the literature. Obstet Gynecol lSurv
1981; 36:277.

Int J Med Res Health Sci. 2015;4(2):460-463

462

7. Rudd NL, Nimrod C, Holbrook KA, Byers PH.


Pregnancy complications in type IV EhlersDanlos Syndrome. Lancet 1983; 1:50.
8. Jones DE, Mitler LK. Rupture of a gravid
bicornuate uterus in a primigravida associated
with clostridial and bacteroides infection. J
Reprod Med 1978; 21:185.
9. Samuels TA, Awonuga A. Second-trimester
rudimentary uterine horn pregnancy: rupture after
labor induction with misoprostol. ObstetGynecol
2005; 106:1160.
10. Nahum GG. Uterine anomalies. How common
are they, and what is their distribution among
subtypes? J Reprod Med 1998; 43:877.
11. Gowda M, Garcia L, Maxwell E, et al.
Spontaneous uterine rupture in a nulligravida
female presenting with unexplained recurrent
hematometra. ClinExpObstetGynecol 2010;
37:60.
12. Sakr R, Berkane N, Barranger E, et al. Unscarred
uterine rupture--case report and literature review.
ClinExpObstetGynecol 2007; 34:190.
13. Conturso R, Redaelli L, Pasini A, Tenore A.
Spontaneous uterine rupture with amniotic sac
protrusion at 28 weeks subsequent to previous
hysteroscopicmetroplasty. Eur J OostetGynecol
2003; 107(1):98100.
14. Jocken S, Britta G, Anton S. Twin gestation with
uterine rupture after hysteroscopy. Gynecological
Endoscopy 2002:11;1459.3.
15. Klein M, Rosen A, Beck A. Diagnostic potential
of cardiotocography (CTG) for silent uterine
rupture. Acta Obstet Gynecol Scand 1989;
68(7):6536.
16. Wali S Aisha , naru y. t. silent uterine rupture of
scarred uterus - an unusual presentation as
amniocele -case report
j ayub med coll
abbottabad 2013;25(1-2):2045
17. Cotton DB. Infant survival with prolonged
uterine rupture. Am J Obstet Gynaecol
1982;142:105960.
18. Yinka O, Jean-Gilles T, Brian C, Anitha N,
Patricia H,Rodney M. Conservative management
of uterine rupture diagnosed prenatally on the
basis of sonography. J Ultrasound Med
2003;22:97780.
19. Martin JN Jr, Brewer DW, Rush LV Jr, Martin
RW, Hess LW, Morrison JC. Successful
Nishi et al.,

pregnancy outcome following mid- gestational


uterine rupture and repair using Gore-Tex soft
tissue patch.ObstetGynaecol 1990;75:51852.
20. Chuan-Yaw C, Szu-Yuan C, I-Lin C, Chun-Sen
H, Kenny H- H C, Pui-Ki C. Silent uterine
rupture in an unscarred uterus. Taiwan J
ObstetGynecol 2006;45(3):2502.
21. Neena M, Charu C. Silent rupture of unscarred
uterus: an unusual presentation at second
trimester
abortion.
Arch
GynecolObstet
2007;275(4): 2835.
22. Rubin L, Baskett TF. Silent uterine rupture
during labor. Can Med Assoc J 1971;104:6125.
23. Katinka KT, Enrico L, Remco GWN, Patrick AB,
Inge LVK. Silent uterine rupture, an unusual
cause of anhydramnios. Am J Obstet Gynecol
2007; 196(2):89.

Int J Med Res Health Sci. 2015;4(2):460-463

463

DOI: 10.5958/2319-5886.2015.00088.0

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 24 Jan 2015
Case report

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 10 Feb2015
Accepted: 27th Feb 2015

BLOCKAGE OF EPIDURAL CATHETER WITHIN CONNECTOR ASSEMBLY


*Gill RavneetK.1, Pathak Debagopal2, Arora Bharat 1,Chauhan Ram C.1
1

Post-graduate, 2Professor and Head, Department of Anaesthesia and Critical Care,Silchar Medical College and
Hospital, Silchar, Assam, India
*Corresponding author email: dr.gini22@yahoo.com
ABSTRACT
Failure to inject a drug through the epidural catheter because of epidural catheter connector malfunction is a rare
complication. In this report, we describe a case of epidural catheter connector malfunction in a 45 years old
male undergoing emergency explorative laparotomy for haemoperitoneum under general anaesthesia and insertion
of epidural catheter for post operative analgesia. After insertion of catheter after completion of surgery, drug
could not be injected in the catheter. After common causes like kinking, knotting, occluded catheter were ruled
out, the cause was found to be in the epidural catheter connector assembly which is not encountered frequently.
This case warrants that anaesthesiologists must also be aware of rare causes and the preventive steps to avoid such
complications.
Keywords: Epidural catheter connector assembly, Blockage of epidural catheter
INTRODUCTION
Epidural technique of anaesthesia is now widely
usedby anaesthesiologists all over the world. By
placing an epidural catheter, regional anaesthesia can
be performed and prolonged by injecting local
anaesthetic drug and postoperative analgesia [1] can
also be provided by injecting epidural local
anaesthetics or narcotics [2]. Adequate post operative
epidural analgesia fastens the recovery as it decreases
the stress response and the load on cardio respiratory,
renal system and leads to decrease in morbidity and
prevent further complications like thrombosis,
embolism [3, 4] etc. Every patient has the right for
adequate pain relief after surgery. Failure to inject
drug through a catheter is a well known [5, 6]
complication which can be due to kinking or knotting
of the catheter but rarely may be because of
connector assembly malfunction.
CASE REPORT
A 45 year old, 70 kg male patient was put for
emergency
exploratory
laparotomy
for
Ravneet et al.,

