Antiepileptics IJCRR

ISSN: 2231-2196 (Print)
ISSN: 0975-5241 (Online)

Internationally Indexed,
Peer Reviewed, Multidisciplinary
Scientific Journal
ICV: 4.18
“Let the Science be your passion”
International Journal of Current Research and Review

(IJCRR)
Section: Healthcare
Vol 04 / Issue 21 / November 2012

Frequency: Fortnightly
Language: English
Published by:
Radiance Research Academy,
Nagpur, MH, India
Aug 2012
I
J Editorial Board
C
Dr. Prof. Dato’ Proom Promwichit
Masterskill University, Malaysia
Dr. Nahla Salah Eldin Barakat
University of Alexandria, Alexandria, Egypt
Dr. Ann Magoufis
Ariston College, Shannon, Ireland
Dr. Pongsak Rattanachaikunsopon
R
Ubon Ratchathani University, Thailand
Dr. Chellappan Dinesh
International Medical University, Malaysia
Dr. R. O. Ganjiwale
Nagpur University, MH, India
Dr. Shailesh Wader
R
Nagpur University, MH, India
Dr. Alabi Olufemi Mobolaji
Bowen University, Iwo, Osun-State, Nigeria
Dr. Joshua Danso Owusu-Sekyere
University of Cape Coast, Cape Coast, Ghana
Dr. Okorie Ndidiamaka Hannah
University of Nigeria Nsukka, Enugu State
ISSN 0975-5241 Dr. Parichat Phumkhachorn
Ubon Ratchathani University, Thailand
IC Value of Journal: 4.18 Dr. Manoj Charde
Amravati University, MH, India
“Let the science be your passion” Dr. Shah Murad Mastoi
Lahore Medical and Dental College, Lahore,
Pakistan
Dr. Hitesh Wadhwa
Vol 4 / Issue 21 / Nov 2012
MD University, HY, India
1 International Journal of Current Research and Review

Vol. 04 issue 21 Nov 2012
I
J About International Journal of Current Research and Review (ijcrr)
International Journal of Current Research and Review (IJCRR) is one of the popular
fortnightly international multidisciplinary science journals. IJCRR is peer reviewed
C
indexed journal which is available online and in print format as well.
Indexed in: ScopeMed, Google Scholar, Index Copernicus, Science Central,

Revistas Médicas Portuguesas, EBSCO, DOAJ, BOAI, SOROS, NEWJOUR,
ResearchGATE, Ulrich's Periodicals Directory, DocStoc, PdfCast, getCITED,
SkyDrive, Citebase, e-Print, WorldCat (World's largest network of library content
and services), Electronic Journals Library by University Library of Regensburg,
SciPeople.
R
Aims and Scope:
IJCRR is a fortnightly indexed international journal publishing the finest peer-
reviewed research and review articles in all fields of Science and
Technology. IJCRR follows stringent guidelines to select the manuscripts on the
basis of its originality, importance, timeliness, accessibility, grace and astonishing
conclusions. IJCRR is also popular for rapid publication of accepted manuscripts.
R
Mission Statement:
To set a landmark by encouraging and awarding publication of quality research and
review in all streams of Science.
About the editors:

IJCRR journal management team is very particular in selecting its editorial board
members. Editorial board members are selected on the basis of expertise, experience
and their contribution in the field of Science. Editors are selected from different
countries and every year editorial team is updated. All editorial decisions are made
“Let the science be your passion” by a team of full-time journal management professionals.
IJCRR Award for Best Article:

IJCRR editorial team monthly selects one ‘Best Article’ for award among published
articles.
Vol
Vol42/ /Issue
Issue2112/ /Nov
Dec2012
2010
IJCRR is official publication of Radiance Research Academy, Nagpur, India
Administrative Office: Radiance Research Academy, 148, IMSR Building, Near

NIT Complex, Ayurvedic Layout, Umrer Road, Sakkardara, Nagpur, Nagpur-24,
MS, India. editor@ijcrr.com, www.ijcrr.com

I S.
N.
1
Title
Healthcare
Index
Prelimanary Study of Lung Functions in

Authors
Meenakshi
Page
No.
J
Athletes and Nonathletes in Marathwada Shyamsunder Sable, 57
Region Shyamsunder S.
Sable, U.S. Zingade,
A. N. Kowale
2 Comparitive Study of Conventional and B.R Ashwini,
Ultrasound-Guided Fine Needle Vernekar Sunita, 64
Aspiration Cytology of Thyroid in a Kulkarni Mohan H.,
C
Tertiary Care Center of North Karnataka T. Kiran
3 Physicochemical and Biological Ajij Ahmed, Nasreen
Properties of Adiantum Capillus-Veneris Jahan, Abdul 70
Linn: An Important Drug of Unani Wadud, Hashmat
System of Medicine Imam,
Syeda Hajera, Alia
Bilal
R
4 Diagnostic Dilemma due to Diverse Shrivastava Deepti,
Presentation of Tuberculosis: Series of 3 Patil Vijya, Bhute 76
Cases Sindhu, Mukherjee
Satarupa
5 Grip Strength and Hand Function Mohamed Faisal
Changes in Unilateral Cervical C.K., Nirmal 82
R
Radiculopathy Mathew, Lawrence
Mathias, Ajith S.
6 A Study on Modified Alvarado Scoring C.P. Ganesh Babu,
System in Diagnosing Acute E.M.J. Karthikeyan, 91
Appendicitis K. Bharaniraj Kumar
7 Role of Fine Needle Aspiration Agravat Amit H.,
Cytology in Salivary Gland Pathology Dhruva Gauravi A., 95
“Let the science be your passion” and its Histopathological Correlation: A Pujara Krupal M.,
two year Prospective Study in Western Sanghvi Hardik K.
India
8 Variant Axillary Artery – a Case Report Sharadkumar Pralhad
Sawant, Shaguphta 102
T. Shaikh, Rakhi
Milind More

I S.
N.
9
Title
Healthcare
Does Thermal Stress Alters the

Index
Authors
Hundekari Jagdish
Page
No.
J
Autonomic Functions in Men Exposed C., Bondade A.K. 109
to Heat?
10 Comparison Regarding Knowledge, Gunvanti B. Rathod,
Attitude and Practice of Blood Donation Pragnesh Parmar 114
between Health Professionals and
General Population
11 Accessory Spleen – A Case Report Pushpalatha M.,
C
Sujana M., 121
Sharmada K.L.
12 Oxidative Stress and Antioxidant Al- Ghonaim
Enzyme Status in Patients with Type 2 Mohammed I., 123
Diabetes Mellitus with and without Ramprasad N,
Coronary Artery Disease Abdel-Ghaffar
Mamdouh H.
13 Antiepileptics and Pregnancy: A Review Sanjay Kumar,
R
Biswa Bhusan 132
Mohanty, Divya
Agrawal, Pramila
Nayak, Shantilata
Patnaik, Jyotsna
Patnaik, Susanta
Kumar Mahapatra
R
14 Comparison of Post 24 Hours Effect of Shilpa Khandare,
Cooling and Sustained Passive Tushar J Palekar 144
Stretching as Treatment Techniques for
Reduction of Spasticity in Hemiplegics
using H-Reflex
15 Lower Respiratory Tract Infection- Supriya Panda,
Bacteriological Profile and Antibiogram B. Prema Nandini, 149
Pattern T.V.Ramani
“Let the science be your passion”

PRELIMANARY STUDY OF LUNG FUNCTIONS IN ATHLETES AND NONATHLETES IN
Meenakshi S. Sable et al
MARATHWADA REGION
PRELIMANARY STUDY OF LUNG FUNCTIONS IN

ATHLETES AND NONATHLETES IN MARATHWADA
REGION
IJCRR Meenakshi S. Sable1, Shyamsunder S. Sable2, U. S. Zingade1, A. N. Kowale1
Vol 04 issue 21
1
Section: Healthcare Dept. of Physiology, B J Medical College and Sasoon Hospital, Pune, M.S., India
Category: Research 2
Dept of Surgery, D Y Patil Medical College and Hospital , Pune, M.S., India
Received on: 26/08/12
Revised on:09/09/12 E-mail of Corresponding Author: meenakshisable@rediffmail.com
Accepted on:15/09/12
ABSTRACT
Aim: The aim of this study was to compare the effect of running training on lung functions of runners
and nonrunners and whether the regular exercise and training given to the runners improve the lung
functions or not. Methods: The subjects selected for this study were 40 runners and 40 nonrunners of
aged 18-21 years. The mean value of Ht and Wt of runners was 167.52+_6.449 (cm), 56.55+_6.97 (Kg)
and that of nonrunners were 161.87+_6.44 (cm), 57.17+_9.129 (Kg). Mean value of Ht in runners was
more than that of nonrunners due to regular physical activity and training. There was no difference in
wt in both groups.The mean values of Forced vital capacity (FVC), Forced expiratory volume (FEV1)
at one second and Maximum voluntary ventiliation (MVV) in runners were 3.73+_0.78(L)
3.39+_0.78(L) and 120.09+_25.8(L/MIN) respectively and in nonrunners were
3.16+_0.59(L),2.98+_0.53(L) and 88.74+_28.74(L/MIN). Results: There were significant increased in
FVC, FEV1and MVV in runners than nonrunners may be due to training there is improvement in the
lung functions and strengthing of respiratory of muscles
Keywords: Athletes Nonathletes
FVC FEV1
MVV
INTRODUCTION pulmonary change following training.Wasserman

Athletics is a great fun and people of all ages can et al 1995,Twisk et al 1998 who showed that
enjoy it.Running is the most natural of athletics following exercise athletes tend to have an
movements and common aerobic exercise. And increase in pulmonary capacity when compared to
have a profound effect on lung functions.Several nonexercising individuals especially when the
factors like Age, Height Weight, heredity, exercise is strenuous. This ventilatory adaptation
environment, diet, training, hormone status etc to exercise may differ in different populations
also contribute to the performance of sportsman such as Black and Caucasian subjects suggested
(1,2).There have been many studies documenting by Cerny 1987 particularly under different
Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Page 57
MARATHWADA REGION
climatic conditions that is it may be related to conducted in Dept of Physiology, GMC,

ethnic and environmental factors. Aurangabad.
Lung function test provide quantitative and The lung functions were recorded in Pulmonary
qualitative evaluation of pulmonary function and function test laboratory by Body Plethysmograph
are therefore of definitive value in the diagnosis (MEDGRAPHICS) USA, Elite DX-Model.Forced
and therapy of patients with cardiopulmonary vital capacity (L), Forced expiratory volume at one
disorders as well as those with obstructive and second (L), and Maximum voluntary ventilation
restrictive lung diseases shown by Belman and (L/MIN) were recorded.Statistical analysis was
Mittman 1980,Robinson and kjeldgaard 1982. done for all parameters ‘p’ value was determined
The parameters used to describe lung function are p>o.o5-nonsignificant, p<0.01-significant and
the lung volumes and capacities.while the various p<o.oo1-Highly significant ‘z’ test was applied for
lung volumes reflect the individual’s ability to comparison between two groups
increase the depth of breathing the capacities is
simply a combination of two or more lung RESULTS
volumes. Resuls are expressed as Mean+_Standard
The aim of present study was to compare the Devitation. Statistical significance was determined
values of lung functions in runners and nonrunners by’ Z’ Test. The mean value of significance was
and whether the regular training in the form of evaluated with ‘p’ values. The differences were
running improves the lung functions in runners. considered significance at p<0.001. Findings are
compiled and presented in tabular.
MATERIALS AND METHODS
The present study was conducted on 40 Runners DISCUSSION
and 40 nonrunners Aged-18-21 years. Runners Respiratory system is important system of human
selected were taking training under Sports body where gaseous exchange takes place with
Authority of India ,Krida prabhodini diffusion of enormous amounts of oxygen into the
Hostel,Aurangabad for short and middle distance blood during physical activity.It is first and
running event .Runners selected for this study furthermost organ in the body responding to
were training themselves by running a distance of change during exertional activities such as
2-3 km,two times a day for 45-60 min, 7 days a running, cycling, swimming etc.Increase in lung
st
week Nonrunners selected for this study were 1 volumes and capacities depends upon workloads
nd
and 2 MBBS students.They were not practicing or the intensity of training programme.
any athletics event .Informed consent was Many studies conducted on respiratory system
obtained from all participants.Clinically examined following training shows linear relationship with
to rule out any respiratory diseases .The study was different level of exercise programme.Odunuga et

Page 58
MARATHWADA REGION
al reported that among male athletes only male high in athletes than nonathletes.The proable
shot putters had a significantly higher vital reason for observation could be that following
capacity than male nonathletes suggesting that training there is increased requirement of oxygen
intensity of sports engaged in by the athletes in the working muscles which stimulates the
determines the extent of strengthening of chemosensitive area located bilaterally in the
respiratory muscles with resultant increase in lung medulla in turn stimulating the dorsal group of
volume and chronic exercise cause an increase in nucleus tractus solitaries which send strong signals
respiratory function which could be due to to inspiratory group of muscles which cause
increased development of respiratory musculature forceful inspiration and expiration .Repeated
incidental to physical training. forceful inspiration and expiration cause increased
Hagberg reported that values for static lung secretion of surfactant which decreases tension in
volume of accomplished marathoners and other alveoli and decreases physiological dead space this
endurance trained athletes were no different from in turn manifest increased lung volume and
those of untrained controls of comparable body capacities in athletes.
size. However Cordain 1990 reported larger than The purpose of this study is to investigate the
normal static lung volume in swimmers and possibility of change/adaption of lung function in
drivers when compared to normal nonathletes.This athletes who have regular exercise/trained for 2-3
was attributed to strengthening of the inspiratory hrs a day a 7 day a week and involved in sports for
muscles as they were against additional resistance more than 3-4 yrs. Hence results from the present
caused by weight of water that compresses the study suggest that the intensity or severity of
thoracic cage.Reports from other workers sports engaged by athlete probably determines the
Onadeko et al 1976, Bjorstorm 1987 also indicates extent of strengthening of respiratory muscles with
a significantly higher vital capacity in athletes resultant increase in lung volume and capacities
compared with nonathletes.
The conflicting finding may be due to genetic and CONCLUSION
ethnic factors as suggested by Lakhera and Klain The study validates the physiological adaptions in
1995 who compared pulmonary function amongst spirometric functions of respiratory system to
athletes in different Indian populations.The lung regular training programme.The effect of
function parameters were found to vary in strengthening of respiratory muscles resultant
different settings with results suggesting that the increase in lung volume and capacities with
size of lung is governed by genetic, environmental improved endurance of the body following regular
and nutritional factors. training is evident in a significantly increased in
In our study spirometric measurements i.e FVC, FEV1and MVV in athletes than nonathletes.
FEV1,FVC andMVV were found significantly

Page 59
MARATHWADA REGION
Highlighting the importance of regular training on 8. Hagberg JM.Pulmonary function in young and
respiratory functions and endurance of the body older athletes and untrained men: ZJ Appl
ACKNOWLEDGEMENT Physiol 1988;65:101-104.
Authors are grateful to 2005-2006 first MBBS 9. Cordain L: Lung volumes and maximal
batch and second MBBS batch GMC, respiratory pressures in collegiate swimmers
AUGANGABAD and athletes from SAi hostel and runners.Res Exer Sport 1990; 61: 70-77.
Aurangabad for their support and enthusiasm 10. Onadeko BO, Fulase AO: Pulmonary function
REERENCES studies in Nigerian
1. Seidman DS, Solev E, Deuster PA et al: sportsman.Atr.J.Med.sci.1976; 5:291-295.
Androgenic response to long term physical 11. Bjourstrom R.L: Control of ventiliation in
training.Jsports Med 1990;421-424. Elite synchronized swimmers.1987; 63:1091-
2. Dasgupta PK, Mukhopadhyay AK et al: A 1095.
study of cardiopulmonary Efficiency in 12. Lakhera SC, Kain TC: Comparison of
Different categories in Runners.Indian J pulmonary function amongst Ladakhi, Delhi,
Physiology Pharmac 2000;44(2):220-224. Varanasi and Siddhi boy
3. Wassreman K, Gift A,Wekel HE:Lung athletes.J.Physiol.pharmac 1996; 39(3):255-
function changes and exercise induced 258.
ventilator Responses to External Restive 13. Odunga AC, Jaja S: Some ventilator
Loads in Normal subjects.Respiration parameters in well trained Nigerial
1995;62(4):177-184. athletes.Nigerian Journal of physiological sci:
4. Twick IW, Staal BJ, Kemper HC et al: 1989;5:7-16.
Tracking of lung function parameters and 14. Williams C: Assessment of physical
Logitudinal Relationship with Life performance: ABC of sports
style.Eur.Resp.J. 1998 ; 12(3):627-634. Medicine.Br.Med.j.1994; 309: 180-186.
5. Beiman MJ, Miman C.Ventilatory Muscle 15. Pakkala A, Veerannan.A comparative study of
Training Improves Exercise capacity in COPD cardiopulmonary efficiency in athletes and
patients.AM Resp Dis.1980; 121:273-279. nonathletes.J.Indian Med Assoc.2005;
6. Robison EP, Kjeldgard JM: Improvement in 103(10):522-527.
ventilator Muscle function with 16. Leith DE, Bradley M: Ventilatory muscle
Running.J.Appl Physiol.1982; 52:1400-1405. strength and Endurance Training.J Appl
7. Cenry FJ.Breathing pattern during exercise in physiol.1976;41: 508-516.
young black and Caucasian subjects.J.Appl 17. Lakhera SC, Kain TC: Lung function in
physiology. 1987; 62(6):2220-2223. middle distance Adolescent

Page 60
MARATHWADA REGION
Runners.Ind.j.physiol.pharmac.1994; Nonathletes.Ind J Physiol Pharmac:

38(2):117-120. 1991;35(4):245-248.
18. Martin BJ.Slager JM: Ventilatory Endurance 20. DE AK, Debnath pk, RoY DC et al: A
in Athletes and nonathletes.Med.sci.sports comparison of physical efficiency between
Exercise 1981; 13(1):21-26. Indian physical education and Medical
19. Dasgupta PK, DE AK: Assessment of students.Brit.j .sports Med.1978; 12: 93-96.
cardiopulmonary efficiency in Athletes and
RESULT : Standard statistical analysis tests were applied in terms of mean &
SD, For comparison ‘Z’ test applied
Table 1: Comparison of age in runner and non runner group
Parameter Runner Non runner Z Value P Value
Mean ± SD Mean ± SD
(n=40) (n=40)
Age (Yrs) 19.07 ± 0.99 19.12 ± 0.96 0.22 >0.05
Multiple bar diagram showing comparison of age in runner and non

runner group
20
18
16
14
12
Average
10
8
6
4
2
0
Age (Yrs)
Runner Non runner
Table 2: Comparison of FVC in runner and non runner group

Parameter Runner Non runner Z Value P Value
(n=40) (n=40)
FVC (Lit) 3.73 ± 0.78 3.16 ± 0.59 3.65 <0.001*
*- significant
Multiple bar diagram showing comparison of FVC in runner and non

runner group
*-
*- significant
significant
3.5
2.5
Average
1.5
0.5
0
FVC (Lit)
Runner Non runner

Page 61
MARATHWADA REGION

Page 62
MARATHWADA REGION
Table 5: Comparison of height in runner and non runner group
Parameter Runner Non runner Z P Value

Value
(n=40) (n=40)
Height 167.52 ± 6.44 161.87 ± 7.04 3.75 <0.001*
*- significant
Multiple bar diagram showing comparison of height in runner and non
runner group
180
160
140
120
Average
100
80
60
40
20
0
Height (cm)
Runner Non runner
Table 6: Comparison of weight in runner and non runner group

Parameter Runner Non runner Z P Value
Mean ± SD Mean ± SD Value
(n=40) (n=40)
Weight 56.55 ± 57.17 ± 0.34 >0.05
(Kg) 6.97 9.12
>0.05-Not significant
Multiple bar diagram showing comparison of weight in runner and

non runner group
60
50
40
Average
30
20
10
0
Weight (Kg)
Runner Non runner
Medgraphics Body Plethysmograph Machine