haemoperitoneum (as revealed on FAST scan)


following blunt trauma to the abdomen. On arrival to
operation theatre, he was quickly examined for any
co morbidities, Nil per Oral status. Intravenous
access was gained by placing two 18 G cannula in
both hands and normal saline was started.He was
premedicated with inj Ranitidine iv 50 mg, inj
Ondanseteron iv 4 mg, inj Glycopyrolate iv 0.2mg,inj
Tramadol iv 1mg/kg. Patients vitals like Non
Invasive Blood Pressure, Electrocardiography, SpO2
(oxygen saturation) were recorded and found to be
within normal limits. Inj Lidocaine iv 1.5mg/kg was
given to attenuate the hemodynamic response to
laryngoscopy and intubation. Preoxygenation with
100% oxygen was followed by induction with
propofol iv 2mg/kg and succinylcholine iv 75 mg
using modified Rapid Sequence Intubation (RSI)
technique. Patient was intubated with size
8.5Endotracheal tube and position was confirmed by
bilateral auscultation of breath sounds and EtCO2
monitor was attached. Anaesthesia was maintained
464
Int J Med Res Health Sci. 2015;4(2):464-466

with inj. Atracurium(30 mg bolus and 5 intermittent


top up doses of 10 mg at 25 minutes interval), N20 :02
67:33%and Isoflurane inhalation at 0.6%.Duration of
the surgery was 140 minutes and1.5litres of Normal
saline 500ml of Ringers lactate and 1 unit of whole
blood were transfused. Urine output at end of the
surgery was 250 ml.
After completion of the surgery, insertion of epidural
catheter (Perifix 300 mini set Braun) was planned for
post operative analgesia. He was put in the left lateral
decubitus position, and under aseptic conditions,
epidural Tuohy needle 18 G was advanced in L2-3
intervertebral space and epidural space was identified
by LOR (loss of resistance technique) to air at 5 cm
marking on Tuohy needle. After test dose, single shot
0.125% bupivacaine (12 ml total volume) was
injected for postoperative analgesia and also to
facilitate insertion of catheter by predistension of the
epidural space. After that, epidural catheter was
inserted through the needle and fixed at 11 cm
marking. Catheter was secured in place with adhesive
tapes, avoiding any kinking of catheter at the
insertion point or at the neck and then patient was
carefully turned to supine position. For reversal, inj.
Neostigmine 2.5mg iv and inj Glycopyrrolate 0.5 mg
iv was given. After satisfactory reversal from
neuromuscular blockade, patient was extubated.
Before shifting from OT, 2ml of 0.125 % bupivacaine
was tried to be injected through the catheter to check
for patency, but even after using moderate force, it
could not be injected. Kinking of the catheter was
thought to be the cause of obstruction. Adhesive tapes
were removed carefully, but no kinking was noticed
along the course of the catheter. Catheter was then
pulled 0.5 cm out but still drug could not be injected.
After repeated attempts, failure to inject drug using
moderate force also, led to the removal of the
catheter. The tip of catheter was checked for blockage
by blood clot but it was not the case. Even after
removal from the patient, drug could not be injected
through the catheter using moderate force. To check
for patency of the catheter, a different connector was
attached to the first catheter, and it led to free flow of
drug. So cause of obstruction was thought to be in the
connector assembly and was confirmed by the fact
that even when the catheter from the different set was
attached to the first connector, drug could not be
injected.

DISCUSSION
Though epidural route is routinely used for regional
anaesthesia and analgesia in terms of PCEA, post
operative analgesia, pain relief in chronic
conditions[7]but the failure of the block remains a
great concern to the anaesthesiologist. 14% of all
failure of epidural block has been found to be due to
technical reasons [8].Failure to inject the drug through
the catheter can be due to various reasons:
Malposition of tip of catheter, blocked tip of catheter
by blood clot[9], kinking , knotting[9], transection of
catheter, manufacturing defect[10] or rarely connector
assembly[11]
The connector used in this case hadtwo parts. It was a
type of snap catheter connector [12]. It had a
transparent flap and a yellow base. The catheter
passes through the yellow base and the transparent
flap clicks over the base and holds the catheter in
place i.e. in the port for catheter at the base. The
connector assembly has a midline arch in the upper
flap which holds the catheter [11] and helps in correct
placement of the catheter in the connector. A distinct
click sound confirms correct placement of the
connector which can then be attached to the syringe.
Filters may be used which provide an additional
degree of safety in preventing bacterial infections.
Minimal dead space enables accurate dosing. A high
pressure resistance up to 7 bars enhances safety
during manual injection. It provides proper grip, thus
providing more secure catheter connection [12].
Kinking and knotting can occur if more than adequate
length is inserted into the epidural space.
Anaesthesiologist must be aware not to advance the
epidural catheter more than 5 cm into the epidural
space as greater length of the epidural catheter
increases the risk of complications like
kinking/curling/knotting[13,14,15] which subject the
patient to further complications. As these are the
common causes of catheter blockage that can be
thought of, these should be ruled out by carefully
observing the length and depth of the catheter. As in
our case, when all other causes were ruled out,
catheter was withdrawn carefully from the patient and
the procedure abandoned. Then the connector
assembly was properly examined as the catheter
seemed to be patent. Failure to inject drug through the
connector could be because of two causes: inadequate
length of catheter in connector which may partially
occlude it
465