Page 63
COMPARITIVE STUDY OF CONVENTIONAL AND ULTRASOUND-GUIDED FINE NEEDLE
B.R. Ashwini et al ASPIRATION CYTOLOGY OF THYROID IN A TERTIARY CARE CENTER OF NORTH
KARNATAKA
COMPARITIVE STUDY OF CONVENTIONAL AND ULTRASOUND-

GUIDED FINE NEEDLE ASPIRATION CYTOLOGY OF THYROID IN A
TERTIARY CARE CENTER OF NORTH KARNATAKA
IJCRR B.R Ashwini1, Vernekar Sunita2, Kulkarni Mohan H3, T. Kiran4

Vol 04 issue 21 1
Section: Healthcare Department of Pathology, Bangalore Medical College and Research Institute,
Bangalore, K.A., India
Category: Research 2
Karnataka Institute of Medical Sciences, Hubli, K.A., India
3
Received on: 08/08/12 Consultant Pathologist, Adhyapaknagar, Hubli, K.A., India
4
Revised on:19/08/12 Department of Gen Surgery, Rajarajeshwari Medical College and Research Institute,
Bangalore, K.A., India
E-mail of Corresponding Author: dr_ashwinibr@yahoo.co.in
ABSTRACT
Fine needle aspiration cytology (FNAC) is a minimally invasive and cost effective technique. However
some of the deep seated lesions may have occult carcinomas which could be missed on conventional
FNAC of a multinodular goitre or non–palpable nodules. Ultrasound guidance is helpful in directing
the needle to solid portions of the cystic or mixed nodules and reduce the need for repeat FNAs but
adds to cost and turn-around time of patient. Objectives: The study was conducted to compare the
results of conventional FNAC with Ultrasound (USG)-guided FNAC and correlate with histopathology
to evaluate the sensitivity, specificity and diagnostic accuracy of both types of FNAC. Materials and
Methods: The study was conducted on 140 patients who underwent conventional FNAC in the
department of Pathology and subsequently USG-guided FNAC in department of Radiology. Smears
were prepared from both the FNA and were reported separately by the same pathologist. Statistical
Indices used in the present study for both conventional and USG-guided FNAC with histopathology as
gold standard are Sensitivity, specificity, and diagnostic accuracy. Comparison of the FNAC results
with histopathology showed that there were five false negative results in conventional FNAC and two
false negative results in USG-guided FNAC. Results: The sensitivity and diagnostic accuracy were
77.8%, 92.9% on USG-guided FNAC and 44.4%, 82.1% on conventional FNAC. In conclusion, USG-
guided FNAC improved the cytological diagnostic accuracy, sensitivity and reduced the false-negative
rates in comparison to conventional FNAC especially in case of multinodular goitre.
Keywords: Conventional FNAC, USG-guided FNAC, Histopathological correlation, Sensitivity,
Diagnostic accuracy.
INTRODUCTION between benign and malignant lesions

Fine needle aspiration cytology (FNAC) of thyroid sonographically. An accurate diagnosis is
is a simple, cost effective method in the necessary to obtain results with surgery. USG-
management of palpable thyroid lesions1. Some guided FNAC has advantage of both specialities
cases have more than one lesion co-existing in but add to cost and turn around time to patients.
thyroid which could be missed on conventional The study was conducted in Department of
FNAC. Multiple revision surgeries are not Pathology at our institute with the aim of
possible on thyroid due to its location. Ultrasound identifying whether USG-guided FNAC is
(USG) simulates the gross appearance of thyroid significantly better in identifying the neoplasia
in the patient. However USG alone cannot be used than conventional FNAC. With this objective the
as gold standard as there are over lapping features diagnostic accuracy of USG-guided FNAC and

Page 64
KARNATAKA
conventional FNAC were compared with with histopathology as gold standard include
histopathology as the gold standard. Sensitivity = TP/ (TP+FN) X100, Specificity =
TN/ (TN+FP) X100, PPV= TP/ (TP+FP) X100,
MATERIALS AND METHODS NPV= TN/(TN+FN) X100, FPER =FP/total no of
The study was conducted from 1st October 2007 cases X 100, FNER = FN/Total no cases X 100,
to 31st march 2009, during which 417 thyroid Diagnostic accuracy = TP+TN/TP+TN+FP+FN
FNAC were done in the department of Pathology. X100 in order to evaluate their sensitivity,
Among them, 140 patients gave the consent for the specificity and diagnostic accuracy. (TP = True
study and underwent both conventional and USG- Positive, FP = False positive, TN = True Negative,
guided FNAC. All patients included in the study FN = False Negative, PPV= Positive predictive
were referred for FNAC with complaints of value, NPV=Negative predictive value,
thyroid swelling. No age and sex criteria were FPER= false positive error rate, FNER= false
included in the study. negative error rate)
Conventional FNAC was done in the Department
of Pathology. Subsequently USG was done with RESULTS
high frequency probe (5 to 12MHz transducer) in The thyroid aspirations were done on patients with
the department of Radiology, at our institution. an age range of two to seventy years with mean
The number of nodules, size and echogenecity age of 33.8 yrs. Majority of them were females
patterns were noted. FNAC was then repeated on accounting for 124 cases (88.6%) out of 140. Male
the patients under USG-guidance on a were 16 (11.4%). Aspiration was unsatisfactory in
representative or suspicious area. In both the three cases (2.2%), on conventional FNAC and in
methods, FNAC was done under aseptic one case (0.7%) on USG-guided FNAC. Non-
precautions using 22-gauze needle fitted to 5ml neoplastic lesions were more common in the
syringe without aspiration with patient in supine or present study on both conventional and USG-
sitting posture with neck extended. The material guided FNAC.
collected in the bore by capillary action. In some The various lesions found on conventional and
cases aspiration technique was used. The aspirate USG-guided FNAC were as in table 1. Differences
was then expressed on the clean glass slide and were found in the number of nodular goitre and
fixed with 95% alcohol and by air dry technique. neoplastic lesions in both FNAC. Nodular goitre
A minimum of four slides were smeared with the was the commonest lesion found on both
aspirate. The smears were then stained with conventional and USG-guided FNAC. Figure 1
Hematoxylin and Eosin (H&E), and Wright’s showing clear correlation between cytological
stain. The slides prepared from conventional findings and USG features of nodular goitre. Out
FNAC and USG-guided FNAC were reported of 140 cases histopathology was available in 28
separately by the same pathologist. Smears with cases. Histopathology showed 16 cases of nodular
atleast four clusters of follicular cells were goitre, one Hashimoto’s thyroiditis, two primary
considered adequate for reporting. Among 140 hyperplasia, five papillary carcinomas, three
cases, twenty-eight patients underwent surgery and follicular adenomas and one Hurthle cell adenoma.
thus histopathological correlation was obtained in The results of conventional FNAC and USG-
them. guided FNAC were correlated with
Histopathological results were correlated with histopathological diagnosis to know their
results of conventional FNAC and USG-guided sensitivity, specificity and diagnostic accuracy as
FNAC. Statistical Indices used in the present study histopathology forms the gold standard.
for both conventional and USG-guided FNAC

Page 65
KARNATAKA
Nineteen non neoplastic lesions and nine difficult-to-access locations, in nodules with
neoplastic lesions were reported on extensive cystic change, fibrosis or calcification.
histopathology. In comparison, out of 28 cases, USG-guidance is also helpful in directing the
conventional FNAC showed 24 non-neoplastic needle to solid portions of the cystic or mixed
lesions with 21 cases of nodular goitre, two nodules and reducing the need for repeat FNAC3.
primary hyperplasia and one Hashimoto’s The present study was undertaken to compare the
thyroiditis. There were four neoplastic lesions with results of conventional and USG-guided FNAC
three papillary carcinoma and one Hurthle cell with histopathology as gold standard to determine
neoplasm. USG-guided FNAC showed 21 non- their diagnostic accuracy.
neoplastic lesions with 18 cases of nodular goitre, The inadequacy rate of 2.2% was seen in
two primary hyperplasia, one Hashimoto’s conventional FNAC and 0.7% in USG-guided
thyroiditis and seven neoplastic lesions with four FNAC. The inadequacy rate was not statistically
papillary carcinomas, two follicular neoplasms, significant in our study in comparison to other
and one Hurthle cell neoplasm. Oncomparing the studies4,5. Majority of the cases were females with
results of conventional and USG-guided FNAC 124 cases. Among them 113 cases (80.7%) had
with histopathology, differences were found in non neoplastic lesions and eleven (7.9%) had
five cases as showed in table 2. There were no neoplastic lesions. Both neoplastic and non
false positive results in our study. The correlation neoplastic lesions were more commonly seen in
of conventional FNAC and USG-guided FNAC females comparable with other studies6,7. There
with histopathology showed four true positives, 19 were five false negative cases on conventional
true negatives and five false negatives on FNAC and two on USG-guided FNAC. The false
conventional FNAC. USG-guided FNAC showed negative error rates of 17.9% on conventional
seven true positives, 19 true negatives and two FNAC and 7.1% on USG-guided FNAC were
false negatives. The statistical evaluation with comparable with several other studies8,9. The
various parameters showed 44.4% sensitivity, cytological criteria for diagnosis of the lesions are
100% specificity, 100% PPV, 79.2% NPV and well defined but there can be overlapping
82.1% diagnostic accuracy on conventional FNAC cytological features, making the diagnosis of the
and 77.8% sensitivity, 100% specificity, 100% lesions and further more distinction between the
PPV, 90.4% NPV and 92.9% diagnostic accuracy neoplastic and non-neoplastic lesions difficult.
on USG-guided FNAC. USG show various patterns due to echogenic
variations in the lesions. These patterns include
DISCUSSION cyst with avascular colloidplug, blocks
It is a well-known fact that FNAC is safe, rapid, ofhyperechogenicity separated by bands of
inexpensive and reliable in the diagnosis of hypoechogenicity,uniform hyperechogenicity,
thyroid nodules2. It is possible to classify non- intense hypervascularity, hypoechogenicity,
neoplastic and neoplastic lesions with the help of isoechogenicity with or without halo, or nodules
FNAC and subtype them. However, some of the with intense peripheralvascularity.The absence of
deep seated lesions may have occult carcinomas features like calcification, halo, hypoechogenecity,
which could be missed on conventional FNAC of isoechogenecity and increased peripheral
a multinodular goitre or non–palpable nodules. In vascularity favors benignity. These patterns are
clinical practice, it is recommended that USG- sensitive in predicting the neoplastic lesions with
guidance should be sought after a failed varying specificity10. However in cases with
conventional FNA, in small nodules, in non- overlapping cytological features these USG
palpable nodules, in lesions that are located in patterns help in differentiating and providing more

Page 66
KARNATAKA
accurate cytological diagnosis of some of the reducing the turnaround time in the accurate
lesions. There were two false negative results on management of the patient.
conventional FNAC due to overlapping
cytological features particularly between nodular ACKNOWLEDGEMENT
goitre and follicular neoplasm as seen in other Dr G C Patil (Professor and Head), Department of
studies11. Figure 2 shows a case with features of Radiodiagnosis, Karnataka Institute of medical
both nodular goitre and follicular neoplasm sciences, Hubli. The authors acknowledge the
cytologically and USG showing features of immense help received from the scholars whose
follicular adenoma supporting the diagnosis of articles are cited and included in references of this
follicular neoplasm. Histopathology confirmed a manuscript. The authors are also grateful to
diagnosis of follicular adenoma in this case. authors/editors/publishers of all those articles,
Cellular microfollicular patterns are seen in journals and books from where the literature for
hyperplastic microfollicular nodule of a this article has been reviewed and discussed.
multinodular goitre, Hashimoto’s thyroiditis,
microfollicular adenomas and a well differentiated REFERENCES
follicular carcinoma and are the most challenging 1. Klemi PJ, Joensuu H. FNAC in the diagnosis
ones in diagnosing cytologically12. In our study of the thyroid nodules. ActaCytol
features of nodular goitre was seen on 1991;35:434-38
conventional FNAC in a patient in whom USG 2. Cappel RJ, Bouvy ND, Bonjer HJ,
examination showed a single hypoechoic area in Muiswinkel JM, Chadha S. Fine needle
left lobe of thyroid. Aspiration from this area aspiration of thyroid nodules: How accurate it
under USG-guidance showed features of papillary is and what are the causes of discrepant cases?
carcinoma as in figure 3. Histopathological Cytopathology 2001;12:399-405
diagnosis of micropapillary carcinoma was made 3. TamasSolymosi, GyulaLukacsToth,
in this case. The results obtained in our study MiklosBodo. Diagnostic accuracy of Fine
showed that the sensitivity and the diagnostic Needle Aspiration Cytology of Thyroid.
accuracy of USG-guided FNAC was more than the Impact of Ultrasound and
conventional FNAC and was comparable with Ultrasonographically Guided Aspiration.
other study13. ActaCytol 2001;45:669-74
In conclusion, thyroid is an organ where multiple 4. Izquierdo R, Arekat MR, Knudson PE, Kartun
revision surgeries are not possible and it is also KF, KhuranaK,et al. Comparison of palpation
difficult to obtain the patient’s consent for the versus ultrasound guided FNAB of thyroid
same. The cytological criteria for identification of nodules an outpatient endocrinology practice.
a lesion are well defined. But some cases show EndocrPract 2006;12:609-14
overlapping cytological features of different 5. Cai XJ, Valiyaparambath N, Nixon P,
lesions. USG-guided FNAC as an added Waghorn A, Giles T, et al. Ultrasound-guided
advantage of a multi-modality approach and aids fine needle aspiration cytology in the
in providing a more accurate diagnosis of the diagnosis and management of thyroid nodules.
lesion or the lesions in thyroid. In our study USG- Cytopathology 2006;17:251-56.
guided FNACreduced the false-negative rates in 6. Martinek, J.Dvorackova, M.Honka, J.Horacek,
the diagnosis of the neoplastic lesions, in Klvana. Importance of Guided FNA for the
comparison to conventional FNAC and improved Diagnosis of thyroid nodules-Own
the sensitivity and diagnostic accuracy especially experiences. Biomed Pap Med
in cases of multinodular goitre and thereby

Page 67
KARNATAKA
FacUnivPalacky Olomouc Czech Repub Can Be Left Alone? AJR Am J Roentgenol

2004;148:45-50. 2009;193:207-13
7. Lin JD, Hsueh C, Chao TC, Weng HF, Huang 11. H. R Harach, Silvia B. Zusman, E. Saravia
BY. Thyroid Follicular Neoplasms Diagnosed Day. Diagnostic Dilemma. Nodular goiter: A
by High-Resolution Ultrasonography with histo-cytological study with some emphasis on
Fine Needle Aspiration Cytology. ActaCytol pitfalls of fine-needle aspiration cytology.
1997;41:687-91. DiagnCytopathol 1992;8:409-19
8. Suen KC, Abdul-Karim FW, Kaninsky DB, 12. Nugen GK, Lee MW, Ginsberg J, Wragg T,
Layfield LJ, Miller TR et al. Guidelines of the Bilodeau D. Fine Needle Aspiration Of
Papinicoloau Society of Cytopathology for the Thyroid: An Overview. Cytojournal 2005;2:12
examination of Fine Needle Aspiration 13. Danese D, Sciacchitano S, Farsetti A,
Specimen from Thyroid Nodules. Mod pathol Andreoli M, Pontecoryi A. Diagnostic
1996;9:710-15. accuracy of conventional versus sonography-
9. John Boey, C.Hsu, Robert J.Collins. False guided fine-needle aspiration biopsy of thyroid
negative errors in Fine needle aspiration nodules. Thyroid 1998;8:15-21.
biopsy of dominant thyroid nodules: A
prospective follow up study. World J Surg
1986;10:623-30
10. John A. Bonavita, Jason Mayo, James Babb,
Genevieve Bennett, ThairaOweity et al.
Pattern Recognition of Benign Nodules at
Ultrasound of the Thyroid: Which Nodules
Table 1: Table showing various lesions obtained on both conventional and USG-Guided FNAC
Lesions Conventional FNAC USG-Guided FNAC
Nodular Goitre 91 (65%) 88 (62.9%)
Hashimoto’s thyroiditis 27 (19.3%) 29 (20.7%)
Primary Hyperplasia 5 (3.7%) 5 (3.7%)
Dyshormonogenic goitre 2 (1.4%) 2 (1.4%)
Acute thyroiditis 1 (0.7%) 1 (0.7%)
Follicular neoplasm 3 (2.1%) 5 (3.6%)
Papillary carcinoma 6 (4.3%) 7 (5.0%)
Anaplastic carcinoma 1 (0.7%) 1 (0.7%)
Hurthle cell carcinoma 1 (0.7%) 1 (0.7%)
Inadequate sample-no opinion 3 (2.1%) 1 (0.7%)
Table 2: Table showing cases with a false negative results on conventional and USG-guided FNAC
Diagnosis on Diagnosis on US-
No of cases Histopathology Diagnosis
Conventional FNAC Guided FNAC
2 Nodular goitre Follicular neoplasm Follicular adenoma
Micropapillary
1 Nodular goitre Micropapillary Carcinoma
Carcinoma
1 Nodular goitre Nodular goitre Follicular adenoma
1 Nodular goitre Nodular goitre Micropapillary Carcinoma

Page 68
KARNATAKA
Fig 1: [A]: Mixed echoic lesion with specks of

calcification in thyroid. [B]: Gross showing colloid
filled nodules with specks of calcification on the Fig 3: [A]: Arrow showing 0.5 cm hypoechoic area
septa. [C& D]: FNAC from different area showing in left lobe of thyroid [B]: Gross of corresponding
clusters of follicular cells with cyst macrophages. area showed gray-white areas. [C,D]: US-Guided
Wright’s stain 10x. FNAC from hypoechoic area showed features of
papillary carcinoma with INC†. Wright’s stain 40x. †
Intra nuclear inclusion
Fig 2: [A]: Single well circumscribed hypoechoic

lesion. [B]: Gross of corresponding area showed well
circumscribed grey white area. [C]: FNAC showed
microfollicles. Wright’s stain 10x [D]: Anisocytosis
with honeycomb pattern. Wright’s stain 10x.

Page 69
PHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF ADIANTUM CAPILLUS-VENERIS LINN:
Ajij Ahmed et al
AN IMPORTANT DRUG OF UNANI SYSTEM OF MEDICINE
PHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF

ADIANTUM CAPILLUS-VENERIS LINN: AN IMPORTANT DRUG OF
UNANI SYSTEM OF MEDICINE
IJCRR
Vol 04 issue 21 Ajij Ahmed1, Nasreen Jahan1, Abdul Wadud1, Hashmat Imam2,
Section: Healthcare Syeda Hajera3, Alia Bilal1
Category: Review 1
Dept. of Ilmul Advia, National Institute of Unani Medicine, Kottigepalya, Magadi
Received on: 06/09/12 Main Road, Bangalore, K.A., India
2
Dept. of Tahaffuji Wa Samaji Tib, National Institute of Unani medicine,
Revised on:15/09/12
Kottigepalya, Magadi Main Road, Bangalore, K.A., India
Accepted on:23/09/12 3
Dept. of Obs. and Gynaecology, Govt. Nizamia Tibbi College, Charminar,
Hyderabad, K.A., India
E-mail of Corresponding Author: aziznium@gmail.com
ABSTRACT
The aim of the present paper is to provide information regarding the therapeutic uses and scientific
studies carried out on Adiantum capillus-veneris Linn. The key words used for the literature search
were Adiantum capillus-veneris, Parsioshan, physico chemical, phytochemical and pharmacological
study. The search was carried out through Unani classical books, ethno botanical literature and Google
scholar. The drug is popularly known as “Parsiaoshan” in Unani and used to treat a number of diseases.
It is traditionally used as a diuretic, resolvent, antipyretic, demulcent, emmenagogue, expectorant and
deobstruent. It is also useful in the treatment of hair fall and skin diseases. Chemical analysis of
Parsioshan shows that it contains triterpenoids, flavonoids and various other constituents. Research
studies have shown that it possesses anti fungal, anti inflammatory, anti bacterial, hypoglycemic and
lithotriptic activities. An extensive review of ancient literature of Unani medicine revealed that the drug
having numerous therapeutic actions, several of which have been established scientifically which may
help the researchers to set their minds for approaching the utility, efficacy and potency of Adiantum
capillus-veneris.
Key Words: Adiantum capillus-veneris, Parsioshan, Physico Chemical, Phytochemical and
Pharmacological study
INTRODUCTION fascinating group of pteridophytes is distributed in

As folk medicine, the pteridophytes which the Himalaya, Western Ghats, and Vindhya, hilly
constitute ferns and fern allies have been known to areas of Bihar, Orissa and Madhya Pradesh as well
man for more than 2000 years and also have been as in the Aravalli, particularly in Mount Abu in
mentioned in ancient literature. It has been Rajasthan2. Adiantum capillus-veneris Linn is a
observed that pteridophytes are not infected by graceful delicate fern of damp places, found
microbial pathogens, which may be one of the chiefly in the western Himalayas, ascending to an
important factors for the evolutionary success of altitude of 2,400 m, and extending into Manipur. It
pteridophytes and the fact that they survived for is common in Punjab, Bihar, Maharashtra, and
more than 350 million years1. south India. It grows among rocks and on walls3, 4.
Fern and fern allies, also known as botanical Theophrastus (327-287B.C.) and Dioscorides
snakes or plant reptiles, have always been in the (100A.D.) have referred to medicinal attributes of
center stage of attraction to botanist, horticulturists certain ferns. Adiantum capillus-veneris Linn is
and nature lovers since ancient times. This

Page 70
Ajij Ahmed et al
one such fern whose medicinal values have long and resolvent, useful for clearing the primaviae of
been mentioned by Sushrata and Charaka5. bile, and phlegmatic humors; also, expectorant,
diuretic, emmenagogue, and alexipharmic
Taxonomical Classification6 properties are also ascribed to it. Used as a plaster,
Kingdom : Plantae it is considered to be discutient, and is applied to
Division : Pteridophyta chronic tumours of various kinds. Theophrastus
Class : Pteridopsida mentions two kinds of Adiantum, “white” and
Order : Pteridales “black,” used in making hair oil. Greek synonyms
Family : Adiantaceae for the plant are polytrichon, calitrichon,
Genus : Adiantum trichomenis, and ebinotrichon8.
Species : cappilus- veneris
Geographical Distribution
7
Vernaculars A native of tropical America Adiantum capillus-
Arabic : Shairuljin, Shaar-ul-jibal, Shaar-ul- veneris Linn found throughout the world in moist
arz and shady places. In India it is distributed in Tamil
Ayurvedic : Hansaaraja, hansapadi Nadu up to 1800 meter on the mountains,
English : Maiden hair fern, Maria’s fern, Our Himalaya and in north India9.
Lady’s hair
Gujarati : Hanspadi Botanical Description
Hindi : Hansraj, Mubaraka, Pursha Adiantum capillus-veneris is a delicate graceful
Kannada : Hansraj fern. Stipes is blackish, 10-23 cm long10. Fronds
Persian : Sirsiapeshane bipinnate with short terminal pinna and numerous
Tamil : Seruppadai erect patent lateral ones on each side, the lowest
Kashmir : Dumtuli being slightly branched; segments cuneate, 1.5-2.5
Urdu : Persia – ushan cm broad; sori borne at the roundish sinuses of the
Unani : Barsioshan, Kazbaratul Ber crenations, obreniform or rounded 4,5.
History Pharmacological Actions and Uses in Unani

As early as in 100 A.C. Dioscorides described Literature
Adiantum capillus-veneris by the name of It has Dafe humma (antipyretic), Mulattif
Adiavrov for having leaves serrated at the top like (demulcent), Munaffise balgham (expectorant),
coriander. The Western Arabs, however, appear to Mudire baul (diuretic), Mudirre haiz
use Adiantum capillus-veneris, as they call the (emmenagogue), Muhallil (resolvent) and Mujaffif
plant Kuzburat-el bir or “coriander of the wall”, (siccative) properties11, 12. The whole herb is used
indicating a habitat where A. venestum is not as medicine in various forms like decoction,
found. Other Arabic names for the genus powder, paste, oil etc. in different aliments. The
Adiantum are shaar-el-jinn i.e. “fairies hair”, whole plant is used as a hair tonic. Decoction in
shaar-el-jibal i.e. “hair of the mountains”; shaar- wine is given in cases of hard tumors of spleen,
el-fual i.e. “hair of omens”; sak-el-aswad i.e. liver and other viscera. The fronds are powdered
“black stem” and Nasif-el-aswad i.e. “black veil,” and given with honey against bad cold. It is also
Ibn Sina and other medical writers describe the useful in splenic pain and jaundice. It expels the
drug under the name of Barsiawashan, which is stone from the kidneys and bladder. It is
the Arabic form of its Persian name therapeutically used to promote diuresis. Due to its
Parsiawashan. It is considered to be deobstruent mucilaginous, pectoral and expectorant properties,

Page 71
Ajij Ahmed et al
its decoction is used in breathing difficulties, Reaction of chemicals with crude powdered
bronchitis, and cough. Along with vinegar and drug
olive oil it is useful in alopecia and with the oil of Chemicals Observations
Habbul Aas it is useful in maintenance of hair Powder treated with An emulsion formed
colour and hair loss. It is also useful in insect and water
dog bite9, 11, 12, 13, 14. Powder shaken in a test No frothing, floats
tube with water partially
Powder treated with 5% Turns dark chocolate
Ethnomedicinal Uses NaOH brown
It is used as demulcent, expectorant, astringent, Powder treated with Turns dark blakish
antitussive, diuretic, and emmenagogue, febrifuge 66% H2SO4 brown
and also as a hair tonic5, 15, 16, 17. In Punjab, the Powder pressed between No oily stain appears
fronds are given with pepper as a febrifuge; two filter papers
pounded with honey, they are administered in
catarrhal affections. They are smoked to relive Identity, purity, strength and assay
cold. The dried fronds are used as a substitute for Foreign organic matter Nil
tea. The herb is used as a pectoral, and also in Purity 100%
catarrhal affections. It is reported to be used as a
hair tonic. The fern is boiled in wine or mead, and Physico chemical constants (%)
drunk in case of hard tumors in the spleen, liver Loss on drying at 105ºC 7.36
and other visceras4. Its decoction is also used to Solid contents 74.48
remove dandruff. Fresh leaves are boiled in water
along with sugar; one cup of this decoction is Ash values
taken orally twice a day for a week to treat Total ash 7.81
jaundice and hepatitis15. The fronds are chewed for Acid insoluble ash 4.42
the treatment of mouth blisters. Frond extract Water soluble ash 0.42
mixed with honey is used as an eye ointment18.
Successive extractive values (%)
Physico Chemical Studies 9 Pet. Ether (60-80º) 4.49
Study of the powdered drug Chloroform 3.03
The powder is fine and a bit fluffy in texture. It is Acetone 4.60
dark brownish green in colour and has no taste. Ethanol 9.27
The powder after being cleaned in charcoal Distilled water 14.07
hydrate, when observed under microscope,
showed mostly fragments of leaves and petioles Phytochemical Studies 19
mostly with no distinguishing character. A very Nine new compounds were identified in the
few isolated pieces of sporangial wall with twenty-two isolated triterpenoids, from the fresh
characteristic transverse thickening were also fronds of Adiantum capillus-veneris Linn collected
visible. Occasional triangular spore tetrads were in Japan. The plant of Chinese and Egyptian origin
also present. Reaction of chemicals with crude were also identified with the two new triterpenoids
powdered drug and fluorescence analysis (Table 1) each as 4a -hydroxyfilican- 3-one and fern-9 (11)-
are as follows: en-12b –o and oleanane triterpenoids; olean-12-
en-3-one and olean-18-en-3-one19.
Four triterpenoidal compounds belonging to
adiantane and filicane groups, isoadiantone;

Page 72
Ajij Ahmed et al
isoadiantol-B; 3-methoxy-4-hydroxyfilicane and Salmonella arizonae, Salmonella typhi and

3,4-dihydroxyfilicane, from the hexane fraction Staphylococcus aureus strains of Bacteria.
and three flavonoids from the ethyl acetate
fraction as: quercetin , quercetin-3-O-glucoside Anti inflammatory activity
and quercetin-3-O-rutinoside (rutin) were Alcoholic extract of A. capillus-veneris and its
identified in Chromatographic fractionation of the hexane fraction showed a significant anti-
alcoholic extract of the dried fronds of Adiantum inflammatory activity against formalin induced
capillus-veneris Linn. The identification of the inflammation. The hexane fraction and compounds
isolated compounds has been established through 3, 4 showed topical anti-inflammatory activity
their physical, chemical and spectroscopic after 6 h and continued for 30 h in croton oil-
methods including IR, 1H NMR, 13C NMR, induced inflammation23.
HSQC, HMBC, NOESY and MS 23. The ethyl acetate fraction of the ethanolic extract
of A. capillus-veneris showed significant
Scientific Reports inhibition of hind paw oedema induced by
Antifungal Activity carrageenan when evaluated for its anti-
The water extracts and extracted phenols from inflammatory activity 24.
gametophytes and different parts of sporophytes Analgesic activity
of, Adiantum capillus-veneris L. was investigated The analgesic activity of the ethanolic extract of A.
for its antifungal activity and found to be bioactive capillus-veneris and its fraction has been carried
against Aspergillus niger and Rhizopus stolonifer. out by tail flick method and writhing test result
Antifungal activity was found to be higher in showed significant analgesic activity with
gametophytes. Among the different parts of insignificant ulceration as compared to the
sporophytes, immature pinnule possesses highest standard drug 24.
fungi static property20. Hypoglycemic activity
Antioxidant activity The alcoholic extract of A. capillus-veneris
Antioxidant potential of leaf extract of Adiantum showed a significant hypoglycaemic effect in
capillus-veneris Linn was studied in vitro by Anil OGTT using rabbit model. Started after 30 min
Kumar, against H2O2 induced oxidative damage in and continued for 4 hours23.
peripheral blood lymphocytes. Pre treatment with Lithotriptic activity
plant leave extract for 18 hours could effectively In vitro antilithiasic activity of hydro alcoholic
inhibited lipid peroxidation and enhanced the extract of Adiantum capillus-veneris was
activities of antioxidant enzymes and glutathione evaluated by crystallization, aggregation and
content significantly. The results indicate that it nucleation assays. The result showed significant
might be due to its direct action in scavenging free inhibition of crystallization and aggregation which
radicals and thereby modulating the antioxidant was further confirmed by in vivo study against
defence system21. Ethylene glycol (0.75%) and ammonium chloride
Antibacterial activity (1%) induced Urolithiasis in male Sprague Dawley
Pradeep investigated the in vitro antibacterial rats. Urine microscopy showed significant
activity of twelve important pteridophytes plants reduction in the number of crystals in test groups
25
by disc diffusion method. The aqueous and .
alcoholic leaves extract of Adiantum capillus-
DISCUSSION
veneris Linn were found to be effective against
The present review reveals that Adiantum capillus-
Agrobacterium tumefaciens, Escherichia coli,
veneris Linn is used in treating various ailments.
Recent ethno botanical, phytochemical and

Page 73
Ajij Ahmed et al
pharmacological studies have reported the Division, Lucknow: National botanical

medicinal values of Adiantum capillus and its research institute, India.
active constituents. This review provides evidence 2. Sharma NK. Ethno medicinal Studies on Ferns
based scientific validation to some of the and Fern Allies of Hadoti Plateau, South
therapeutic uses and actions described for Estern Rajasthan. Zoo’s Print Journal 2002;
Parsioshan in classical texts of Unani medicine. It 17(3): 732-4.
is popularly used as diuretic and for the treatment 3. Anonymous. The wealth of India. Volume- I:
of kidney stone in Unani system of medicine since A. New Delhi: National institute of Science
long. Its pharmacological activities like anti Communication and Information Resources
oxidant21, anti bacterial22, anti-inflammatory24, (CSIR); 2003. p. 79-80
lithotriptic activities25 clearly justify its therapeutic 4. Chatterjee A, Pakrashi SC. The treatise on
efficacy in nephrolithiasis. It is further suggested Indian medicinal plants. Vol 1. New Delhi:
that phytochemical and pharmacological studies National institute of Science Communication
on some of the less known or controversial Unani and Information Resources(CSIR); 2005.p. 8
drugs may be taken up on priority basis not only to 5. Parihar P, Leena p. Some pteridophytes of
scientifically validate therapeutic uses , but revive medicinal importance from Rajasthan. Natural
the faith and confidence of Unani practitioners in Product Radiance 2006; 5(4): 297-301
its actions to serve the large strata of the rural 6. www.usda.gov/java/namesearch (natural
society. resource conservation service, USA Dept. of
Agriculture. (Cited on 13-4-2012)
CONCLUSION 7. Kirtikar KR, Basu BD. Indian medicinal
This article briefly reviews the traditional plants with illustration. 2nd edi. Vol-11th.
knowledge and ethno medicinal reports on Dehradun: International Book Distributors;
therapeutic activities of the plant Adiantum 2003. p. 3747-49
capillus-veneris Linn. The physicochemical, 8. Dymock W, Warden CJH, Hooper D.
phytochemical and pharmacological studies of this Pharmacographia Indica vol- III. New Delhi:
plant provide a scientific basis for its therapeutic Srishti book Distributors; 2005. p. 624-25
use. 9. Standardisation of single drugs of Unani
medicine, part II. New Delhi: CCRUM; 1992;
ACKNOWLEDGEMENT p.240- 47.
Authors acknowledge the immense help received 10. Narayan DP, Purohit S, Arun K. Sharma,
from the scholars whose articles are cited and Tarun K. A hand book of medicinal plants, a
included in references of this manuscript. The complete source book Jodhpur: Agrobios
authors are also grateful to authors/editors/ India; 2009. P. 17
publishers of all those articles, journals and books 11. Abu Sayeed BAM. Kitab al fatah fi al – tawdi
from where the literature for this article has been (Urdu translation). Ist edi. New Delhi: Jamia
reviewed and discussed. Hamdard; 2007. p. 66
12. Hakim IHB. Kitabul mukhtarat fil Tib (Urdu).
REFERENCES Published by New Delhi: CCRUM; 2005. Vol
1. Singh M, Singh N, Khare PB, Rawat AKS. II, p.77 Vol III. p.321-25
Antimicrobial activity of some important 13. Hakim MK. Ilmul Advia Nafisi. New Delhi:
Adiantum species used traditionally in Aijaz Publishing House; 2007. p. 255-56.
indigenous systems of medicine.
Pharmacognocy and Ethno pharmacology

Page 74
Ajij Ahmed et al
14. Central council of research in Unani Medicine. extracted phenols from gametophytes and
Qarabadin Sarkari. 2nd edi. New Delhi: sporophytes of two species of Adiantum.
CCRUM; 2006. p. 30 Taiwania, 2005; 50 (4): 272-83.
15. Arsahd MA, Khan MA, Ahmad M, Zafar M, 21. Pourmorad F, Hosseinimehr SJ, Shahabimajd
Khan H, Muhammad N et al., Medicinal N. Antioxidant activity, phenol and flavonoid
plants used for the treatment of jaundice and contents of some selected Iranian medicinal
hepatitis based on socio-economic plants. African Journal of Biotechnology 2006
documentation. African Journal of June; 5 (11): 1142-45.
Biotechnology 2009 April 20; 8 (8): 1643-50 22. Pradeep P, Leena P, Bohra Achaleshwar. In
16. Khare CP. Indian medicinal plants an vitro antibacterial activity of fronds (leaves) of
illustrated dictionary. New York: Springer some important pteridophytes. Journal of
Science Media; 2007. p.19-20 Microbiology and Antimicrobials 2010
17. Ambasta SP. The useful plants of India. New March; 2 (2): 19-22
Delhi: National Institute of Science 23. Ibrahim ZZ, Ahmed AS, Gouda YG.
Communication and Information Resources Phytochemical and biological studies of
Council of scientific and industrial research; Adiantum capillus-veneris L. Saudi
2006. p. 15 Pharmaceutical Journal 2011 January 7; 1-10
18. Upreti K, Jewan SJ, Tewari LM, Joshi GC, 24. Haider S, Nazreen S, Alam, MM, Gupta A,
Pangtey YPS, Tewari G. Ethno medicinal uses Hamid H, Alam MS. Anti-inflammatory and
of pteridophytes of Kumaun Himalaya, anti-nociceptive activities of
Uttrakhan, India. Journal of American Science hdroalcoholicextract and its various fractions
2009; 5(4): 167-70 from Adiantum capillus veneris Linn. Journal
19. Takahisa N, Yoshiko M, Hideharu E, Yoko A, of Ethnopharmacology 2011; 138: 741-747
Kazuo M, Akihito T et al., fern constituents: 25. Ahmed SA. Antilithiasic activity of
Triterpenoids from Adiantum capillus-veneris Parsiaoshan in experimental models
. Chem. Pharm. Bull. 2002; 50 (9): 1273-75 [dissertation]. Nationa Institute of Unani
20. Piyali G, Mukhopadhyay R, Gupta K. Medicine: RGUHS, Bangalore; 2012.
Antifungal activity of the extracts and
Table 1: Fluorescence analysis of the powdered drug
Observation under
Ultra violet
Treatment Ordinary light
light
Powder as such Dark dull green colourless
Powder treated with 1N Dark brown colourless
NaOH in methanol
Powder treated with 1N Dark brown colourless
NaOH in water
Powder treated with 1N Hcl Brown colourless
Powder treated with 50% HNO3 Dark cherry brown colourless
Powder treated with 50% H2SO4 Dark brownish green colourless
Powder mounted in nitro cellulose in amyl acetate Almost black colourless
Powder treated with 1N NaOH in methanol, dried and then mounted
in nitrocellulose in amyl acetate Dark chocolate colourless
brown
Powder treated with 1N NaOH in water, dried and then mounted in Dark brown colourless
nitrocellulose in amyl acetate

Page 75
DIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION OF TUBERCULOSIS: SERIES OF 3
Shrivastava Deepti et al
CASES
DIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION

OF TUBERCULOSIS: SERIES OF 3 CASES
IJCRR Shrivastava Deepti, Patil Vijya, Bhute Sindhu, Mukherjee Satarupa

Vol 04 issue 21
Section: Healthcare
Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College,
Category: Case Report
AVBRH, DMIMS Sawangi, Meghe, Wardha
Revised on:07/09/12
Accepted on:17/09/12 E-mail of Corresponding Author: deepti_shrivastava69@yahoo.com
ABSTRACT
Tuberculosis is still a common culprit for illhealth in India, particularly in rural areas. For infertility
and other gynaecological disorders we routinely rule out any possibility of it but less stress is given for
its co-incidental association in obstetric patients High degree of suspicion remains the only tool in
some cases .We are hereby presenting 3 cases of tuberculosis presented altogether differently, along
with obstretic conditions.
Key Words: Tuberculosis, Infertility, Gynaecological disorders
INTRODUCTION with 4-5 episodes of vomiting per day. She was