Ravneet et al.,

Int J Med Res Health Sci. 2015;4(2):464-466

(Ruled out in our case) or manufacturing defect


(defective flap connection or increased or malaligned
arch completely occluding the catheter)[11]
According to Goswami et al[11], connector malformation due to slightly enlarged midline arch can
also be a cause of failure of injection of drug which
could have been the reason in this case.
Changing of the connector from a sterile set could
have been the remedy and should be thought of prior
to removal of the catheter from the patient thus
avoiding the unnecessary removal and depriving the
patient from post operative analgesia by epidural
route.
CONCLUSION
After ruling out common causes of failure to inject
drug through the catheter, catheter connector
assembly malfunction should be thought of as a
possible cause, whether due to misplacement of the
catheter into the connector or manufacturing defect.
Whether proper functioning of the catheter along with
the connector assembly should be confirmed by
flushing the catheter[16]prior to its placement in the
patient or not remains an open question for every
anaesthesiologist as excessive manipulation and
handling of the catheter should be avoided to prevent
even the slightest possibility of contamination.

4.

5.

6.

7.

8.

9.

10.

ACKNOWLEGEMENT

11.

We are thankful to our Department of


Anaesthesiology and Critical care, Silchar Medical
College, Silchar. Assam for helping us with this
article. Authors are also thankful to the scholars
whose articles are cited and included in the
manuscript and also to our families for being the
source for guidance.

12.

13.

Conflicts of Interest: Nil


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Ravneet et al.,

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DOI: 10.5958/2319-5886.2015.00089.2

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
th
Received: 7 Feb 2015
Case report

Coden: IJMRHS
Copyright @2015
ISSN: 2319-5886
th
Revised: 20 Feb 2015
Accepted: 24th Feb 2015

DIAGNOSTIC DILEMMA IN A CASE OF GINGIVAL LESION PLASMA CELL GRANULOMA


VERSUS EXTRAMEDULLARY PLASMACYTOMA- RESOLVED BY IMMUNOHISTOCHEMISTRY:
A CASE STUDY
*Amita K1, Vijayshankar S2, Anusha K3, Hemalatha AL1
1

Associate Professor, 2Professor, 3Post graduate, Department of Pathology, Adichunchanagiri Institute of Medical
Sciences, B.G. Nagara, Nagamangala taluk, Mandya, Karnataka
*Corresponding author: Amita K Email: dramitay@gmail.com
ABSTRACT
Plasma cell granuloma is a rare reactive tumor- like lesion composed of polyclonal plasma cells. It primarily
affects the lungs but occurs in other anatomic locations such as orbit, paranasal sinuses, larynx, tonsils, ears,
tongue, lip, oral cavity and gingiva. A 65- year old female presented with the chief complaint of swelling over the
right upper gingiva and mobility of right upper 2nd and 3rd molar teeth since 3-4 months At histopathology due to
presence of uniform population of plasma cells a histopathological diagnosis of plasma cell rich lesion was made
with a differential diagnosis of extramedullary plasmacytoma and plasma cell granuloma. However,
immunohistochemical staining for kappa and lambda chains showed a polyclonal process and antibodies to
CD138 were strongly positive, confirming the diagnosis of plasma cell granuloma. The case describes a rare
condition of plasma cell granuloma occurring at an unusual site. Authors also emphasize the importance of
immunohistochemistry in differential diagnosis of plasma cell rich lesions.
Key words: Gingiva, Immunohistochemistry, Plasma cell
INTRODUCTION
Plasma cell granuloma is a rare, reactive, nonneoplastic lesion composed of polyclonal plasma
cells. This entity in the gingiva was first described in
1968 by Bhaskar, Levin and Firch. [1] This lesion does
not have a sex predilection and may occur at any age.
The exact incidence and etiopathogenesis is unclear.
However, it may arise due to periodontitis
orperiradicular inflammation due to a foreign body or
an idiopathic antigen. Parasitic etiology has also been
postulated.[2] It affects various organs like lungs,
paranasal sinuses, reticuloendothelial system, orbit,
ears, larynx, tonsils, lip, oral cavity and rarely
gingiva.[3] In exceptional cases, synchronous and
metachronous
involvement
has
also
been
[2]
documented. Histopathologically, it is composed of
polyclonal population of plasma cells in a

fibrovascular background.Russell and Dutcher bodies


can be seen. It is important to distinguish it from
plasmacytoma, since the later can be an early feature
of multiple myeloma. [3] Immunohistochemistry helps
in making this distinction. Treatment is complete
resection of the mass. There are conflicting reports
about the biological behavior and prognosis. [3]
The present report highlights the occurrence of
plasma cell granuloma occurring at an unusual
location i.e, gingival with emphasis on the need for
distinguishing this tumor like lesion from the other
plasma cell rich lesions like solitary bone and soft
tissue plasmacytoma. The report also depict the role
of immunohistochemistry in arriving at an accurate
diagnosis.
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Int J Med Res Health Sci. 2015;4(2):467-470