Tuberculosis is the leading infectious disease in married since 3 months with her menstrual cycles
the world. In developing countries and certain being regular with scanty flow. On examination,
areas of industrialized countries, rates of she was thin built. Her other findings and routine
tuberculosis are highest among women and men of antenatal investigations were within normal limits.
childbearing age. Tuberculosis (TB) and Ultrasound showed single live intrauterine
pregnancy are two different types of stresses pregnancy of 7.5 weeks gestation with good
experienced by women. Their simultaneous cardiac activity. She was prescribed folic acid and
presence affects them both physically and doxylamine tablets. She returned back after 2 days
mentally. India accounts for 30% of the burden of with increasing episodes of vomiting, her general
all TB cases in the world1.A early diagnosis of TB condition appeared poor, hence was advised
infection in a pregnant woman is important as admission, but as patient was not willing for
Infant and maternal mortality are between 30% admission, she was prescribed oral hydration with
and 40% in untreated active TB cases. glucose supplements and anti-emetics, after urine
However, unfortunately the diagnosis of TB ketone examination revealed negative. She
during pregnancy is usually delayed (for 2–30 returned again after 2 days with uncontrolled
weeks) because of its non-specific symptoms and vomiting and severe abdominal pain. Her general
protean manifestation. Up to 20% of pregnant condition was further poor and tenderness over the
women with TB are asymptomatic or have only abdomen was present with mild distention.
atypical symptoms2. Here we are presenting 3 Ultrasound was repeated which suggested
cases of tuberculosis with different presentations. distended bowel loops with intrauterine pregnancy
of 8 weeks with absent cardiac activity. Surgeons‟
CASE REPORTS opinion was obtained and on abdominal x-ray,
Case 1 multiple gas-fluid levels were seen. Laparotomy
A 23 year old primigravida attended the antenatal along with D& E was planned. Resection
clinic with history of amenorrhea since 2 months anastomosis of small intestine was done due to

Page 76
CASES
stricture present at terminal ileum along with history of receiving AKT 10 years back. Opinion
multiple fibrous adhesions, which later on of Chest physician was sought, all 3 samples of
confirmed as Koch‟s abdomen on histopathology sputum AFB were negative. She was diagnosed as
and microbiology of resected part of ileum where Category1, seriously ill, smear negative
typical caseating granulomas were present. Her pulmonary tuberculosis7 hence Along with broad
intra and post operative period was uneventful spectrum Antibiotics, Ethamsylate,
and later on she responded very well to anti- 2H3R3Z3E3+4H3R3 regimen, patient was shifted to
tubercular treatment as per advice of TB-Chest TB ward. She still had persistent haemoptysis, on
physician .She was not having any evidence of and off, received 5 units of whole blood
pulmonary tuberculosis and diagnosed as extra- transfusion and after 20 days, she was back at
pulmonary , category1-case of TB and drugs given labour ward and delivered a near term male baby
were 2H3R3Z3E3 + 4H3R3 as per RNTCP norms7. of weight 2.7kg. Baby did not exhibit any
signs/symptoms of congenital tuberculosis but
Case 2 prophylactic Isoniazide 5mg/kg body weight was
A 25 years old lady G4A3 of good socio- started to him along with Vitamin K. After 7 days
economic status was admitted on 29th of may of delivery, she had sudden collapse of left
2008, during emergency hours with amenorrhea lung[Fig-1] due to blood clots in left bronchus,
since 8 months, with complaints of fever and which was diagnosed and removed by rigid
cough since 20 days, with haemoptysis since 4 bronchoscopy[Fig-2]. Later on after 7 days,
hours and dyspnea. She was not a booked case of patient was totally asymptomatic and discharged.
our institute but admitted in some private nursing Anti tubercular treatment was given to both
home of nearby peripheral town since 7 days for mother and baby. Baby was on mixed feeds of
fever and cough. On general examination, she was formula and breast milk, as in between mother was
of average built, pale, temperature of 100 degree not able to feed him properly due to her poor
Fahrenheit, pulse- 90 beats per minute, blood general condition. Patient was discharged in a
pressure was 130/80mmHg. On examination of the stable condition with exclusive breast feeding and
respiratory system, basal crepitations and rhonchi to be followed up at the local TB center for direct
were present on the left side. Abdominal observation therapy. No further episode of
examination revealed a fundal height of 32 weeks, hemoptysis was reported at follow up after 6
with cephalic presenttion, FHS was 140/min, weeks of delivery at our OPD and baby gained
regular and uterus was relaxed. On internal adequate weight and was on total breast feeding.
examination, cervical os was 1 cm. dilated, 50%
effaced, membrane was present, station was at -2
and pelvis was adequate for baby size. Routine
investigations revealed Hb of 6 gm%, TLC-
16,400. peripheral smear showed microcytic,
hypochromic blood picture. Blood group was
O+ve . Her other investigations were within
normal limits. Ultrasound suggested single live
intrauterine fetus of gestational age of 34 weeks,
placenta was fundoposterior. Ultrasound suggested
left sided pleural effusion of 40-50cc fluid. X-ray
chest suggested left upper lobe consolidation and
suspicious of Koch‟s abdomen .Her mother gave

Page 77
CASES
investigations were within normal limits. Wound

Fig. 1 Showing Complete left lung collapse. was healthy, high vaginal swab, urine for culture
and sensitivity and blood culture was sent, which
later on showed sterile. She was having spikes of
102-103 degree Fahrenheit temperature,
intermittently, hence injection chloroquine along
with broad spectrum antibiotics were continued.
Her fever subsided on day 6th post-op. she was
taking full oral diet and bowel/bladder habits were
normal. Her sutures were removed on day 8 and
she had rise of temperature the next day. On her
abdomen examination, mild ascites was suspected,
hence ultrasound directed fluid aspiration was
done and samples were sent for routine and
microscopic examination along with culture and
sensitivity. Abdominal wound was absolutely
normal without any discharge or induration. To
our surprise report of ascitic fluid was positive for
AFB staining, Her endometrial sampling was sent
for histopathology and microscopy but not positive
Fig. 2 : Clot in the left bronchus for AFB. Baby did not show any signs/symptoms
of congenital TB but prophylactic Isoniazide
Case 3 therapy was started to him along with injectable
A 36 year old primigravida was referred from a vitamin K. Although during LSCS intestines,
peripheral centre, during emergency hours, with omentum and peritoneal fluid appeared normal but
history of amenorrhea since 9 months with presence in peritoneal fluid made it to think as
premature rupture of membrans since 2 days and primary peritoneal disease only. She had history of
non-progress of labour. Patient had a history of primary infertility but endometrial tissue was
spontaneous conception 15 years after her negative for it and she had conception without any
marriage. Her general examination was within treatment. She was Categorised as CAT-1 , extra
normal limits. On per abdomen-uterus was full pulmonary tuberculosis and , 2H3R3Z3E3+4H3R3
term size, cephalic presentation, FHS was present, regimen was prescribed. Patient was discharged
being 110 beats/min, irregular in nature. On per without any fever or ascitis on 15th postoperative
vaginum, cervix was 3 cm. dilated, 25% affected, day on continued AKT with DOT centre.
caput was present with head being at station -3.
She underwent Emergency LSCS in view of Here H= Isoniazide, R=Rifampicine,
PROM with fetal distress. A male baby of wt. Z=Pyrizinamide and E=Ethambutol.All our cases
3.2kg was delivered with mild birth asphyxia. She were weighing between 30-60 kilogram hence
was started on liquid diet from 2nd postoperative dosage were H-600mg, R-450mg,Z-1500mg and
day and catheter was removed on 3rd day. From E-1200mg. all these drugs are safe in pregnancy
day 3rd post-op she started developing high graded and during breast feeding .The important drug
fever, associated with chills. TLC count was which is contraindicated is Streptomycin.7
21,000 along with features of septicemia. Toxic
granules were present on peripheral smear; other

Page 78
CASES
DISCUSSION despite giving antibiotics for 1-2 weeks. The

M. tuberculosis is transmitted by airborne droplet presence of suggestive radiographic abnormalities
nuclei, which may contain fewer than 10 bacilli and a medical officer‟s decision to treat with ATT
and humans are the only known reservoir for M. labels the patient as a „smear-negative‟ TB case7.
tuberculosis. Individuals at high risk for M. A pregnant woman with extra-pulmonary TB has
tuberculosis infection in industrialized countries constitutional and organ-affection symptoms.
include close contact a patient with infectious TB, Routine haematology and Mantoux test (not
IV drugs abusers, migrant farm workers or commonly advocated in programme) along with
homeless persons and individuals who may have investigations specific for the site are carried out
occupational exposure to TB; individuals with for the establishment of specific diagnosis1.
immune-suppressing conditions like HIV or
medication use, individuals with a history of Many patients with suspected pulmonary TB do
inadequately treated TB, and infants. Chances that not produce sputum spontaneously or are smear-
an individual acquires infection depend on the negative for AFB. We could not obtain sputum
infectiousness of the index case, duration of the sample positive in our patient even with
exposure, environment (crowding, poor hemoptysis. With the use of PCR, nucleic acid
ventilation), and virulence of the organism.3,4,5 sequences unique to M. tuberculosis can be
detected directly in clinical specimens with better
Atypical presentations and slow confirmation by accuracy and urgency than AFB smear and
culture often delay the diagnosis and treatment of culture, respectively. Probes are used for rapid
patients with TB. Other reasons include an under identification and maximizing cost effectiveness.
use of tuberculin skin tests, misinterpretation of Used alone or in combination with other
unusual chest X-rays, and waiting for culture identification methods, they serve as a substitute
results in patients with AFB-negative smears2,5. for biochemical testing and are also more accurate.
Pregnancy is not thought to change the course of Molecular tests in combination with “classic tests”
tuberculosis, however, tuberculosis poses a risk to can enhance the diagnostic ability particularly in
the pregnant woman and her fetus.1 Diagnosis pauci-bacillary infections and in patients with
during pregnancy is delayed because the disease is atypical presentations like ours.5 If proper and
frequently extrapulmonary with few symptoms. adequate chemotherapy is given to pregnant
Although sites reported are pulmonary as well as women with TB, they are not a higher risk than
laryngeal, pleural, cerebral, miliary, peritoneal, non-pregnant women with TB. Neither the disease
ileocaecal, skeletal or dermal.1,2,3,4,5 Diagnosis is nor chemotherapy is threatening to mother or
usually require high degree of suspicion because newborn. However, today the ominous
of similarities of symptoms between TB and combination of human immunodeficiency virus,
pregnancy like tachycardia, anaemia, raised ESR due to the influence of HIV, drug resistant TB and
and low serum albumin level, as well as dissimilar patient compliance and pregnancy poses a new
parameters (like increase in weight during challenge to obstetrocians1,3,5,6
pregnancy and decrease due to TB, hypertension
in the former and hypotension in the latter etc.) The incidence of TB is around 1-2% amongst
Under RNTCP, sputum examination done as per hospital deliveries, especially in the under
an algorithm is the preferred method for diagnosis privileged sections of the society.6. Treatment
of pulmonary TB. A chest skiagram (performed should also be initiated when the probability is
after shielding the abdomen) is done if all the 3 moderate-to-high. Although the drugs in the initial
sputum smears are negative and symptoms persist treatment regime cross the placenta, these

Page 79
CASES
concentrations do not appear to have harmful prevention of pulmonary TB in both children and
effect on the fetus1,5,6. Pregnant women with TB adults4. In our as well as opinion of other authors2,
should also be tested for HIV as there is a higher the most crucial step in managing TB in pregnancy
incidence of extrapulmonary TB and multidrug- is an early diagnosis. Obstetricians should be alert
resistant TB (MDR TB) in this set of patients. to this “old disease” in their daily practice.
Though none of our patients were HIV positive. Screening of TB should be considered for the
Effective methods for prevention and treatment of following groups of pregnant women: (A) patients
the disease are available and inexpensive but still with symptoms suggestive of TB (B) patients with
are not used appropriately in most parts of the HIV infection (C) women who were in close
developing world. The clinician caring for contact with infectious TB patients, who visited
pregnant women should be aware of the risk high TB-prevalent areas recently without being
factors for tuberculosis infection and disease and screened for TB previously (D) patient having
should test women and families according to risk.5 history of infertility.
Patient compliance has to be good to ensure the
success of the DOTS strategy. DOTS have CONCLUSION
emerged as one of the most reassuring tool to A high index of suspicion and awareness of the
improve the challenging situation of pregnancy rapid advances and innovations made in the
with TB.6 diagnosis is required to recognize the changing
face and disease spectrum of tuberculosis and
Early diagnosis and prompt treatment of initiate treatment for better outcomes. Atypical
Tuberculosis during pregnancy would give better presentation may lead to misdiagnosis or a delay
results. Drug therapy in appropriate dosage has no in diagnosis. Also the absence of systemic
major adverse effects on the offspring. Breast- symptoms does not rule out TB. Radiological
feeding should be actively encouraged. Early ANC imaging, sputum smear, and PPD only aid in the
registration, intensive intrapartum monitoring and diagnosis but a high degree of suspicion is
post partum surveillance, adequate rest and required to ascertain an accurate diagnosis.
nutrition are crucial. Establishing an early diagnosis of TB infection
Breast feeding should not be discouraged in and disease in a pregnant woman is important as it
women being treated with first-line affects the health of both mother and infant.
antituberculosis drugs because the concentrations
in the breast milk are subtherapeutic and too low ACKNOWLEDGEMENT
to produce toxicity in the nursing new born. The We are extremely thankful to Dr Sameer Singhal,
effect would likely be much lower if the mother Associate Professor, Deptt of Chest and TB for his
breast feeds before taking the medication. valuable guidance and support in management of
Similarly, breast milk is also inadequate as a all these cases and making this article possible.
treatment option for TB or latent TB infection in
newborns5. Close follow up of patients is essential REFERENCES
since current therapy for TB infection is long and 1. Arora V K and Gupta R :TUBERCULOSIS
suboptimal .Role of Bacillus of Calmette-Guérin
AND PREGNANCY : Ind J Tub, 2003, 50, 13
(BCG) vaccine in preventing TB in adults is
debatable due to its variable efficacy (0–80%)1,5. 2. GAO Xue-lian, Gyaneshwar R. An unusual
Its efficacy in prevention of tuberculous presentation of tuberculosis in pregnancy
meningitis and miliary TB in young children has
been easier to document than in adults or in the

Page 80
CASES
Chinese Medical Journal, 2007, Vol. 120 No. 6. Rao S B, Dalal SJ, Badhwar VR, Patil M;
15 : 1378-1380 Tuberculosis in Pregnancy and the Impact of
3. Song J Y , Park CW , Kee SY , Choi WS , Directly Observed Therapy - Short Course
Kang EY , Sohn JW. Disseminated (Dots) Bombay Hospital Journal. Volume 48
Mycobacterium avium complex infection in an No. 02, April 2006
immunocompetent pregnant woman, BMC 7. Revised National Tuberlosis Control
Infectious Diseases 2006, 6:154 Programme; PPM Training Module for
4. Llewelyn M, Cropley I, Wilkinson RJ, Medical Practitioners. Central TB Division,
Davidson RN. Tuberculosis diagnosed during Directorate General of Health Services,
pregnancy: a prospective study from October 2006 page 22.
London.Thorax. 2000 Feb;55(2):129-32
5. Maddineni M and Panda M ;Pulmonary
Tuberculosis in a Young Pregnant Female:
Challenges in Diagnosis and treament , Infect
Dis Obstet Gynecol. 2008; 2008: 628985

Page 81
GRIP STRENGTH AND HAND FUNCTION CHANGES IN UNILATERAL CERVICAL
Mohamed Faisal et al
RADICULOPATHY
GRIP STRENGTH AND HAND FUNCTION CHANGES IN

UNILATERAL CERVICAL RADICULOPATHY
IJCRR Mohamed Faisal C.K.1, Nirmal Mathew1, Lawrence Mathias3, Ajith S.1
Vol 04 issue 21 1
Section: Healthcare Nitte Institute of Physiotherapy, Nitte University, Mangalore, KA,India
2
Category: Research Department of Orthopaedics, K.S.Hegde Medical Academy, Nitte University,
Received on: 05/09/12 Mangalore, KA, India
Revised on:19/09/12
Accepted on:02/10/12 E-mail of Corresponding Author: faisal77mpt@gmail.com
ABSTRACT
Back Ground and Objective: This study was to know and compare the extent of ill effect of cervical
radilculopathy in upper limb, by measuring the hand grip strength and hand functions comparing with
the normal or unaffected side. Materials and Method: It was a retrospective covariance study, where
30 subjects were selected who satisfied the inclusion and exclusion criteria with a mean age group of
45. All the subjects were explained about the procedures and an informed written consent was
obtained. The 30 patients were assessed for grip strength by hand dynamometer and hand function by
Jebsen – Taylor hand function test. The assessments were taken three times with an adequate interval
of five minutes and the average values were taken. Results: The grip strength and hand functions of
the affected side were compared with the unaffected or normal side. Paired and independent t test was
used for the analysis of data. High significance was seen in hand grip strength with P = 0.028 P< 0.05
between affected and unaffected side. Hand function data was analyzed by independent t test for the
seven sub tests, in which five tests showed very high significance with P= 0.000, 0.015, 0.000,0.000,
0.043 P < 0.05. Interpretation of Results: Hand grip strength and hand functions were significantly
reduced in patients with cervical radiculopathy. There was significant reduction in the hand grip
strength and hand function in the patients with unilateral cervical radiculopathy when compared with
the unaffected side.
Keywords: Cervical radiculopathy, Hand Grip Strength, Hand function, Jebsen Taylor Test, Hand
dynamometer
INTRODUCTION of adults over the age of 50 years and almost

Cervical radiculopathy is as condition caused by 100% by 70 years [3]. Isolated root pathology is
compression of a nerve root in the cervical spine. commonly caused by protrusion of a disc,
It is generally from a herniated disc or a bone spur although chronic degenerative arthritic changes or
that is pressing against an inflamed nerve root [1]. abnormalities of the superior facet region may also
Nerve roots compression may lead to weakness, play a role. The most commonly affected level is
numbness and pain where the nerve travels. The C5 -C6, with 86% of specimens having observable
pain may be felt as deep, dull and achy or may abnormalities. The C6 – C7 level is the next most
have sharp shooting pain along the path of the frequently affected site in the cervical region.
nerve. Muscles controlled by the affected nerve Finally, involvement of the 8th cervical nerve root
root may also be weakened [2]. by a herniated C7 –T1 disc produces a significant
Degenerative disc disease (DDD) is extremely weakness of the intrinsic musculature of the hand.
common, occurring in up to 5% of women and This involvement can lead to rapid atrophy of the
13% of men during the 3rd decade, more than 90% interosseous muscles. Loss of the interrossei leads

Page 82
RADICULOPATHY
to significant loss in fine hand motion. The most dynamometer is frequently used as a parameter to
common areas of the disc herniation are C6 – C7 asses hand function [9, 10].
and C5 – C6 [4]. Jebsen-Taylor hand function test consist of 7
The existing treatments for these conditions are subtests. Each test is timed, and there are
medications, surgical management and published standardized times against which to
physiotherapy [5]. The physiotherapy management evaluate the performance of the patient. It has
for the condition includes; educating the patient, been widely used to evaluate hand functions in a
teaching the natural history of Osteoarthritis of the number of medical and surgical conditions. It
cervical spine, heating modalities like SWD, evaluates unilateral grasp and prehension patterns.
ultrasound, TENS, infrared lamps, hydrocollator Although this test cannot be purchased
packs, hydrotherapy, stretching of the neck commercially, the therapist can assemble it
muscles and range of motion exercises. inexpensively. It is fast and easy to administer too
Intermittent cervical spine traction, Special [11].
pillows, cervical massage, relaxation techniques to Since cervical radiculopathy can decrease the
relieve the emotional stress that aggravates the handgrip strength and the associated functions,
symptoms and cervical manipulation and manual there are chances of alternate functional
traction are also found to be effective [6]. impairment during unilateral cervical
Functional tests assess a broad spectrum of hand radiculopathy, towards the affected side. This can
and upper extremity function including ADLs, be assessed by using the hand dynamometer for
gross and fine motor abilities, tool usage, grip strength and Jebsen-Taylor test for functional
manipulations, dexterity, grasp and release of activity. So this study is to know the extent of the
objects and unilateral and bilateral hand use and effect of cervical radiculopathy in grip strength
sensibility [7]. Power is a good indicator of hand and hand functions and to compare the extent of
function, and its measurement must be included as the ill effects of cervical radiculopathy by grip
the part of any hand assessment. The most strength and hand functions with the normal side
commonly measured aspects of hand functions or unaffected side.
include grasp, lateral pinch and opposition pinch.
The hand function tests are often timed and used MATERIALS AND METHODS
to analyze patterns of grip and form a problem The study included a sample of 30 subjects with
index. They are particularly useful in an age group between 30 to 60 years who were
assessment situation where the therapist has not diagnosed with unilateral cervical radiculopathy of
had the opportunity to observe the patient using the right side, based on their clinical findings,
the hand. The hand function test may be used to irrespective of their sex. The diagnosed cases were
analyze and evaluate treatment outcomes [8]. recruited from the Department of Orthopaedics
Measurement of handgrip strength is an important and Neurology of K S Hegde Hospital, Mangalore.
component of hand rehabilitation because it
assesses the patients’ initial limitation as compared Methods of Data Collection
with norms. Its utility continues throughout the This study was a retrospective covariance study.
treatment process because it provides a quick The subjects were explained about the condition,
reassessment of the patient’s progress. Without the experimental procedures, and outcome measures.
ability to grasp, a person ceases to be functionally Formal written consent was obtained from each
independent and is unlikely to be able to work or subject and ethical clearance was obtained from
play. Measuring the strength of hand muscles with the Institutional Ethical Committee.

Page 83
RADICULOPATHY
Inclusion Criteria objects (4) Simulated feeding, (5) Stacking

 Diagnosed cases of unilateral cervical checkers, (6) Picking up and placing large empty
radiculopathy of the right hand dominant side, objects, (7) Picking up and placing large heavy
where the patients were under control of pain. objects.
 Age group between 30 to 60. The examiner reads the directions to the patient
 Both males and females and records the time that the patient requires to
Exclusion Criteria complete each subtest with the non dominant and
 Subjects who have any other musculo skeletal then the dominant hand. The results are compared
disorders with normative data available relative to gender
 Neurovascular Impairment and age. Seven subtests were chosen to provide a
 Bilateral cervical radiculopathy broad sampling of hand function. Each of the
 Cervical Myelopathy subtests was designed to be administered in
 Acute cases of cervical radiculopathy precisely the same manner to each subject. The
results measured objectively using a stop watch.
Materials required Each subject was seated in a chair of 18-inch
 Jamar Hand Dynamometer height at a desk of 30-inch height in a well –
 Jebsen Taylor Hand Function Kit lighted room. Questions were answered after the
instructions were given to be certain that the
METHODOLOGY instructions were understood. The subtests were
The hand dynamometer measures cylinder grip always presented in the same sequence and were
strength and it is widely available to hand always performed with the non dominant hand
therapist, has a standardized method of use, has first.
normative values established for its use, and is SUBTEST 1: Writing
widely accepted by hand therapist. The normative Procedure: The subject is given a black ball point
values are particularly useful when it is necessary pen and for 8-by-11 inch sheets of un ruled white
to compare the patient against norms. paper fastened one on top of the other, to a clip
The patients were seated in a chair with shoulder board. The sentence to be copied has 24 letters.
adducted, neutrally rotated, elbow flexed at 90 The sentence is typed in all capital letters and
degree, forearm neutral, wrist between 0 degree centered on a 5-by-8 inch index card. The card is
and 15 degree dorsiflexion and 0 degree and 15 presented with the typed side faced down on a
degree ulnar deviation. Hold the dynamometer book stand. After the articles are arranged to the
lightly around readout dial. Then the patient has comfort of the subjects the card is turned over by
instructed to hold the handle and “squeeze” as the examiner with an immediate command to
hard as possible and then “Relax”. Same technique begin. The item is timed from the word “go” until
was repeated with same instructions for the second the pen is lifted from the page at the end of the
and third trial. Both the right and left hand has sentence. The item is repeated with the dominant
been tested in the second handle position. The hand using a new sentence.
peak reading of the three trials was noted and SUBTEST 2: Card turning (simulated page
average was taken [9]. turning)
The Jebsen-Taylor hand function test is composed Procedure: Five 3 X 5 inch index cards ruled on
of seven subtests that represent various hand one side only, are placed in a horizontal row 2
activities. The seven subtests include; (1) Writing, inches apart on the desk in front of the patient.
(2) Turning over 3 by 5- in cards (which simulates Each card is oriented vertically five inches from
page turning), (3) Picking up small common the front edge of the desk. Timing is from the

Page 84
RADICULOPATHY
word “go” until the last card is turned over. No from the word “go” until the fifth can has been
accuracy of placement after turning is necessary released. The item is repeated with dominant hand.
the item is repeated with the dominant hand. SUBTEST 7-Picking up large heavy objects
SUBTEST 3- Picking up small common objects Procedure: Five full 1 pound cans are placed in
Procedure: An empty 1 pound coffee can is placed front of the subject with five inches from the front
directly in front of the subject, five inches from the edge of the desk. The cans are spaced two inches
front edge of the desk. Two 1 inch paper clips apart. Timing is from the word “go” until the fifth
oriented vertically, two regular sized bottle caps can has been released. The item is repeated with
each 1-inch in diameter placed with inside of the the dominant hand [12].
cap facing up and two coins are placed in a
horizontal row to the left of the can. The paper RESULTS
clips are to the extreme left and the coin nearest Thirty patients were taken with unilateral cervical
the can. The objects are two inches apart. Timing radiculopathy of the dominant right side. The
is from the word “go” until the sound of the last average ages of the patient were 45 +\- 8.75. Out
object striking the inside of the can is heard. The of 30 patients, 18 were males and 12 were
item is repeated with the dominant hand. females. The analysis was done using Paired and
SUBTEST 4- Simulated feeding independent t-test.
Procedure: Five kidney beans of approximately 5X The data were compared to check whether there is
8 inch length are placed on the desk in front of the any significant difference in handgrip strength
subject 5 inches from the front edge of the desk. between the affected and the unaffected side and
The beans are oriented to the left of the centre 2 the statistical analysis shows in hand grip of the
inches apart. An empty 1 pound coffee can is total 30 subjects, there was a mean difference of -
placed centrally in front of the patient. A regular 1.87 with t-value of -2.34 with P-value 0.028,
teaspoon is provided. Timing is from the word where is P<0.05. It shows there is a highly
“go” until the last bean is heard hitting the bottom significant difference in handgrip strength between
of the can. The item is repeated with the dominant the affected side and the unaffected side. Handgrip
hand, the beans being placed to the right of the strength is less on the affected side when
centre. compared to the unaffected side. [Figure 1]
SUBTEST 5 –Stacking checkers The data for the hand functions were compared to
Procedure: Four standard sized red wooden check whether there is any significant difference
checkers are placed in front of the subject, five in the hand functions between the affected side
inches from the front edge of the desk. The and the normal. The mean, standard deviation and
checkers are oriented two on each side of the standard error on hand function were compared.
centre in a 0000 configuration. Timing is from the [Table 1 & 2]
word “go” until the fourth checker makes contact The statistical analysis shows that in the writing
with the third checker. The fourth checker need speed, there was a mean difference of 6.4 with t-
not stay in place .The item is repeated with value 4.28 with P-value 0.000, which is P <0.05. It
dominant hand. shows there is a very highly significant difference
SUBTEST 6- Picking up large light objects in the writing speed on the affected side when
Procedure: Five empty cans are placed in front of compared to the normal.
the subject five inches from the front edge of the The statistical analysis shows that in the card
desk. The cans are spaced two inches apart with turning, there was a mean difference of –0.82 with
the open end of the can facing down. Timing is t-value of 0.98 with P-value 0.152, which is
P>0.05. It shows there is a non significant

Page 85
RADICULOPATHY
difference in the card turning on the affected side there could be a myotomal involvement which
when compared to the normal. ultimately can lead to the weakness of the intrinsic
The statistical analysis shows that in picking up muscles of hand. This finding has been matched
small objects, there was a mean difference of – with the findings of Friendenberg et al, where the
1.02 with t-value of 1.23 with P-value 0.105, results of their study showed that the involvement
which is P>0.05. It shows there is a non significant of the lower cervical segments produces a
difference in picking up small objects on the significant weakness of the intrinsic muscles of the
affected side when compared to the normal. hand, which in turn leading to significant loss in
The statistical analysis shows that in simulated the hand grip and leading to reduction in fine hand
feeding, there was a mean difference of 0.866 functions [4]. Even though in the current study we
with t-value 2.49 with P- value 0.015,which is have found all of them had an involvement in the
P<0.05. It shows there is a very highly significant lower cervical regions, we have not separately
difference in simulated feeding on the affected analyzed the difference in the effects of
side when compared to normal. radiculopathy at various levels.
The statistical analysis shows that in stacking In this study we have used Jebsen –Taylor hand
checkers, there was a mean difference of 1.10 with function test to know the functional deficits, which
t-value 5.04 with P-value0.000, which is P<0.05. It is a reliable and valid measure of hand function
shows there is a very highly significant difference assessment in any hand impairments and this
in stacking checkers on the affected side when scale, consists of tasks representative of everyday
compared to the normal. functional activity.
The statistical analysis shows that in picking up In our study we found that, out of the seven
large light objects, there was a mean difference of subtests of the Jebsen –Taylor hand function tests,
1.15 with t-value 4.84 with P-value 0.000, which only five subtests have got a very highly
is P<0.05. It shows there is a very highly significant difference, when compared between the
significant difference in picking up large light affected and the normal. The subtests which had a
objects on the affected side when compared to the significant difference were; writing speed,
normal. simulated feeding, stacking checkers, picking up
The statistical analysis shows that in picking up large light objects and picking up large heavy
large heavy objects,, there was a mean difference objects, where as the remaining two subtests; card
of 0.52 with t-value 2.06 with P-value0.043, which turning and picking up small common objects
is P<0.05. It shows there is a very highly were shown as there was no statistically
significant difference in picking up large heavy significant difference. The reason could be those
objects on the affected side when compared to the were the activities, which patients were
normal [Figure 2]. encountering on daily life. Since majority of the
components of the Jebsen-Taylor hand function
DICUSSION test are affected, it can come in to a conclusion
The present study was designed to know the extent that the functional activities of hand in patients
of ill effects of unilateral cervical radiculopathy of with radiculopathy are also impaired very
the dominant side, by checking the handgrip significantly.
strength and hand functional activities. In the present study, we were also trying to find
The study result showed a highly significant out whether the reduction of hand grip has an
reduction in handgrip strength on affected side impact on the hand function activities, which
when compared to the unaffected side ultimately shows that there was a significant
(p=0.028<0.05). This is because in radiculopathy, reduction in the hand function activities in

Page 86
RADICULOPATHY
majority of the subtests of the Jebsen-Taylor hand And to check the grip strength we have adopted
function test in those patients with radiculopathy. the method suggested by Joseph A. Balogun et al
The evaluation of handgrip strength and functional [9], where they found that grip strength was
activities of hand are useful to provide an significantly higher (p<0.05) in the elbow 90-
objective index for the functional integrity of the degree flexion than in the fully extended position,
upper extremity. Grip strength is an important which is further supported by Hebert R, Mercier L
prerequisite for good performance of the upper et al [17]. Further studies could be conducted with
limb and checking the normal activities of hand larger samples and in other conditions of neck pain
function also plays a major role in upper extremity too.
assessment. Hence it is not only the pain
assessment, but also the assessment of hand grip CONCLUSION
strength and hand function should also be a part of Handgrip strength and hand functions were
the evaluation in patients with radiculopathy who significantly reduced in the patients with unilateral
come for the rehabilitation program. cervical radiculopathy. There were significant
In the current study we had included only the right reductions in the handgrip and hand functions on
side dominant radiculopathy patients to avoid any the affected side in the patients with unilateral
bias because the study done by Crosby et al [13] to cervical radiculopathy when compared with the
find out normal hand strength value with unaffected or normal side.
dynamometer concluded that the right-sided
subjects were 10% stronger in grip strength on the ACKNOWLEDGEMENTS
dominant side. In the left-handed subjects, the Authors would like to thank the Department of
mean grip was the same for both hands and a study Orthopaedics and Department of Neurology of K
done by Petersen et al [14] to find out the effect of S Hegde Hospital and the participants for their
grip strength and hand dominance concluded that support. We also like to extend our thanks to all
10% rule was valid for right dominant handed the authors of the references cited for this study.
persons and for left handed persons, grip strength
should be considered equivalent in both the hands. Conflict of Interest
And in a study by Ozcan et al, suggested that in a Authors agree that there was no source of conflict
right- dominant handed subjects, the dominant of interest.
hand was significantly faster with the time
perform test [15]. REFERENCES
In this study we have used the Jamar hand 1. Tanaka.Y, Kokuban.S, Sato.T. Cervical
dynamometer to assess the grip strength which is Radiculopathy and its unsolved problems.
having a high intra and inter tester reliability and J.Current Orthopaedics.1998; 12: pg 2.
reference values for checking the hand grip 2. Ludwing Ombert, Pierre Bischop, Ter Van
strength, according to Peolsson A et al. The H.J, Tony Van A. System of Orthopaedic
reliability studies showed that handgrip strength Medicine. 1st Edition: WB Saunders
measured with the Jamar dynamometer is a Company; London, 1995; pg: 20-24.
reliable method (ICC values 0.85 –0.98) and can 3. Irvine D.H, Forster J.B, Newell D.J.
be recommended for using in clinical practice. The Prevalence of Cervical Spondylosis in a
reference values for hand strength improve the general practice. Lancet.1965 ;( 1):1089-
potential for objective evaluation of patients with 1091.
arm / hand disorders caused by cervical
radiculopathy [16].

Page 87
RADICULOPATHY
4. Friendenberg ZB, Ediken J, Spenser N. 11. Barbara G. Stanely, Susan M. Tribuzi.

Degenerative changes of the cervical spine. Concepts in Hand Rehabilitation. F.A.Davis
Journal of Bone Joint Surg Am. 1959; 41: 61. Company. Philadelphia; 1992; pg: 5, 7.
5. Rubin D. Cervical radiculitis - Diagnosis and 12. Robert Jebsen, Neal Taylor. An Objective and
treatment. Archives of Physical Medicine Standardized test of Hand function. Achieves
Rehabilitation. 1960; 41 (l):175. of Physical Med Rehabilitation. 1969 June:
6. John Ebenezer. Essentials of Orthopaedics for 311-319.
Physiotherapists. 1st Ed. Jaypee Brothers 13. Crosby CA, Wehbe MA. Hand strength:
Medical Publishers; New Delhi; 2003: pg: normative values. American Journal of Hand
223. Surgery. 1994 July; 19(4): 665-70.
7. Apfel E. Preliminary Development of 14. Petersen P, Petrick M. Grip strength and hand
Standardized Hand function Test. Journal of dominance: challenging the 10% rule.
Hand Therapy. 1990; 3 (4): 191. American Journal of Occupational Therapy.
8. Maureen Salter, Lynn Chesire. Hand Therapy 1989 July; 43(7): 444-7.
Principles And Practice. 1st Ed. Butterworth- 15. Ozcan A, Tulum Z. Comparison of Pressure
Heinemann Publishers, Oxford; 2000; pg: pain threshold, grip strength, Dexterity and
40,53. Touch pressure of Dominant and Non
9. Joseph Balogun. A, Charles Akomolafe.T, dominant hands with in right and left handed
Lateef Amusa O. Grip Strength: Effects of subjects. Journal of Korean Med Science.
testing posture and elbow position. Archives 2004 Dec;19(6): 874-8
of Physical Medical Rehabilitation. 1991; 16. Peolsson A, Hedlund R. Intra and inter-tester
April; 72:280-283. reliability and reference values for hand
10. Annemike J. Videler, Anita Beelen. Hand strength. Journal Rehabilitation Medicine.
strength and fatigue in patients with 2001 Jan; 33(1): 36-41.
hereditary motor and sensory neuropathy 17. Bravo G, Hebert R. Impact of elbow position
(Types 1 and 2). Archives of Physical Med on grip strength of elderly men. Journal of
Rehabilitation. 2002 Sept; 83: 1274-1278. Hand Therapy. 1995 Jan-Mar; 8(1):27-30.
Table 1: Mean, standard deviation and standard error of the hand function
AFFECTED NORMATIVE
Variable
MEAN SD SE MEAN SD SE
Writing speed 22.8 8.01 1.46 16.32 2.09 0.38
Card turning 4.4 1.16 0.21 5.2 0.39 0.07
Small objects 5.6 1.42 0.26 6.6 0.29 0.05
Simulated feeding 8.3 1.8 0.34 7.5 0.24 0.04
Stacking checkers 5.06 1.2 0.21 3.9 0.04 0.009
Large light objects 4.6 1.2 0.23 3.4 0.09 0.01
Large heavy objects 4.1 1.37 0.25 3.5 0.09 0.01

Page 88
RADICULOPATHY
Table 2: Comparison of hand function between the affected and the normal
Variable MEAN DIFFERENCE T-VALUE P-VALUE RESULT
Writing speed 6.4 4.28 0.000 P<0.05 VHS
Card turning -0.82 0.98 0.152 P>0.05 NS
Small objects -1.02 1.23 0.105 P>0.05 NS
Simulated feeding 0.866 2.49 0.015 P<0.05 VHS
Stacking checkers 1.10 5.04 0.000 P<0.05 VHS
Large light objects 1.15 4.84 0.000 P<0.05 VHS
Large heavy objects 0.52 2.06 0.043 P<0.05 HS
Figure 1: Comparison of hand grip in the affected and the unaffected side
Affected and Unaffected Grip

21
20.5
20.44
20
Affected
Mean
Unaffected
19.5
19 19.16
18.5

Page 89
RADICULOPATHY
Graph 2: Comparison of hand function between the affected and the normal
comparison of hand function between the affected and

the normal
25
22.8
20
16.32
15
Mean
10
8.3
7.5
6.6
5.2 5.6
5.06
4.4 4.6
5 3.9 4.1
3.4 3.5
0
1 2 3 4 5 6 7
Affect
Subtests ed
Norma
l

Page 90
A STUDY ON MODIFIED ALVARADO SCORING SYSTEM IN DIAGNOSING ACUTE
C.P. Ganesh Babu et al
APPENDICITIS
A STUDY ON MODIFIED ALVARADO SCORING SYSTEM IN

DIAGNOSING ACUTE APPENDICITIS
IJCRR C.P. Ganesh Babu, E.M.J. Karthikeyan, K. Bharaniraj Kumar

Vol 04 issue 21
Section: Healthcare
Dept. of General Surgery, MAPIMS, Melmaruvathur.
Category: Research
Revised on:21/09/12 E-mail of Corresponding Author: ganeshvanicp@yahoo.co.in
ABSTRACT
Aim: To study the role of Modified Alvarado scoring system in diagnosing acute appendicitis
in clinical practice. Materials and Methods: A prospective study was conducted on 250
patients admitted with abdominal pain suggestive of acute appendicitis and were operated, from
January 2008 to December 2009 in AVMC&H and MAPIMS. Both males and females patients
from 8 years to 60 years of age were included.
Preoperative modified Alvarado score was used in all, and the results were compared with
operative finding and biopsy. Results: 155 patients were identified to have score of 8 or more. 149
patients were confirmed by biopsy. 91 patients have score 5 -7 and 66 were confirmed by biopsy.
Conclusion: This scoring system is a reliable and diagnostic modality to increase the accuracy
in diagnosing appendicitis.
Keywords: Alvarado. Scoring system. Acute appendicitis
INTRODUCTION The aim of the study is to evaluate the

Acute appendicitis is one of the most common sensitivity of modified Alvarado scoring
surgical emergency. Its lifetime prevalence is 1 in system in the diagnosis of acute appendicitis,
7, incidence is 1.5 to 1.9 / 1000 in male and to reduce the rate of negative appendicectomy
female population. Surgery for acute and to reduce the complications of acute
appendicitis is the most frequent operation appendicitis.
performed in all emergency.
The diagnosis of acute appendicitis is purely MATERIALS AND METHODS
based on history, clinical examination and A total number of 250 cases of clinically
laboratory investigations. Negative suspected acute appendicitis were studied from
appendicectomy rate is 15 to 40% as per the period of January 2008 to December 2009
literatures. Delay in diagnosis definitely in AVMC&H in pondy and MAPIMS . Data
increases the morbidity, mortality and cost of including age , sex, symptoms, physical sighs
treatment. Early diagnosis is a primary goal to and laboratory findings such as white blood
prevent morbidity and mortality.(1) cells total and differential count were recorded
Alvarado in 1986 introduced a criterion for in modified Alvarado form. (Table 1). (6)
the diagnosis of acute appendicitis which was In addition, urine for routine examination was
later modified to accommodate additional done for all cases. ultra sonogram of abdomen
parameters along with original Alvarado was performed when diagnosis was doubtful,
scoring system.( 2- 5). especially in female patients to exclude
gynecological diseases.