CASE REPORT
A 65- year old female presented with the chief
complaint of swelling over the right upper gingiva
and mobility of right upper 2nd and 3rd molar teeth
since 3-4 months. There was no history of rapid
increase in the size of swelling. There was no history
of trauma. On clinical examination, a solitary, welldefined swelling measuring 1.5 x 1cms, involving the
upper free gingival margin and part of the attached
margin was present. The swelling was mildly tender,
had a smooth pink surface and was bleeding on
probing the gingival crevices. There was no
exudation of pus. Patient was not a case of diabetes
mellitus. A provisional diagnosis of pyogenic
granuloma was made. Excision biopsy was done and
specimen sent for histopathologic examination.
Routine hematoxylin and eosin stain was done.
Immunohistochemical staining for ki67, CD138,
kappa and lambda immunoglobulin light chains was
done.
Histopathological examination of the specimen
revealed sub- epithelial sheets and clusters of plasma
cells in perivascular location with many Russell and
Dutcher bodies (Figure 1A and B) There was
evidence of binucleation and multinucleation(Figure
1 C). At places few plasma cells showed coarse
chromatin and prominent nucleoli (plasmablasts)
(Figure 1 D). No other inflammatory cells were seen.
Hence a histopathological diagnosis of plasma cell
rich lesion was made with a differential diagnosis of
extramedullary plasmacytoma and plasma cell
granuloma.

(H&E, 1000) Inset depicts multinucleated plasma


cell (H & E, 1000) D: Section shows mild
pleomorphism with plasmablasts (H & E, 1000).
Inset depicts mott cell-Intracytoplasmic inclusions.
( H & E, 1000)
In view of these findings further work up done to rule
out plasma cell dyscrasias. Whole body X ray, renal
function test, serum protein electrophoresis, urine for
Bence Jones proteins and serum calcium were within
normal limits. Hematological profile was normal
except for anemia of 9 g %.
Further, immunohistochemical staining for kappa and
lambda chains showed a polyclonal process,
antibodies to CD138 were strongly positive and
immunostaining for ki-67 was negative, confirming
the diagnosis of plasma cell granuloma (Figure 2).

Fig 2: A: Immunohistochemical stain for CD 138


showing strong positivity (H & E, 100), B:
Negative immunostaining for ki- 67 ( H & E, 100),
C: Immunohistochemical stain for kappa chains show
strong positivity (H & E, 400), D:
Immunohistochemistry for lambda chains show
strong positivity ( H & E, 400)
DISCUSSION

Fig 1: A: Section shows acanthotic epithelium with


sub- epithelial sheets and clusters of plasma cells (H
& E, 40) B: Section showing clusters of plasma
cells (H & E, 1000) C : Binucleated plasma cells
(single arrow) and Russell body (double arrow)

Plasma Cell Granuloma is an uncommon tumor like


lesion characterized by proliferation of predominantly
plasma cells admixed with other inflammatory cells,
lymphocytes, histiocytes, mast cells and eosinophils.
Myofibroblast has also been demonstrated in the
lesion which shows a myxoid/collagenous stroma.
The lesion imitates multiple myeloma or
plasmacytoma histologically. [4]
This proliferative lesion has predilection for lungs.
Other than this it is known to occur in brain, kidney,
stomach, heart. When it occurs in the head and neck
region, the common sites affected are oral mucosa,
468

Amita et al.,

Int J Med Res Health Sci. 2015;4(2):467-470

tongue, lip, buccal mucosa, tonsil, paranasal sinuses


and rarely gingiva. [3]
Different terminologies have been adopted to
describe this lesion which include inflammatory
myofibroblatic tumor, inflammatory pseudo tumor,
inflammatory myofibrohistiocytic tumor, and so on.
[4]
In 2002, WHO included it under the intermediate
category of fibro myofibroblastic tumors. [5] Varied
nomenclature used to describe this lesion has led to a
uncertainty over the exact incidence and biologic
nature as to inflammatory or neoplastic.
Plasma cell granuloma need to distinguished from
other plasma cell rich lesion like osseous solitary
plasmacytoma, multiple myeloma, and soft tissue
plasmacytoma. Histologically plasmacytoma shows
monomorphic population of plasma cells with
presence of plasmablast, bi and multinulcation and
many Russell and dutcher bodies. In contrast,
however, plasma cell granuloma though shows
predominance of plasma cells, there will be
intermingling of other inflammatory cells like
lymphocytes, mast cells and eosinophils. [6]
However histological examination, at times, is
misleading as in our case. The absence of
inflammatory cells other than plasma cells and
abundance of Russell and dutcher bodies
accompanied by cells with plasmablastoid
morphology lead us to consider plasmacytoma in the
diagnosis. Likewise absence of any history of
infection or trauma, habit of chewing tobacco or betel
nuts furthered up
to the diagnostic dilemma.
Differentiation from plasma cell neoplastic lesions is
imperative given that 14% of multiple myeloma show
signs of oral manifestations and that 24% present as
solitory plasmacytoma which eventually progress to
multiple
myeloma.
Likewise
soft
tissue
plasmacytoma has predilection for head and neck
region. [7, 8]
Although the main contributing pathways for the
pathogenesis are hard to pin down, many authors
have favored an immunologic basis for the etiology
of plasma cell granuloma. Data concerning the
molecular mechanisms involved in the pathogenesis
is unknown, Coffin et al have documented the
finding of human herpervirus -8 DNA sequence and
over expression of IL 6 and Cyclin D 1 in PCG. [9]
Similar Kim et al in their study on cyclosporine
induced plasma call rich gingival growth, have