Page 91
APPENDICITIS
The score of each patient was correlated with the and 1 – 4 have accuracy of 96%, 72.5% and
clinical, operative and histopathological findings. 0% respectively. Fengo at al reported a
sensitivity of 90.2% and others reported a
RESULTS sensitivity of 73% with negative laparotomy
Age of the patients ranged from 7 years to 60 rate 17.5% .(11)
years with the majority of the patients in the In this series, the sensitivity of the patients
third decade (46%) followed by second decade with the score 8 and above was 98,04% in
(25%). (Table 2). males and 92.45% in females and combined
Out of 250 patients, 155(62%) were males and sensitivity is 95.45% whereas the sensitivity
95 (38%) were female. clinically males were with score less than 7 was 79.24% in males,
more susceptible than females. (Table 3). 57.15% in females and combined sensitivity is
All the specimen were sent to laboratory for 68.75%.
histopathological examination. The reports This study also reveals that scoring system
showed features of acute appendicitis in 215 was more helpful in male patients by showing
(86%) cases and 35 (14%) patients did not high accuracy rate as compared to female
have acute appendicitis. (Table 4). patients.
In this series, patients with score of 8- 10, 5 Lower values in female patients were due to
– 7, and 1- 4, had 96%, 72.5%, and 0% presence of diseases in genital system (i.e.)
sensitivity respectively. (Table 5). ovaries, salpinges (4, 12) . In females, additional
Patients with score 8 and above, the investigations are required. Different literatures
sensitivity is 98.04% in male and 92.45% in also support these observations (13).
females.(table 6). However there are no signs , symptoms or
Patients with score less than 8, the sensitivity laboratory test that are 100% reliable in the
is 79.24% in male and 57.15 % in females and diagnosis of acute appendicitis. In this study
overall is 68.72.%. (Table 7). modified Alvarado scoring system showed that
the accuracy of the diagnosis was very
DISCUSSION dependable and acceptable in higher scores but
Results of this study shows acute appendicitis patients with lower scores should be observed.
was most common in the 21 – 30 years(46%). Patients with score 8 to 10 are almost certain
Next most common group was 11 -20 (26%). All to have appendicitis and they should undergo
the studies have shown that appendicitis is operation immediately. Patients with a score 5 to
more common in 10- 30 years of age .(7) 7 indicate probable appendicitis. they should be
Males more susceptible than females .(8) observed and evaluated every 4 to 6 hrs, if
A negative rate of appendicectomy of 20- the score remains the same or increases after
40% is not unusual finding in literature (9) . this, reevaluation is required and patients with
Negative appendicectomy in this study is 15.75%, the score of 4 or less are very unlikely but
male (8.4%), females (23.1%). The percentage not impossible to have appendicitis and they
of normal appendicectomy in varies series can be discharged from hospital after giving
varies from 8 to 33%. In this era many initial conservative treatment.
surgeons accept 15 to 20% negative
appendicectomy (10) . CONCLUSION
From this study it was found that the higher In the diagnosis of acute appendicitis, the
the score, more of its sensitivity. Patients modified Alvarado score is a fast, simple,
with the Alvarado score ranges 8 -10, 5 – 7 reliable, noninvasive repeatable and safe

Page 92
APPENDICITIS
diagnostic modality without extra expense and Table 4: Peroperative Findings

complication. It can be very useful for junior Inflammation 128 60%
doctors provided it is applied purposefully and Suppuration 65 30%
objectively in patients. The application of this Gangrenous 13 06%
scoring system improves diagnostic accuracy Perforation 09 04%
and consequently reduces negative Total 215
appendicectomy and this reduces complication
rates. Table 5: Sensitivity of different score range
No. of Acute Normal
Score sensitivity
Pt appendicitis appendix
Table 1: Modified alvarado score 8 -10 155 149 6 96%
symptoms Migratory rt. Iliac fossa pain 1
5-7 91 66 25 72.5%
Anorexia 1
Nausea / vomiting 1 1 -4 04 00 04 00%
signs 1) Tenderness in rt. Iliac fossa 2
Table 6: Sensitivity of modified alvarado score > 8
2) rebound tenderness 1
No. of Acute Nornal
3) elevated temperature 1 Sex sensitivity
Pt appendicitis appendix
4) extra signs eg: cough test 1 Male 102 100 2 98.03%
and or rovsing sign and or
Female 53 49 4 92.45%
rectal tenderness
Total 155 149 6 95.5%
laboratory leucocytosis 2
Total score 10 Table 7: Sensitivity of modified alvarado score <7
Interpretation: No. of Acute Normal
Sex Sensitivity
Score 1- 4: acute appendicitis very unlikely Pt appendicitis appendix
Score five -7: acute appendicitis probable Male 53 42 11 79.24%
Score eight -10: acute appendicitis definitive.
Female 42 24 18 57.15%
Table 2 Total 95 66 29 68.72%
Age Groups (yrs) No of patients Percentage
Up to 10 5 2% REFERENCES
11 - 20 65 26% 1. Wagner JM, McKinney WP, Carpenter JL,
21 - 30 115 46% Does this patient have appendicitis?
31 - 40 35 14% JAMA 1996; 276; 1589-94.
41 - 50 25 10% 2. Alvarado A. A practical score for the
51 - 60 05 2% early diagnosis of acute appendicitis. Ann
Total 250 100 Emerg Med 1986;15: 557- 564.
3. Owen TD, William H, Stiff G, Jinkinsen
Table 3: Distribution of patients as per sex LR , Rees BI, Evaluation of Alvarado
Sex No. of patients Percentage score in acute appendicitis. J R Soc Med
Male 155 62% 1992; 85: 87- 8.
Female 95 38% 4. 0hnmann C, Yang O, Frank C. Diagnostic
Total 250 100% score for acute appendicitis. Abdomen pain
study group. Eur J Surg 1995; 161: 273-
281.
5. Macklin CP, Radcliffe GS, Merei JM,
STRINGER md. A prospective evaluation
of modified Alvarado score for acute

Page 93
APPENDICITIS
appendicitis in children. Ann R Coll Surg 10. Jones PF, suspected acute appendicitis ,
Engl 1997; 79: 203 -205. trend in management over 30 years. B J
6. Al-Fallouji MAR, Postgraduate surgery, the Surg 2001; 88: 1570 – 1577.
candidates Guide. Oxford: Butterworth- 11. Fengo G, Lindberg G, Blind P, Enochsson L,
Heinemann; 1998: 388- 389. Oberg A. Diagnostic decision in suspected
7. Addiss DG, Shaffer N, Fowler BS, et al. The acute appendicitis : validation of simplified
epidemiology of appendicitis and scoring system. Eur J Surg 1997: 163; 831
appendicectomy in united states. Is J – eight.
Epidemiology 1990: 132: 910 -25. 12. Baber MD, Mclarn J, Rainay JB. Recurrent
8. Williams NS, Bulstrode CJK, O’Connell appendicitis. Br J Surg 1997: 84: 110 -112.
PR, Bailey and love’s short practice of 13. Shrivastona UKJ, Gupta A, Sharma D ,
surgery. 25th Ed. London. Hodder Arnold, Evaluation of the Alvarado score in the
2008; 1205- 1206. diagnosis of acute appendicitis. Trop
9. Al Qahatani HN, Muhammed AA, Gastroenterol 2004; 25:184-6.
Alvarado score as an admission criterion
for the suspected appendicitis in adults.
Saudi J Gastroenterology 2004: 10: 86- 91.

Page 94
ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY GLAND PATHOLOGY AND ITS
Agravat Amit H. et al
HISTOPATHOLOGICAL CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN INDIA
ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN SALIVARY

GLAND PATHOLOGY AND ITS HISTOPATHOLOGICAL
CORRELATION: A TWO YEAR PROSPECTIVE STUDY IN WESTERN
IJCRR INDIA
Vol 04 issue 21
Section: Healthcare Agravat Amit H., Dhruva Gauravi A., Pujara Krupal M., Sanghvi Hardik K.
Category: Research
Received on: 13/09/12 Department of Pathology, P.D.U. Government Medical College, Rajkot, Gujarat, India
Revised on:20/09/12
Accepted on:29/09/12 E-mail of Corresponding Author: dr.amit.patho@gmail.com
ABSTRACT
Background and objectives: Salivary gland lesions account for 2-6.5% of all the neoplasm of the head
and neck. Fine needle aspiration cytology (FNAC) is being increasingly used in the diagnosis of
salivary gland lesions. The objective of this study was to evaluate the diagnostic accuracy and the
sensitivity and specificity of FNAC in various salivary gland lesions in correlation with their
histopathology, which helps in the appropriate therapeutic management.
Methods: A total of 120 FNACs were done on salivary gland tumors from July 2010 to June 2012 in
the Department of Pathology, P.D.U. Government Medical College, Rajkot (Gujarat, India). Formalin
fixed (10%), surgically resected specimens were received, they were processed and slides were
prepared for histopathological diagnosis. The stained cytological and histopathological slides were
studied, analyzed and correlated.
Results: The cytomorphological features were studied and analyzed and the following lesions were
observed: Pleomorphic adenoma (88), Warthin’s tumor (2), Cystic lesion (4), Mucoepidermoid
carcinoma (6), Acinic cell carcinoma (2), Primary lymphoma (2), Carcinoma EX pleomorphic
adenoma(4), metastatic malignancy deposits (2), benign parotid tumor (8) and malignant tumor
(unspecified)(2). A histopathological correlation was available in 78 cases. Out of these, 71 cases were
true positive, 1 was false positive, 2 were false negative and 4 were true negative.
Interpretation and conclusion: The overall sensitivity, specificity and the diagnostic accuracy were
97%, 80% and 92% respectively. Hence, the appropriate therapeutic management could be planned
earlier. This study documents that FNAC of the salivary gland tumors is accurate, simple, rapid,
inexpensive, well tolerated and harmless for the patient.
Keywords: Salivary gland tumors, FNAC, Diagnostic accuracy, Sensitivity, Specificity, Benign,
Malignant.
INTRODUCTION Among the primary epithelial tumors, 64-80%

Fine needle aspiration cytology (FNAC) is occur in the parotid glands, 7-11% occur in the
accurate, simple, rapid, inexpensive, well tolerated sub-mandibular, less than 1% occur in the
and harmless for the patient (1),(2),(3),(4),(5). sublingual and 9-23% occur in the minor salivary
Although salivary gland tumors are rare and they glands (1),(9),(10). In the files of the Armed
account for 2-6.5% of all the head and neck Forces Institute of Pathology, about 1/3rd of the
tumors, their superficial location, easy major gland and half of the minor gland tumors
accessibility and high diagnostic accuracy makes are malignant (10). The ratio of the malignant to
FNAC a popular method for evaluating the benign tumor is the greatest (>2.3:1) in the
them (6),(7),(8). sub-lingual gland and in the minor salivary glands

Page 95
of the tongue, the floor of the mouth and the wherever required. The stained cytological and
retromolar area (11). A review of the recent histopathological slides were studied, analyzed
reported series found that the diagnostic sensitivity and correlated.
of FNAC varied from 81-100%, that the
specificity varied from 94-100% and that the RESULTS
diagnostic accuracy varied from 61- During the study period, 343 cases of salivary
80% (11),(12). Hence, the appropriate therapeutic gland swellings were aspirated, out of which 120
management could be planned earlier, whether it were diagnosed as salivary gland tumors by
was local excision for benign neoplasm, FNAC. Among these, histopathological
conservative management for non-neoplastic correlations were available for 78 cases. All the
lesions, radical surgery for malignant tumors and cases occurred in the age group of 11-80 years and
chemotherapy or radiotherapy for metastasis and a majority of them were seen in the range of 21-30
lymphoproliferative disorders (8). Hence, the years (25%), with a male to female ratio of
present study was done to know the diagnostic 1.4:1 (Table/Fig 1). The number of cases which
accuracy, which helps in an early diagnosis and were seen in the parotid gland, the sub-mandibular
appropriate therapeutic management. gland and the minor salivary glands were
74(61.7%), 42(35%) and 4(3.33%) respectively.
SUBJECTS AND METHODS There were 102 (85%) benign and 18(15%)
The present prospective study was undertaken malignant tumors. The commonest gland which
from July 2010 to June 2012 at the P.D.U. was involved was the parotid gland in both males i
Government Medical College, Rajkot (Gujarat, e., 44(59%) and females 30(41%). Out of the 120
India), which comprised of 120 cases of salivary cases, 88(73.33%) were pleomorphic adenomas
gland tumors which were diagnosed by FNAC. (PA), 2 (1.7%) were Warthin’s tumors (WT),
After taking the informed consent, the aspiration 6(5%) were mucoepidermoid carcinomas (MEC),
was done following a thorough clinical 2(1.7%) were acinic cell carcinomas, 4(3.33%)
examination. The cytological findings were were carcinoma ex pleomorphic adenomas,
correlated with the histopathology. 2(1.7%) were primary lymphomas of the parotid
gland, 2(1.7%) were metastatic deposits, 8(6.7%)
MATERIAL AND METHODS were benign parotid tumors, 4(3.33%) were cystic
The nodule of interest was palpated and fixed with lesions and 2(1.7%) were malignant tumors
the thumb and the index finger of one hand. Under (unclassified) (Table/Fig2).
aseptic precautions, a 10 cc syringe with a 22-25 PA and MEC were the commonest benign and
gauge needle was introduced into the nodule. The malignant tumors respectively.
material was aspirated and smeared onto clean There were 88 PAs, out of which only 64 cases
glass slides. The air dried and ethanol fixed smears had a histopathological correlation. Fifty two of
were stained with Giemsa and Haematoxylin and them were concordantly diagnosed as PA
Eosin (H&E) respectively. In cases of fluid histopathologically. Two cases each were of basal
aspiration, slides were prepared from the cell adenoma, myoepithelioma, WT and MEC,
centrifuged sediment. whereas 4 were diagnosed as sialadenosis by
Formalin fixed (10%), surgically resected histopathology. Out of 2 cases of WT, 1 was
specimens were received in the Department of concordantly diagnosed by histopathology,
Pathology, processed and stained with whereas the other one was not available for
haematoxylin and eosin for histopathological correlation. Among the 8 cases of benign parotid
examination. Special stains like PAS was done tumors, a histopathological correlation was

Page 96
available for 6 and all were diagnosed as PA. Pleomorphic Adenoma

Among 4 cases of cystic lesions, all were PA is the most common tumor which accounts for
histopathologically correlated. Of these, 2 were 60-70% of all the salivary gland tumors. These
diagnosed as mucocele and the other 2 as benign tumors occur in the middle age group and they can
lymphoepithelial cysts. be bilateral in 5-6% of the cases. They have a
Among 4 cases of carcinoma ex PA, 2 were striking sex difference, with 85-90% of the cases
available for histopathological correlation, which occurring in the male population. The reliability of
were diagnosed as MEC. Among 4 cases of MEC, FNAC in diagnosing PA has been reported as 90-
2 were concordantly diagnosed by histopathology. 97% (13). Among the 120 cases of salivary gland
Two cases were reported as acinic cell carcinomas, tumors in the present study, 88 cases (73.3%) were
both of which were not available for diagnosed as PA cyto-logically. Sixty four of them
histopathological correlation. There were 2 were available for histopathological correlation,
cytologically diagnosed cases of primary out of which 52 were concordantly diagnosed. The
lymphoma of the parotid, both of which were commonest changes which were observed were
concordantly diagnosed by histopathologically as epithelial and mesenchymal like elements with a
non-Hodgkins lymphoma- diffuse large B cell wide variety of patterns within the tumor. The
type. Two cases were cytologically diagnosed as commonest elements that were seen included
metastatic squamous cell carcinomas, both of fibrous, mucinous, myxochondroid and chondroid
which were not available for histopathological tissues.
correlation. Out of the 64 cases which were
In the above cyto-histopathological correlation histopathologically correlated, 2 were discordantly
study, the sensitivity, specificity and the diagnostic diagnosed as basal cell adenomas and 2 as
accuracy were 97%, 80% and 96%. myoepitheliomas. In both these cases, the FNAC
slides were reviewed; both showed highly cellular
DISCUSSION smears with scanty stromal elements and were
Salivary gland neoplasm are rare and they account mistakenly diagnosed as PA. From the practical
for 2 to 6.5% of all the neoplasm of the head and perspective, this confusion was of minor
neck (1). Among all the parotid gland tumors, 15- importance, since the surgical treatment was
30% was malignant, in contrast to about 40% in similar in both the cases. Two cases were
the submandibular gland, 50% in the minor discordantly diagnosed as Warthin’s tumor. The
salivary gland and 70-90% in the sublingual reviewed FNAC slides showed an oncocytic
glands. The likelihood that a salivary gland tumor change, which we suspected as epithelial cells
being malignant is inversely proportional to the with metaplastic change. The lymphoid
size of the gland. component was not present in the FNAC slides
Salivary gland tumors usually occur in adults, but due to a sampling error.
5% can occur in children who are younger than 16 There were 2 cases of false negative diagnoses in
years of age. FNAC of the salivary gland tumors is our study, which were diagnosed as
advantageous for both the patients and the mucoepidermoid carcinomas histopathologically.
clinicians because of its immediate results, This erroneous diagnosis was due to a sampling
accuracy, lack of complications and economy (8). error. This can occur when the malignant
Many studies have revealed the high diagnostic component is small and it can be resolved with a
accuracy of FNAC when it was used for salivary wider sampling of the tumor, in order to obtain
gland tumors (13), (14), and (15). smears from the malignant transformation. Many
studies showed similar findings [13-15]. There

Page 97
were 4 cases which were diagnosed as sialadenosis Mucoepidermoid Carcinoma

histopathologically. The FNAC slides were MECs comprise 5-10% of all the salivary gland
reviewed, which showed increased cellularity with tumors and 9/10th of these tumors occur in the
epithelial components and fibrocollagenous tissue, parotid gland (15). Zajicek et al. reported a DA of
which were mistaken as chondromyxoid stromal 37% when all the 3 cellular components
fragments. (epidermoid cells, intermediate cells and mucous
Warthin’s Tumor (WT) cells) were present. Cellular smears from well
WT is the second most common benign salivary differentiated MECs usually pose no problem in
gland tumor (5-6%) and a majority of these can their diagnosis. However, the high grade, poorly
occur in the parotid or periparotid area. These differentiated tumors may be difficult to recognize
tumors are bilateral in 5-6% of the cases, they may as MECs and they may be misdiagnosed as poorly
be multiple and may occur in the older aged differentiated squamous cell carcinomas. When
groups, and with the striking sex difference that the tumor is cystic and the aspiration yields only
85-90% of the cases occurs in males. A mucous material, a diagnosis of MEC may be
combination of oncocytes, lymphoid tissues and missed.
cystic macrophages help in the diagnosis. In our study, out of 120 cases, there were 6 cases
Among the 120 cases in the present study, 2 cases of MEC, which were diagnosed by FNAC. The
were diagnosed as WT by FNAC. Both of these smear showed 3 types of cells, epidermoid cells,
were not available for histopathological intermediate cells and mucus cells against a dirty
correlation. necrotic background. Two cases were available for
Salivary Cysts histopathological correlation, which were
Small cysts (mucoceles or mucus retention cysts) concordantly diagnosed.
which arise from minor salivary glands are not Acinic Cell Carcinoma (ACC)
uncommon. The favored sites are in the sub- ACCs comprise 1% of the salivary gland tumors
mucosa of the oral cavity of the lower lip, the and 95% of them occur in the parotid glands,
cheeks, the dorsal surface of the tip of the tongue accounting for about 2.5-4% of all the parotid
and the floor of the mouth. tumors.
The cysts in the salivary gland can occur in some Among the 120 cases in the present study, 2 cases
neoplasm like PA, WT, MEC, acinic cell of ACCs were reported cytologically in a 60 year
carcinomas and squamous cell carcinomas. In the old male and another was reported in a 52 year old
present study, out of the 120 cases, there were 4 female, both presenting with hard parotid masses.
cases of cysts, which were diagnosed by FNAC. The patients were not available for further follow
All the 4 cases were available for up since they were referred to higher centers for
histopathological correlation. Two were further management.
concordantly diagnosed as mucocele and the other Carcinoma ex pleomorphic adenoma (CA ex
2 as benign lymphoepithelial cysts. The FNAC PA) and malignant mixed tumor
slides were reviewed, which showed plenty of cyst The incidence of CA ex PA is 1.5-6.5%.
macrophages and degenerated epithelial cells Among the 120 cases in the present study, 4 were
against a myxoid background. There were no diagnosed as CA ex PA cytologically. The smears
lymphoid components in the smear. This may be which were studied showed epithelial cell clusters
due to a sampling error where the needle might which revealed a prominent nuclear enlargement
have hit only the cystic area. and atypia with clusters of benign epithelial cells
and myxoid stroma.