recognized the role of interleukin -6


and
phospholipase C- 1 [10]
Most of the time, complete surgical excision is
curative. Controversy exists on role of radiotherapy
or steroids in unrespectable cases. [5,6]
Regardless of the verity that PCG is a benign entity,
cases showing aggressive behavior and recurrences
are on record.
What was known: Presence of other inflammatory
cells and Dutcher bodies favor a polyclonal, nonneoplastic process.
Novel insight: Even a pure plasma cell lesion
(absence of other inflammatory cells and Dutcher
bodies) does not imply a neoplastic process. Hence it
is mandatory to evaluate with immunohistochemistry
and proliferation markers to rule out a neoplastic
process.
CONCLUSION
This case describes a rare condition of plasma cell
granuloma of the gingiva. This case highlights the
need to biopsy unusual lesions to rule out potential
neoplasms.
It
emphasizes
the
need
for
histopathological examination of all excised tissue
regardless of clinical diagnosis and the need for
immunohistochemistry in the differential diagnosis of
plasma cell rich lesions.
REFERENCES
1. Bhaskar SN, Levin MP, Firsch J. Plasma cell
granuloma of periodontal tissues. Report of 45
cases. Periodontics 1968;6:272-6.
2. Ide F1, Shimoyama T, Horie N. Plasma cell
granuloma of the oral mucosa with
angiokeratomatous features: a possible analogue
of cutaneous angioplasmocellular hyperplasia.
Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2000 Feb;89(2):204-7.
3. Phadnaik MB, Attar N. Gingival plasma cell
granuloma. Indian J Dent Res. 2010; 21:460-2
4. Arthur S. Inflammatory pseudotumor. In: Mills
SE, Carter D, Greenson JK, Reuter VE, Stoler
MH, editors. Sternberg's Diagnostic Surgical
Pathology. 5th ed. Philadelphia: Lippincott
Williams and Wilkins; 2010. pp. 10246.
5. Fletcher CDM, Unni KK, Mertens F. (Eds.):
World Health Organization and Genetics of
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Int J Med Res Health Sci. 2015;4(2):467-470

6.

7.

8.

9.

10.

Tumours of Soft Tissue and Bone. IARC Press:


Lyon 2002.
Betram S, Don K. Lymphoreticular disorders. In:
Batsakis JG, editor. Tumors of the head, Clinical
and Pathologic considerations. 2nd ed. London:
Williams and Willkins; 1980. p. 472-3
Ajay Telang, Lahari A Telang. Oral Plasma Cell
Granuloma: An Enigmatic Lesion. International
Journal of Oral and Maxillofacial Pathology;
2013:4(1):64-67.
Epstein JB, Voss NJS, Stevenson-Moore P.
Maxillofacial
manifestations
of
multiple
myeloma. An unusual case and review of the
literature. Oral Surg Oral Med Oral Pathol
1984;57:267-71.
Coffin CM, Fletcher JA. Inflammatory
myofibroblastic tumor. In: Fletcher CD, Unni
KK, Mertens F, editors. World Health
Organization Classification of Tumors. Pathology
and Genetics of Tumors of Soft Tissue and
Bone. Lyon: IARC Press; 2002. pp. 913
Kim SS, Eom D, Huh J, Sung IY, Choi I, Ryu
SH, Suh PG, Chung SM. Plasma cell granuloma
in cyclosporine-induced gingival overgrowth: a
report of two cases with immunohistochemical
positivity of interleukin-6 and phospholipase Cgamma1. J Korean Med Sci. 2002;17(5):704-7.

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Int J Med Res Health Sci. 2015;4(2):467-470

DOI: 10.5958/2319-5886.2015.00090.9

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2
Coden: IJMRHS
th
Received: 25 Feb 2015
Revised: 10th Mar 2015
Case report

Copyright @2015
ISSN: 2319-5886
Accepted: 31st Mar 2015

ISOLATED MAJOR AORTOPULMONARY COLLATERAL ARTERY CAUSING CCF IN A


NEWBORN: A CASE REPORT
Mohammed Ashfaque Tinmaswala*, Pallavi P Saple, Arpita Gupta, Prachi N, Nitinkumar A, Kaba Amin
Department of Pediatrics, Grant Government Medical College and JJ Hospital Mumbai
*Corresponding author email: dr.ashfaq.memon@gmail.com
ABSTRACT
Major Aortopulmonary collateral artery (MAPCA) is an anamolous vascular connection in between aorta or one
of its main branches and pulmonary artery. It is single or multiple in which case its called multiple
anamolousaortopulmonary collaterals (MAPCAs). These are usually seen in association with congenital heart
diseases with decreased pulmonary blood flow but rarely may it be present as an isolated anamoly without
evidence of any structural heart disease. The infant may present with pulmonary hypertension, bronchopulmonary
dysplasia, recurrent lower respiratory tract infections or Congestive cardiac failure (CCF). We describe here a
case of isolated Aortopulmonary collateral artery causing congestive cardiac failure in a late preterm baby. The
congestive cardiac failure in this infant was successfully managed by obliteration of MAPCA by a single coil.
Key words: Major Aortopulmonary Collateral Artery, Congestive cardiac failure, Micro coil Embolization.
INTRODUCTION
Major Aortopulmonary collateral arteries (MAPCAs)
are anomalous arteries that develop from aorta or its
main branches and are connected with pulmonary
arteries. Usually these MAPCAs are seen in
association with cyanotic congenital heart diseases.[1]
Aortopulmonary collaterals sometimes cause
pulmonary hypertension specially in association with
cyanotic congenital heart diseases with pulmonary
oligemia like Pulmonary atresia or tetralogy of fallot
where these Aortopulmonary collateral arteries are an
important form of alternative blood supply to lungs.[2]
In neonates especially in preterm infants these
collaterals are asymptomatic and usually doesnt need
any intervention.[3].Rarely Major Aortopulmonary
collateral artery may be present without any evidence
of congenital heart disease. In some cases this can be
large enough to cause symptoms and may need
intervention.
MAPCAs
can
also
cause
[4]
bronchopulmonary dysplasia.
Aortopulmonary
arteries, isolated or multiple should always be kept in

mind as a differential diagnosis in infants presenting


with congestive cardiac failure, bronchopulmonary
dysplasia or recurrent respiratory tract infections.[5]
Infants who have clinical features suggestive of
Aortopulmonary collateral should therefore be
subjected to detailed echocardiographic examination
including color Doppler studies and if facilities are
available then cardiac CT can also be done .[6] When
in doubt diagnostic catheterization should be done.
We present here case of a neonate presenting with
CCF secondary to MAPCA who was successfully
managed by obliteration of MAPCA by a single coil.
CASE REPORT
A late preterm, small for gestational age Male child
was delivered by LSCS in view of meconium stained
amniotic fluid. Baby didnt cry immediately after
birth. Endotracheal intubation was done meconium
was recovered from under the cord and intermittent
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Int J Med Res Health Sci. 2015;4(2):471-473

positive pressure ventilation was given for 2 minutes


after which baby developed spontaneous respiration.
Baby was admitted in NICU in view of respiratory
distress. On examination he had mild tachypnea and
grunting along with subcostal and intercostal
retractions. On auscultation there was a continuous
murmur over left infrascapular area. Continuous
positive airway pressure was given for respiratory
distress and he was kept NBM and IV fluids and
antibiotics were started. Respiratory distress started
settling down on D3 of life and hence baby was
shifted from CPAP to oxygen by head box.
Subsequently baby started having tachycardia and
enlarged liver span. In view of presence of a murmur
along with the signs suggestive of CCF an urgent 2D
Echo was done. On 2 D echo there was no evidence
of congenital heart disease. Pulmonary stenosis or
atresia was also ruled out. Color Doppler studies
showed a possible connection between descending
aorta and pulmonary artery. In view of CCF anti
failure measures (Digoxin and Furosemide) were
started. Despite these medications baby had
tachycardia and tachypnea along with gradual
increase in liver span. A provisional diagnosis of
Major aortopulmonarycollateral artery causing CCF
was made and catheterization study was planned.

Fig 1: A Major Aortopulmonary collateral artery


is seen connecting descending aorta and
pulmonary artery
On cardiac catheterization a major aortopulmonary
collateral artery of 1.7mm diameter connecting
descending aorta and pulmonary artery was seen.
This MAPCA was completely embolized using
embolization micro coil of 4mm size. Catheterization
study post embolization showed complete obliteration
of collateral circulation.

Fig 2: Circulation through MAPCA is completely


obliterated. Embolization microcoil is visible
Post Embolization baby was stable. Gradually the
tachycardia settled down and also there was
improvement in CCF. Anti-failure measures were
gradually tapered and baby was started on
Nasogastric tube feeding. Feeding was gradually
increased up to full feeds. A review 2 D Echo was
done which showed blood flow in proximal part of
aortopulmonary artery but there was no flow in distal
collateral. Baby was gradually shifted to direct breast
feeding and later was discharged.
DISCUSSION
Congestive cardiac failure in a neonate and during
early infancy can be due to many etiologies. While
many times this is due to congenital heart diseases
other possibilities should also be kept in mind.
MAPCAs are occasionally described as a cause of
congestive cardiac failure in neonates and in infancy
where they may necessitate surgical intervention in
initial few weeks of life. [7] Other presenting features
of MAPCAs are persistent pulmonary hypertension of
newborn and failure to thrive. Though MAPCAs are
usually seen in association with congenital heart
diseases with decreased blood flow like pulmonary
atresia and stenosis or tetralogy of fallot.[8]
occasionally they can be seen in isolation with no
evidence of any other congenital heart defect.
MAPCAs without congenital heart disease may be
seen in premature babies but in this setting usually
conservative management is all that is required. In
one study MAPCAs were seen in 66% premature
babies out of which 11% had signs suggestive of
congestive cardiac failure and only one was
diagnosed with major collateral artery requiring
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Int J Med Res Health Sci. 2015;4(2):471-473