Page 98
One case was available for histopathological metastases at presentation, especially due to high
correlation, which was concordantly diagnosed as grade MEC (39%) and malignant mixed tumors
MEC. (32%).
Primary lymphoma of the salivary gland: In our study, benign tumors were more common
Lymphoma of the salivary gland accounts for 5% than malignant tumors, which was similar to the
of the cases of extra nodal lymphomas and 10% of findings in all other studies (12), (13), (14). The
all the malignant salivary gland tumors (16). A parotid gland was very commonly involved,
majority of the salivary gland lymphomas (70- whereas PA and MEC were the commonest benign
80%) arise in the parotid gland and most of them and malignant tumor respectively, which was
are low-grade non-Hodgkin’s lymphomas. Among similar to that which was found in other studies
the 120 cases in the present study, two cases (48 (14), (15). The diagnostic accuracy (DA) was
and 64 year old male patients) were diagnosed as 92%, the sensitivity was 97% and the specificity
primary lymphomas cytologically, who presented 80%, which were similar to that which was seen in
with the bilateral enlargement of the parotid other studies (13), (14), and (15).
glands. There was no associated lymphadenopathy
or organomegaly. Both the cases were CONCLUSION
concordantly diagnosed by biopsy as high grade FNAC offers valuable information which is not
non-Hodgkin’s lymphomas (Diffuse large B cell obtained by any other means. FNAC of the
lymphomas) and were referred to higher centers salivary gland tumors is advantageous for both the
for further management. patients and the clinicians because of its
Metastatic Deposits immediate results, accuracy, economy, and lack of
Metastatic carcinoma and melanoma may involve complications. Although FNAC of the salivary
either the salivary glands or the lymph nodes gland tumors has a high diagnostic accuracy (92%
which are adjacent or within the gland. The in the present study), it can further be improved by
commonest primary tumor is cutaneous squamous a wider sampling and ultrasound guided
cell carcinoma of the head and neck. Among the aspirations.
120 cases in the present study, two cases of Awareness of the therapeutic implications and
squamous cell carcinoma metastatic deposits were limitations of the cytological interpretation
diagnosed cytologically in 2 60 and 75 year old amongst both the clinicians and the
male patients with a history of bilateral cytopathologists should enable FNAC to its best
submandibular gland enlargement. Both presented advantage.
with hoarseness of the voice and direct
laryngoscopy revealed ulceroproliferative growths ACKNOWLEDGMENT
in their vocal cords. The smears showed We acknowledge the immense help received from
pleomorphic squamous epithelial cells in clusters the scholars whose articles are cited and included
and singles, tadpole cells and keratin pearls against in references of this manuscript. We are also
a dirty background. Both the patients were referred grateful to authors / editors / publishers of all those
to higher centers for further management and articles, journals and books from where the
hence a histopathological correlation was not literature for this article has been reviewed and
possible. The malignant tumors spread by the discussed.
direct and the haematogenous routes. Interestingly,
20% of the parotid glands, 34% of the
submandibular glands and 14% of the minor
salivary glands will have cervical lymph node

Page 99
REFERENCES 10. Spiro RH. Salivary neoplasms- An overview

1. Fernandes GC, Pandit AA. Diagnosis of of 35 years of experience with 2807 patients.
salivary gland tumors by FNAC. Bombay Head Neck Surg 1986; 8:177-84.
Hospital Journal 2000; 42:108-11. 11. Stewart CJ, MacKenzie K, McGarry GW,
2. Crystallini EG, Stafano A, Raffaelle F, Mowat A. Fine-needle aspiration cytology of
Liberati F, Maccio T, Peciarolo A, et al. Fine the salivary gland: a review of 341 cases.
needle aspiration biopsy of the salivary gland, Diagn Cytopathol 2000; 22:139-46.
1985-1995. Acta Cytol 1997; 41:1412-20. 12. Zbaren P, Nuyens M, Loosli H, Stauffer E.
3. Eveson JW, Cawson RA. Salivary gland Diagnostic accuracy of fine-needle aspiration
tumors. A review of 2410 cases with particular cytology and frozen sections in primary
reference to the histological types, sites, age parotid carcinoma. Cancer 2004; 100: 1876-
and sex distribution. J Pathol 1985; 146:51-58. 83.
4. Kline TS, Merriam JM, Shapshay SM. 13. Layfield LJ, Tan P, Glasgow BJ. Fine-needle
Aspiration biopsy cytology of the salivary aspiration of salivary gland lesions.
gland. Am J Clin Pathol 1981; 76:263-69. Comparison with frozen sections and
5. Lindberg LG, Akerman M. Aspiration histological findings. Arch Pathol Lab Med
cytology of salivary gland tumors: Diagnostic 1987; 111:346-53.
experience from six years of routine 14. Hood IC, Qizilbash AH, Salama SS,
laboratory work. Laryngoscope 1976; 86:584- Alexopoulou I. Basal-cell adenoma of the
94. parotid. Difficulty in the differentiation from
6. Mavec P, Eneroth CM, Franzen S, Moberger adenoid cystic carcinoma on aspiration biopsy.
G, Zajicek J. Aspiration biopsy of salivary Acta Cytol 1983; 27:515-20.
gland tumors. Acta Otolaryngol 1964; 58:471- 15. Matsushita I, Takeda T, Tadao Kobayashi TK,
84. Tanaka B, Sawaraqi I. Mucoepidermoid
7. Persson PS, Zettergren L. Cytological carcinoma of the salivary gland in pleural
diagnosis of salivary gland tumors by fluid. A case report. Acta Cytol 1983; 27:525-
aspiration biopsy. Acta Cytol 1973; 17:351- 28.
54. 16. Agale SV, D’Costa GF, Hastak MS, Shedge
8. Cohen MB, Fisher PE, Holly EA, Ljung BM, RT. Primary non-Hodgkin’s lymphoma of the
Lowhagen T, Bottles K. Fine needle aspiration salivary gland: A spectrum of
biopsy diagnosis of mucoepidermoid lymphoepithelial sialadenitis and low-grade B-
carcinoma. Statistical analysis. Acta Cytol cell lymphoma of the mucosa-associated
1990; 34:43–49. lymphoid tissue with transformation to high-
9. Qizilbash AH, Sianos J, Young JE, Archibald grade lymphoma. Indian J Pathol Microbiol
SD. Fine needle aspiration biopsy cytology of 2010; 53:364-67.
the major salivary glands. Acta Cytol 1985;
29:503-12.

Page 100
Table 1 : Age and sex crosstabulation

Sex
Age Total
Male Female
Below 10 Count 2 2
% within sex 2.9% 1.7%
11-20 Count 8 8 16
% within sex 11.4% 16.0% 13.3%
21-30 Count 16 14 30
% within sex 22.9% 28.0% 25.0%
31-40 Count 12 10 22
% within sex 17.1% 20.0% 18.3%
41-50 Count 6 12 18
% within sex 8.6% 24.0% 15.0%
51-60 Count 12 6 18
% within sex 17.1% 12.0% 15.0%
61-70 Count 12 12
% within sex 17.1% 10.0%
71-80 Count 2 2
% within sex 2.9% 1.7%
Total Count 70 50 120
% within sex 100% 100% 100%
Table 2 : Frequency of cases diagnosed on FNAC

Diagnosis Frequency Percent
Pleomorphic Adenoma 88 73.3%
Benign Parotid Tumor 8 6.7%
Warthin’s Tumor 2 1.7%
Cystic Lesion 4 3.3%
Mucoepidermoid Carcinoma 6 5.0%
Acinic Cell Carcinoma 2 1.7%
Primary Lymphoma 2 1.7%
Carcinoma ex Pleomorphic Adenoma 4 3.3%
Metastatic deposits 2 1.7%
Malignant Tumor (Unspecified) 2 1.7%
TOTAL 120 100%

Page 101
Sharadkumar P. Sawant et al VARIANT AXILLARY ARTERY – A CASE REPORT
VARIANT AXILLARY ARTERY – A CASE REPORT
IJCRR Sharadkumar Pralhad Sawant, Shaguphta T. Shaikh, Rakhi Milind More

Vol 04 issue 21
Section: Healthcare
Department of Anatomy, K. J. Somaiya Medical College, Somaiya Ayurvihar,
Category: Case Report
Eastern Express Highway, Sion, Mumbai, M.S., India
Revised on:28/08/12
Accepted on:10/09/12 E-mail of Corresponding Author: dr.sharadsawant@yahoo.com
ABSTRACT
During routine dissection for the undergraduate medical students, we observed the variations in the
course and distribution of axillary artery in the right upper limb of a 80 years old donated embalmed
male cadaver in the Department of Anatomy, K. J. Somaiya Medical College, Sion, Mumbai, India. In
the present case the axillary artery, 1cm distal to the outer border of first rib divided into superficial and
deep brachial arteries. The superficial brachial artery continued as brachial artery proper and divided at
the level of neck of radius into radial and ulnar arteries. The deep brachial artery performed the role of
axillary artery in the axilla. It gave rise to all branches which are usually given by the axillary artery.
The deep brachial artery first gave superior thoracic, thoracoacromial, lateral thoracic artery & articular
branch to the shoulder joint. It then divided into anterior & posterior divisions. The anterior division
gave anterior circumflex humeral, posterior circumflex humeral and profunda brachii artery. The
posterior division continued as the subscapular artery and it gave rise to the circumflex scapular and
thoracodorsal arteries. The deep brachial artery giving rise to all branches which are normally given by
first, second and third part of axillary artery is very rare and not found in literature. The profunda
brachii artery arising from anterior division of deep brachial artery is also very rare and not found in
literature. The axillary vein was on medial side of superficial brachial artery in the arm. The cords of
brachial plexus were around the superficial and deep brachial artery. The origin, course and distribution
of axillary artery was normal on the left side of the same male cadaver. The photographs of the
variations of axillary artery were taken for proper documentation and for ready reference.
Conclusion: Topographical anatomy of the normal and abnormal variations of the axillary artery is
clinically important for surgeons, orthopaedicians and radiologists performing angiographic studies on
the upper limb. The appropriate diagnostic interpretation and therapeutic intervention can be achieved
on the basis of knowledge of such variations.
Key words: Axillary Artery, Superficial Brachial Artery, Deep Brachial Artery, Anterior & Posterior
Division Of Deep Brachial Artery, Angiographic Studies, Radiologists, Orthopaedicians, Shoulder
Joint.
INTRODUCTION continues as the axillary artery. The axillary

The axial artery of the upper limb is derived from artery ends at the level of the lower border of the
the lateral branch of the seventh cervical teres major muscle and continues downwards as
intersegmental artery. This axial artery becomes the brachial artery. The brachial artery is the main
axillary, brachial, radial and ulnar arteries on artery of the arm. During the course of the
further development. At the level of the outer axillary artery the pectoralis minor muscle crosses
border of the first rib the subclavian artery it anteriorly and divides the course of artery into

Page 102
three parts; proximal to the pectoralis minor circumflex humeral artery orginates at the lower
muscle is the first part, posterior to the muscle is border of sub scapularis muscle from the lateral
second part and distal to the muscle is the third side of the third part of the axillary artery as a
part of the axillary artery. The first part of axillary smaller branch. It runs around the surgical neck of
artery gives one branch i.e. superior thoracic artery the humerus anteriorly and anastomoses with the
which is arising at the level of the lower border of posterior circumflex humeral artery. It gives an
subclavius muscle. The superior thoracic artery ascending branch which supplies the head of the
may arise from the thoraco acromial artery. humerus and the shoulder joint. The posterior
The second part of axillary artery gives two circumflex humeral artery is the larger branch
branches i.e. thoraco acromial artery and lateral originating at the same level of the anterior
thoracic artery. The thoraco acromial artery is circumflex humeral artery. It runs along with
covered by the pectoralis minor muscle. It comes axillary nerve (C5, 6) in the quadrangular space.
out from the medial border of the pectoralis minor The quadrangular space is bounded above by teres
muscle and pierces the clavipectoral fascia. It minor muscle, below by the teres major muscle,
divides into pectoral, acromial, clavicular and medially by the long head of triceps brachii
deltoid branches of which the pectoral branch is muscle and laterally by the surgical neck of the
the largest branch. The lateral thoracic artery humerus. It runs round the neck of the humerus
comes out from the lateral border of the pectoralis and supplies the shoulder joint. It anastomoses
minor muscle. It is large in females and has lateral with anterior circumflex humeral artery. It gives a
mammary branches which supply the breast. The descending branch which anastomoses with the
third part of axillary artery gives three branches ascending branch of the profunda branchii artery
i.e. subscapular, anterior and posterior circumflex (1). The branches of subclavian and axillary
humeral arteries. The subscapular artery is the arteries show extensive collateral circulation
largest branch arising from the lower border of the around the scapula so that the sound knowledge
subscapularies muscle. In the lower part it is of neuromuscular variation is important for
accompanied by the thoracodorsal nerve (C6, 7,8) surgeons who remove the axillary lymph nodes, to
. The subscapular artery terminates into larger anaesthesiologist and orthopaedic surgeons
circumflex scapular and smaller thoracodorsal considering the frequency of procedures done in
arteries. The circumflex scapular artery during its this region. Sometimes many of the branches may
course interrupts the origin of teres minor muscle originate from a common stem or arise separately
and appears into the upper triangular space, which (2). These variation, are well documented in
is bounded above by subscapularis muscle, below literature. The second part of axillary artery may
by teres major muscle and laterally by long head give rise to a third branch i.e. alar thoracic artery.
of triceps brachii muscle. The circumflex scapular The second part of the axillary artery may give
artery gives two important cutaneous branches, the only one branch i.e. the thoraco-acromial artery
upper (scapular) and the lower (parascapular). and the second branch i.e. the lateral thoracic
The scapular flap (upper cutaneous or scapular artery may be absent. Variations are common in
branch) and the parascapular flap (lower cutaneous the branching pattern of the third part of the
or parascapular branch) are used for axillary artery. A common arterial trunk may give
reconstructions in the areas of missing tissues. The rise to the scapular artery and the posterior
thoracodorsal artery runs along the lateral circumflex humeral artery or it may give rise to
(axillary) border of scapula and enters the deep subscapular, anterior and posterior circumflex
surface of the latissimus dorsi muscle along with humeral and profunda brachii arteries. The
the nerve to latissimus dorsi. The anterior profunda brachii artery rarely gives the posterior

Page 103
circumflex humeral artery which will pass below variations of axillary artery were taken for proper
the teres major musle and not through the documentation and for ready reference.
quadrangular space. The axillary artery may give
rise to high origin of radial and ulnar arteries and
rarely the anterior interosseous artery may arise
from axillary artery.
Case Report:
During routine dissection for the undergraduate
medical students, we observed the variations in the
course and distribution of axillary artery in the
right upper limb of a 80 years old donated
embalmed male cadaver in the Department of
Anatomy, K. J. Somaiya Medical College, Sion,
Mumbai, INDIA. In the present case the axillary
artery, 1cm distal to the outer border of first rib
divided into superficial and deep brachial arteries.
Figure 1: Photograph representation of the axillary
The superficial brachial artery continued as
brachial artery proper and divided at the level of artery of right upper limb divided into superficial
brachial and deep brachial arteries.
neck of radius into radial and ulnar arteries. The
deep brachial artery performed the role of axillary
artery in the axilla. It gave rise to all branches
which are usually given by the axillary artery. The
deep brachial artery first gave superior thoracic,
thoracoacromial, lateral thoracic artery & articular
branch to the shoulder joint. It then divided into
anterior & posterior divisions. The anterior
division gave anterior circumflex humeral,
posterior circumflex humeral and profunda brachii
artery. The posterior division continued as the
subscapular artery and it gave rise to the
circumflex scapular and thoracodorsal arteries.
The deep brachial artery giving rise to all branches
which are normally given by first, second and
third part of axillary artery is very rare and not
found in literature. The profunda brachii artery
arising from anterior division of deep brachial Figure 2: Photograph representation of the
artery is also very rare and not found in literature. superficial brachial artery continued in the arm
The axillary vein was on medial side of superficial without giving any branches. The deep brachial
brachial artery in the arm. The cords of brachial artery divided into anterior & posterior division.
plexus were around the superficial and deep
brachial artery. The origin, course and distribution
of axillary artery was normal on the left side of the
same male cadaver. The photographs of the

Page 104
Figure 3: Photograph representation of the deep Figure 5: Photograph representation of the

brachial artery first gave superior thoracic, posterior division of deep brachial artery
thoracoacromial, lateral thoracic artery & articular continued as subscapular artery gave rise to
branch to the shoulder joint. circumflex scapular and thoracodorsal artery.
DISCUSSION
Variations in the arterial pattern of the upper limb
are commonly found in literature. Bergman R.A.
et al, Rodriguez - Baeza A. et al and Tountas
C.H.P.et al have reported variations in the
branching pattern of the axillary artery (3, 4, 5).
According to Jurjus A. et al the variations and
anomalies of the arterial system of the upper limb
can be best explained on the basis of embryologic
development of the vascular plexuses of the limb
buds (6). Senior H. D. and Singer E. have
proposed the model of development of the arteries
of upper limb. According to them arterial
development begins with the appearance of an
axial artery followed by other branches. The axial
artery forms axillary artery, brachial artery and
anterior interosseous artery. The median artery
Figure 4: Photograph representation of the anterior branches from the anterior interosseous artery. The
division of deep brachial artery gave rise to ulnar artery arises from the brachial artery. The
anterior circumflex humeral, posterior circumflex axillary artery gives a superficial brachial artery
humeral and profunda brachii artery. which continues as the radial artery (7, 8).
According to Tan C.B. et al the variations in the
origin, course and distribution of the axillary
artery are not common (9). Jurjus A. R. et al stated
that the axillary artery is the axial artery of upper