Embolization.[9] Haemodynamically these MAPCAs


may cause CCF because of left to right shunting of
blood across collateral artery.[10]
In our case the child was a late preterm with birth
weight of 2.1 kg. The baby was born through
meconium stained amniotic fluid and basically was
admitted in NICU in view of respiratory distress but
later developed signs of congestive cardiac failure in
2nd week of life. The interesting thing about this case
was presence of major aortopulmonary collateral in
absence of any structural abnormality of heart. In our
case the etiology of major isolated aortopulmonary
collateral remains a matter of investigation. Because
the aortopulmonary collateral was symptomatic it
needed intervention. Microcoil embolization was
successful and post procedure patient improved and
subsequently was discharged.
CONCLUSION
Even though the major cause of CCF in neonates and
during early infancy is congenital heart diseases a
possibility of aortopulmonary collateral should be
kept in mind as a differential diagnosis. Though these
MAPCAs are usually present in combination with
cyanotic congenital heart diseases like Pulmonary
atresia, pulmonary stenosis or tetralogy of fallot,
absence of this doesnt rule out the possibility of
MAPCA.
Conflict of interest: Nil
REFERENCES
1. Daniel Bernstein. Cyanotic congenital heart
lesions: Lesions associated with decreased
pulmonary blood flow In: Kliegman RM,
Behrman RE, Jenson HB, editors. Nelson
Textbook of Paediatrics. 17th ed. Philadelphia:
Saunders; 2004; 1529-31
2. Freedom RM, Smallhorn JF, Burrows PE.
Pulmonary atresia and ventricular septal defect.
In: Freedom RM, Benson LN, Smallhorn JF,
editors. Neonatal
heart
disease. London:
Springer; 1992; 108: 22956.
3. Ascher DP, Rosen P, Null DM, de Lemos RA,
Wheller JJ. Systemic to pulmonary collaterals
mimicking patent ductusarteriosus in neonates
with prolonged ventilatory courses. J Pediatr.
1985;107(2):282-4

4. Del Cerro MJ, SabatRots A, Cartn A, Deiros


L, Bret M, Cordeiro M, Verd C, Barrios MI,
Albajara L, Gutierrez-Larraya F. Pulmonary
hypertension in bronchopulmonary dysplasia:
clinical findings, cardiovascular anomalies and
outcomes. PediatrPulmonol. 2014; 49(1):49-59.
5. Patra S, Srinivas SK, Agrawal N, Jayaranganath
M. Isolated majoraortopulmonary collateral
artery in an infant presenting with recurrent lower
respiratory tract infection. BMJ Case Rep. 2013;
12:20-13
6. Murai S, Hamada S, Yamamoto S, Khankan AA,
Sumikawa H, Inoue A, Tsubamoto M,Honda O,
Tomiyama N, Johkoh T, Nakamura H. Evaluation
of major aortopulmonarycollateral arteries
(MAPCAs)
using
three-dimensional
CT
angiography: two case reports. Radiat Med. 2004;
22(3):186-9.
7. Prieto L. Management of Tetralogy of Fallot with
Pulmonary
Atresia. Images
in
Paediatric
Cardiology. 2005; 7(3):24-42.
8. Maeda E, Akahane M, Kato N, Hayashi N, Koga
H, Yamada H, Kato H, Ohtomo K.Assessment of
major aortopulmonary collateral arteries with
multidetector-row computed tomography. Radiat
Med. 2006;24(5):378-83
9. Acherman RJ, Siassi B, Pratti-Madrid G, Luna C,
Lewis AB, Ebrahimi M, Castillo W, Kamat P,
Ramanathan R. Systemic to pulmonary
collaterals in very low birth weight infants: color
doppler detection of systemic to pulmonary
connections during neonatal and early infancy
period. Pediatrics. 2000;105(1):528-32
10. Padhi SS, Bakshi KD, Shastri RK. Multiple coil
closure
of
isolated
aortopulmonary
collateral. Annals of Pediatric Cardiology. 2010;
3(1):65-67.

473
Tinmaswala et al.,

Int J Med Res Health Sci. 2015;4(2):471-473

DOI: 10.5958/2319-5886.2015.00091.0

International Journal of Medical Research


&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 2 Coden: IJMRHS
Copyright @2015
th
th
Received: 12 Jan 2015
Revised: 20 Feb 2015
Case report

ISSN: 2319-5886
Accepted: 29th Mar 2015

PRIMARY HEMANGIOMA OF A SUBMENTAL LYMPH NODE A RARE ENTITY


* Shri LakshmiS1, Durga PrasadD2, Subba Rao D3, PrasanthiC1, Vandana Gangadharan1, Kishore KumarC1
1

Assistant Professor, 2Professor and HOD, Department of Pathology, 3Associate Professor, Department of
Surgery, NRI Institute of Medical Sciences, Bheemunipatnam, Andhra Pradesh

*Corresponding author: Shri Lakshmi S Email: lakshmi2266@yahoo.co.in


ABSTRACT
Primary vascular tumors occurring in lymph nodes are extremely rare. Nodal hemangiomas are benign vascular
tumors that can occur at any age and seen mostly in females. It is usually asymptomatic, affects only one node,
and does not recur. Four histologic types of hemangioma have been identified: capillary/cavernous, lobular
capillary, cellular, and epithelioid. This case has been reported for its rarity
Key words: Hemangioma, Lymph node, Asymptomatic
INTRODUCTION
Benign vascular tumors arising primarily in the
lymph nodes are rare.[1,2,3] There have been few case
reports in literature.[1-10] Although benign nodal
vascular proliferations are uncommon, identifying
these entities can help to avoid misdiagnosing them
as malignant vascular tumors, which occur more
often within lymph nodes.[1,2,3]Hemangioma is one of
the four types of benign nodal vascular
tumors.[4,6] Although hemangioma is common in skin,
mucosa, and soft tissue, its occurrence in lymph
nodes is extremely rare. This case is very rare with
few cases being reported worldwide and brings to
notice the occurrence of such tumors in a lymph node
also. According to various published articles to date,
only 20 cases have been reported so far in the English
language medical literature. [4, 6] We are herewith
presenting another similar case.
CASE REPORT
A 45 year old woman came to the hospital with an
asymptomatic nodular mass in the submental region
present since the last six months. No other significant
clinical findings were present. HIV test was

seronegative. The swelling was freely mobile,


painless, measuring 2x1.5cm. Intraoperatively the
mass was easily enucleated with no evidence of any
haemorrhage or bleeding in the field of operation.
Gross and Microscopy: The well encapsulated
nodular mass measured 2x1.5x1cm Cut section
showed myxoid appearance. (Figures 1 and 2).Under
low magnification it showed a well encapsulated
nodular mass comprising of lobules of small capillary
vessels. Occasional larger vessels were seen. The
vessels were lined by plump endothelial cells with
some of them showing red blood cells within their
lumen. Most of the nodal parenchyma was effaced by
the vascular lesion with remnants of the residual
lymphoid aggregates underneath the capsule. The
lobules of tumor tissue were separated by pink
edematous to eosinophilic proteinaceous material.
There were no significant neutrophilic infiltrate, areas
of necrosis, cytological atypia or any significant
mitotic activity. The endothelial cells in the tumor
showed immunopositivity for CD31, CD34
confirming the vascular nature of the tumor.
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Fig 1: Well encapsulated nodular mass

Fig 2: Cut section shows well encapsulated lesion


showing edematous to myxoid areas
DISCUSSION
Hemangiomas most commonly occur in the skin but
can occur in all internal organs.[2,3]Vascular tumors of
lymph node are rare.[1-10]The age reported in the
literature for presentation of nodal hemangiomas
varies, ranging from 4.5 to 75 years.[4] There is a
female predominance, and usually only a single node
tends to be involved. Hemangiomas occur in both
peripheral and more centrally located lymph nodes,
such as supraclavicular, submental, cervical, axillary,
common iliac, pelvic, inguinal, and oral soft
tissue.[4,5]Intranodal hemangiomas present as an
asymptomatic, solitary palpable lymph node, or they
may be an incidental finding.[4,5]Some nodal
hemangiomas are diagnosed incidentally when lymph
nodes are surgically removed in a radical mastectomy
for breast cancer or radical hysterectomy for
endometrial adenocarcinoma, without any antecedent
radiotherapy.[4,6,7]Grossly, the size of the involved
lymph nodes ranges from 2 to 35 mm.

Microscopically, four histologic types have been


identified: capillary/cavernous, lobular capillary,
cellular, and epithelioid. Capillary/cavernous
hemangioma is more often centered on the lymph
node hilum or medulla with well-preserved nodal
parenchyma and is either, a well-defined or poorly
defined mass of closely packed capillaries or
cavernous vessels lined by flat endothelial cells, and
which can be empty or filled with blood. The lobular
capillary type can almost replace the entire nodal
parenchyma and has an appearance similar to a
pyogenic granuloma. Our case seems to be the
lobular capillary type. [4,5,6]The cellular type is
composed of closely packed, nearly solid to rarely
canalized, vascular channels that can be outlined by
periodic acidSchiff and reticulin stains. The
epithelioid type is characterized by plump endothelial
cells. In all types, no cytologic atypia, necrosis,
mitoses, or extravasated erythrocytes are present. The
endothelial cells in hemangioma show immuno
positivity for smooth muscle actin, CD31, CD34, and
factor VIIIrelated antigen. Our case was identified
as a lymph node because of the presence of a well
defined capsule, remnants of lymphoid aggregates
with
replacement
of
normal
architecture,
hemangiomas being unencapsulated tumors. [5]
Other vascular tumors and tumor-like conditions of
the lymph nodes include lymphangioma, epithelioid
vascular neoplasms, bacillary angiomatosis, vascular
transformation of the of the sinuses, and Kaposis
sarcoma from which it can be easily differentiated.
Surgical excision is curative in primary nodal
hemangioma. Although follow-up has not been
reported in all cases, in those with follow-up, no
recurrences have been documented for nodal
hemangiomas
CONCLUSION
Hemangiomas are benign and, therefore, must be
distinguished from malignant vascular tumors that
usually involve lymph nodes, especially Kaposi's
sarcoma which are more common in AIDS.
ACKNOWLEDGMENT
We acknowledge the help rendered by Vijaya
Medical Centre, Vishakapatnam and technical
services of Mr. Suryanarayana Laboratory Technician
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Int J Med Res Health Sci. 2015;4(2):474-476

Conflict of interest: Nil


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