Page 105
limb derived from the the lateral branch of the artery, Type Ia the profunda brachii artery
seventh cervical intersegmental artery (10). originates by 2 separate branches, Type Ib the
Hamilton W. J. et al documented that the arterial profunda brachii artery originates by 3 separate
variations in the upper limb are due to the defects branches, In Type II the profunda brachii artery
in the embryonic development of the vascular arises as a common trunk with superior ulnar
plexus of the upper limb bud. This may be due to collateral artery, In Type III the profunda brachii
arrest at any stage of development, showing artery arises at lower border of teres major so can
regression, retention, or reappearance and may be considered to be arising from axillary or
lead to variations in the arterial origins and courses brachial, In Type IV profunda brachii artery is the
of the major upper limb vessels (11). According to branch of 3rd part of axillary artery. In Type V
Cavdor et al the axillary artery is having two profunda brachii artery arises as a common trunk
distinct variations one is the high origin of the with posterior circumflex humeral. In Type VI
superficial brachial artery which emerges from the profunda brachii artery arises as a common trunk
axillary or brachial artery and continues in the with subscapular and both circumflex humerals
forearm as the radial artery. Second is the from axillary artery and in Type VII profunda
superficial brachial artery may or may not be a brachii artery is absent (14). In the present case the
brachial artery terminating in to radial and ulnar profunda brachii artery arises from the anterior
arteries. The incidence of such superficial brachial division of the deep brachial artery along with
artery is around 0.1- 3.2% as available in the anterior circumflex humeral and posterior
literature (12). De Garis C.F. has observed the circumflex humeral arteries which is rare and not
division of the axillary artery into superficial and found in literature. The arterial variations
deep brachial arteries more frequent in black documented in the present case are due to the
persons (13.4%) than in white persons (4.6%) defects in the embryonic development of the
(13). In the present case the axillary artery divides vascular plexus of the upper limb bud. This may
in to superficial brachial artery and deep brachial be due to arrest at any stage of development,
artery. The superficial brachial artery has not showing regression, retention, or reappearance and
given any branches during its course in the arm. It may lead to variations in the arterial origins and
terminated in to the radial and ulnar arteries and courses of the major upper limb vessels (11). The
the arterial arches of the hand were normal. The embryological correlation of the variations of the
deep brachial artery giving rise to all branches course and distribution of axillary artery seen in
which are normally given by the axillary artery is present case may be by the persistence,
very rare and no such case report is available in disappearance, incomplete development fusion
literature. The deep brachial artery first gave and absorbtion of vessels and the selection of
superior thoracic, thoracoacromial, lateral thoracic unsual path by primitive vascular plexuses (15).
artery & articular branch to the shoulder joint. It According to Decker G.A. G. the knowledge of
then divided into anterior & posterior division. such variations are important while operating on
The anterior division gave rise to anterior chronic dislocation of the shoulder joint. The
circumflex humeral, posterior circumflex humeral orthopaedicians must take precautions while
and profunda brachii artery. The posterior taking transverse incision in order to avoid injury
division i.e. subscapular artery gave rise to to the deep brachial artery and its branches (16).
circumflex scapular and thoracodorsal artery. Yoshinaga K. et al in his study on “A rare
According to Charles et al there are 7 types of variation in the branching pattern of the axillary
origins for profunda brachii artery. In Type I the artery.” concluded that an accurate knowledge of
profunda brachii artery is the branch of brachial the normal and variant arterial pattern of the

Page 106
human upper extremities is important both for Authors are also thankful to Mr. M. Murugan for
reparative surgery and for angiography (17). his help in typing the manuscript.
According to Samuel L. the presence of deep
brachial artery and its branches must be kept in REFERENCES
mind during the surgical repair of brachial plexus 1. Standring S. Gray’s Anatomy: The
injury in order to prevent bleeding (18). Anatomical Basis of Clinical Practice. 40th
Ed. 2008. Churchill-Livingstone: Elsevier.
CONCLUSION ISBN 978-0-443-06684-89.
The arterial variations of the upper limb have been 2. Hollinshed W.H. Anatomy for surgeons in
implicated in different clinical situations. The general surgery of upper limb. The back
variations in the origin and course of principal and limbs. A Heber Harper Book, New York,
arteries are clinically important for surgeons, 1958. pp- 290-300.
orthopaedicians and radiologists performing 3. Bergman RA, Thomson SA, Afifi AK,
angiographic studies on the upper limb. These Saadeh FA (1988).Compendium of human
variations are compared with the earlier data & it anatomic variations. Urban and
is concluded that variations in branching pattern of Schwarzenberg. Baltimore Munich.
axillary artery are a rule rather than exception. 4. Rodriguez - Baeza A, Nebot J and Ferreira B
Therefore both the normal and abnormal anatomy et al (1995).An anatomical study and
of the region should be well known for accurate ontogenic explanation of 23 cases with
diagnostic interpretation and therapeutic variations in the main pattern of the human
intervention. brachio-antebrachial arteries. J Anat 187;473-
479.
Competing Interests: 5. Tountas CHP, Bergman RA (1993) Anatomic
The authors declare that they have no competing variations of the upper extremity . Churchill
interest. Livingstone, New York pp196-210.
6. Jurjus A, Sfeir R, Bezirdjian R (1986).
Authors' contributions: Unusual variation of the arterial pattern of the
SPS wrote the case report, performed the literature human upper limb. Anat Rec 215;82-83.
review & obtained the photograph for the study. 7. Senior H. D. (1926) A note on the
RMM performed the literature search and assisted development of the radial artery .Anat Rec
with writing the paper. STS conceived the study 32:220-221.
and helped to draft the manuscript. All authors 8. Singer E (1933) Embryological pattern
have read and approved the final version persisting in the arteries of the arm.Anat
manuscript. Rec.55;403-409.
9. Tan C.B., Tan C.K. An unusual course and
ACKNOWLEDGEMENT relations of the human axillary artery.
Authors also acknowledge the immense help Singapore Med J 1994; 35: 263-264.
received from the scholars whose articles are cited 10. Jurjus A.R., Correa-De-Aruaujo R., Bohn
and included in references of this manuscript. The R.C. Bilateral double axillary artey:
authors are also grateful to authors / editors / embryological basis and clinical implications.
publishers of all those articles, journals and books Clin Anat 1999; 12: 135-140.
from where the literature for this article has been 11. Hamilton W.J., Mossman H.W.
reviewed and discussed. All the authors are Cardiovascular system. In: Human
thankful to Dr. Arif A. Faruqui for his support.

Page 107
embryology. 4th ed. Baltimore: Williams and 16. Shoulder joint. In: Decker G.A.G., du plessis
Wilkins, 1972: 271-290. D.J. Lee Mc Gregor’s Synopsis of Surgical
12. Cavdar S., Zeybek A., Bayramicli M. Rare Anatomy. 12th ed. Mumbai: K.M. Varghese
variation of the axillary artery. Clin Anat company, 1986: 451.
2000; 13: 66-68. 17. Yoshinaga K., Kodama K., Kameta K.,
13. De Garis C.F., Swartley W.B. The axillary Karasawa N., Kanenaka N., Kohno S. &
artery in white and Negro stocks. Am J Anat Suganuma T. A rare variation in the
1928; 41: 353. branching pattern of the axillary artery.
14. Charles, C.M.; Pen, L; Holden, H.F; Miller, Indian J. Plast. Surg., 39:222-223, 2006.
R.A. & Elvis, E.B. (1931): The origin of the 18. Cervicobrachial region. In: Samuel L.
deep brachial artery in American White & Turek’s orthopaedics: Principles and their
American Negro males. Anatomical Record. Applications: Vol 2. 4th ed. New Delhi:
50: pp 299-302. Jaypee brothers, 1989:913.
15. Arey L. B. Development Anatomy in :
Development of the arteries , 6th edition.
Philadelphia: W.B. Saunders Co; 1957. pg.
375-77.

Page 108
Hundekari jagdish C. et al DOES THERMAL STRESS ALTERS THE AUTONOMIC FUNCTIONS IN MEN EXPOSED TO HEAT?
DOES THERMAL STRESS ALTERS THE AUTONOMIC

FUNCTIONS IN MEN EXPOSED TO HEAT?
IJCRR Hundekari Jagdish C., Bondade A.K.

Vol 04 issue 21
Section: Healthcare
Department of Physiology, MIMER Medical College, Talegaon D. Pune, M.S., India
Category: Research
Revised on:19/09/12 E-mail of Corresponding Author: jchundekari_31@yahoo.co.in
ABSTRACT
Aim and objectives: The aim of the study was to evaluate the relationship between exposure to heat
(stressful stimuli) and indicators of autonomic functions in workers of thermal power station. Material
and method : 133 male workers were selected out of whom 65 workers were exposed to heat (400C to
450C) emitted by boiler in boiler section for 8 hrs daily and 6 days in a week for estimation of plasma
catecholamines and blood pressure. The control group consists of office workers and staff who were
not exposed to extreme heat. Depending on age, they were divided into four groups. Estimation of
plasma adrenaline and nor-adrenaline was carried out by HPLC method with flurimetre detection and
blood pressure by mercury sphygmomanometer between cases and controls to observe the effect of
heat stress on autonomic functions. Results: It was observed that there is highly significant increase in
plasma level of the adrenaline and nor-adrenaline in workers. Systolic and diastolic blood pressure rose
significantly in workers. Conclusion : The general hypothesis to emerge is that automatically mediated
cardiovascular reactions to stressful stimuli (heat) may initiate progression towards sustained
hypertension and coronary heart disease (CHD) in susceptible individuals
Keywords: adrenaline, nor-adrenaline pressure, diastolic blood, systolic blood pressure, thermal
stress.
INTRODUCTION Several kind of mental stress are associated with

Stress is the reaction of body to stimuli that disturb temporary rise in blood pressure. In animal
its normal physiological equilibrium or experiments, it has been shown that repeated
homeostasis. In our daily lives, some stress exposure to stressful stimuli can cause permanent
prepares us to meet certain challenges. The rise in blood pressure. Such a relationship between
productive stress is called Eustress while the other repeated stressful stimuli and a permanent rise in
harmful stress is called Distress1. Stress causes blood pressure is obviously not so easy to establish
mental, emotional and physical responses in in man, partly due to the fact that environmental
humans. When stressed, an organism first stress is difficult to measure and quantitate.3
experiences arousal of the sympathetic nervous Over the past decade, due to the view that stressful
system, followed by activation of the stimuli may influence the onset and progression of
musculoskeletal, cardiovascular and endocrine number of disorders in human beings leading to
systems. The outcome of this process is a series of hypertension, stroke, depression etc. There is
non-specific psycho-physiologic changes such as considerable evidence that heightened autonomic
an increase of certain neurotransmitters in the nervous system activity may be present early in
bloodstream, and results in adverse effects the aetiology of hypertension. It has become clear
associated with the negative aspect of stress.2 over recent years that autonomic regulation of the

Page 109
cardiovascular system is not confined to the brain volunteers were excluded from the study. Those
stem cardiovascular centres, but it is organised having major cardiovascular illness or Diabetes
longitudinally within the central nervous system mellitus in the past or present, with the H/O
with higher cortical and sub cortical regions consumption of tobacco, alcohol, smoking, history
having an important influence. The general of any systemic illness, history of drug treatment.
hypothesis to emerge is that automatically
mediated cardiovascular reactions to psychological METHODOLOGY
challenges may initiate progression towards Collection of blood sample: Venous plasma
sustained hypertension in susceptible individuals.4 adrenaline and nor-adrenaline concentration were
Effect of different stresses on autonomic changes used as a indices of adreno-medullary and
has been studied widely, but occupational sympathoneural regulation respectively. 5ml blood
exposure to heat stress is least studied part of the sample was collected in supine position (30mins)
subject. from anti-cubital vein of the non-dominant
forearm for determination of plasma adrenaline
MATERIAL AND METHOD: and noradrenaline concentration. The blood
The subjects were 133 workers from thermal samples were centrifuged at 40C and
power plant in the age group of 30-50yrs. This catecholamines were assayed by means of HPLC
study group was divided into control (68) and with flurimetre detection after isolation from
experimental groups (65) based on their exposure plasma by a specific liquid/ liquid extraction
to heat. method.5
Selection criteria Blood pressure measurement: Because large
Cases - Only those workers were selected who variations in blood pressure have been shown to
were exposed to heat emitted by boiler in “Boiler exist with a given subject, it is difficult to detect
section”. The workers were exposed for 8 hrs daily differences between groups may lead to
and 6 days a week and temperature to which they misclassification of individuals. Therefore,
are exposed is in between 400 c to 450 c. multiple blood pressure measurements using
Control -The control group consists of office standard procedures were implemented in this
workers and staff who were not exposed to investigation. Their blood pressure was recorded
extreme heat. in supine position using mercury
In the present study, each subject was made sphygmomanometer. Three readings were taken
familiar with the procedure to alleviate any fear or 10minutes apart and mean was taken as blood
apphrension and before starting the procedure, pressure.
they were asked to relax for five minutes. Statistical analysis: For statistical analysis we
Screening of each volunteer was done with the have applied t-test to compare cases with controls.
help of proforma. After Screening, following

Page 110
RESULTS
Table 1:- Comparision of plasma adrenaline (pg/ml) in supine (30mins) between cases and control belonging
to different age group
Groups 31-35yrs 35-40yrs 41-45yrs 46-50yrs
(Group-I) (Group-II) (Group-III) (Group-IV)
Control Cases Control Cases Control Cases Control Cases
No. of Cases 17 16 18 16 20 21 13 12
Mean 9 12 11 18 26 34 43 47
±SD 3 5 5 9 15 16 16 19
t- test P < 0.05 P < 0.001 P < 0.001 P < 0.05
Significant S H.S. H.S. S
Table no. 1 shows highly significant increase in plasma adrenaline level in workers exposed to heat in Group II and
III while significal increase in Group I and IV.
Table 2:- Comparision of plasma noradrenaline (pg/ml) in supine (30mins) between cases and control
belonging to different age group
Groups 31-35yrs 35-40yrs 41-45yrs 46-50yrs
(Group-I) (Group-II) (Group-III) (Group-IV)
Control Cases Control Cases Control Cases Control Cases
No.of Cases 17 16 18 16 20 21 13 12
Mean 159 163 226 234 416 422 386 390
±SD 44 47 45 47 108 114 86 91
t- test P < 0.05 P < 0.001 P < 0.05 P < 0.05
Significant S H.S. S S
Table no. 2 shows significant increase in plasma nor-adrenaline level in workers exposed to heat as compared to
controls in Group I, III and IV while highly significant increase in Group II.
Fig. 1:- Comparision of Systolic blood pressure (mm of Hg) between cases and control belonging to different
age group
130
128
126
124
systolic blood 122
pressure (m m 120
of Hg) 118 cases
116
controls
114
112
110
Group-I (21- Group-II Group- Group-
30yrs ) (31-40yrs) III(41-50yrs) IV(51-58yrs)
p<0.05 P<0.001 P<0.05 P<0.05
p<0.05=significant,p<0.001=highly significant
Fig. No.1 shows highly significant increase in systolic pressure in Group II while significant increase in Group in I,
II and IV.

Page 111
Fig. 2:- Comparison of Diastolic blood pressure (mm of Hg) between cases and control belonging to different
age group
90
88
86
84
diastolic blood 82
pressure (m m of
Hg) 80
cases
78 controls
76
74
72
Group-I (21- Group-II (31- Group-III(41- Group-IV(51-
30yrs ) 40yrs) 50yrs) 58yrs)
p<0.05 P<0.001 P<0.001 P<0.001
p<0 . 0 0 1=H i ghl y si ni f i c a nt , p<0 . 0 5 =si gni f i c a nt
In fig.no.2 diastolic pressure shows highly significant increase in Group II, III and IV.
DISCUSSION Anders Jonsson et at (1977) 3 in their work on

The present study was conducted to explore prolonged exposure to stressful stimuli (noise)
whether exposure to heat is altering the autonomic suggested that prolonged exposure to stressful
functions of the body. Our study shows highly stimuli may have caused repeated rise in blood
significant increase in plasma catecholamine pressure leading to circulatory adaptation and a
concentration when compared with age matched permanent rise in blood pressure. A similar
controls of all the four age groups. A similar hypothesis put forth by Andrew Steptoe et al
statistical significant increase in plasma (1986)4 that autonomically mediated
catecholamine concentration was reported by cardiocascular reactions to psychosocial
Dimsdale JE et al(1980)6 Fibiger W et al (1988),7 challenges may initiate progression towards
Lefur C et al (1999)8, Shinji Y. Amamoto et sustained blood pressure in susceptible
al(2007),9 Milakofsky L et al(1993),10 De Turck individuals.
KH et al (1980) 11 in acute and chronic cases of The other possible cause of increase in blood
different types of stresses. pressure during exposure to heat stress may be
Stress is known to induce more secretion of increased hematocrit which proportionally
adrenaline and noradrenaline from adrenal increases blood viscosity, which is associated with
medulla which is due to uniform arousal of both increased blood pressure18 Stress induced increase
the flight-fight sympathoadrenal systems.12,13,14 In blood pressure can also be due to overactivity of
the present study, systolic and diastolic pressure hypothalamo adrenal medullary axis.12,13
showed significant increase after exposure to
stressful stimuli (heat) which matches with the CONCLUSION
studies done by Parvizpoor D et al (1976)15 Talbott From the present study it may thus be concluded
et al (1985),16 Jian Cu et al (2010),17 Mathew et al that exposure to heat (stressful stimuli) causes
(1995)18 increased sympathetic activity thereby leading to

Page 112
significant increase in systolic and diastolic blood 9. Shinji Y. Amamoto et al. Evaluation of the
pressure. It can also be concluded that prevalence effect of heat exposure on the autonomous
of hypertension, CHD and its risk is higher in nervous system by HRV and urinary
workers exposed to heat stress as compared to catecholamines. Journal Occupational Health.
controls. 2007;49 : 199-204
10. Milakofsky L et al. Effect of repeated stress
ACKNOWLEGEMENT on plasma catecholamine and taurine in
Authors acknowledge the immense help received young and old rats. Neurobiology aging. 1993
from the scholars whose articles are cited and ; 14(4) : 359-366
included in references of this manuscript. The 11. De Turck KH et al. Factors influencing
authors are also grateful to authors / editors / plasma catecholamines during rest and mental
publishers of all those articles, journals and books stress: effect of posture. Pharmaco Biochem
from where literature for this article has been Behaviour. 1980; 13(1) : 129-13
reviewed and discussed. 12. .Nagraja H.S. et al. Effect of different types
of stress on selected cardiovascular
REFERENCES parameters in rats. IJJP. 1999 ; 43(3) : 296-
1. R. Archana et al. The effect of acute noise 304
stress on neutrophil functions. IJPP.1999; 13. Kulkarni S et al. Stress and hypertension.
43(4) : 491-495 WMJ. 1998; 97(11) : 34-8
2. Young-Hee Lee et al. The effects of heat and 14. Saha S et al. Effect of noise stress on some
massage application on Autonomous Nervous cardiocascular parameters and audiovisual
System. Yonsei Med Journal .2011 ;52(6) : reaction time. IJPP. 1996; 40(1) : 35-40.
982-989 15. Parvizpoor D et al. Noise exposure and
3. Anders Jonsson et al. Prolonged exposure to a prevalence of high blood pressure amongs
stress stimuli (noise) as a cause of raised weaver in Iran. J. occupational medicine.
blood pressure in man. Lancet.1977 ; January 1984; 18 : 730-1
8: 186(7) 16. Talbott et al. Occupational noise exposure,
4. Andrew Steptoe. Stress mechanism in noise induced hearing loss and the
hypertension. Postgraduate medical epidemiology of high blood pressure.
journal.1986; 62: 697-699. American J. of epidemiology. 1985; 120(8) :
5. Davies CL et al. Routine determination of 501-514
plasma catecholamines using HPLC with 17. Jian Cui et al. Heat stress attenuates the
electrochemical detection. J Chromatography. increase in arterial blood pressure during the
1982; 231:41-51. cold pressor test. J. applied physiology. 2010
6. Dimsdale J E et al. Plasma catecholamine in ; 109 : 1354-1359
stress and exercise. JAMA 1980; 243: 340- 18. Mathew F et. Acute cholesterol responses to
342 mental stress and change in posture. 1995;
7. Fibiger W et al. Relationship between 152 : 775-780
catecholamines in urine and physical and
mental stress. Int. journal
Psychophysiology.1984; 1: 325-333
8. Lefur C et al. Urinary epinephrine increases
during mental stress.1999 ;48

Page 113
COMPARISON REGARDING KNOWLEDGE, ATTITUDE AND PRACTICE OF BLOOD DONATION
Gunvanti B. Rathod et al
BETWEEN HEALTH PROFESSIONALS AND GENERAL POPULATION
COMPARISON REGARDING KNOWLEDGE, ATTITUDE AND

PRACTICE OF BLOOD DONATION BETWEEN HEALTH
PROFESSIONALS AND GENERAL POPULATION
IJCRR Gunvanti B. Rathod1, Pragnesh Parmar2
Vol 04 issue 21
Section: Healthcare 1
Department of Pathology, Mahatma Gandhi Medical College and Research Institute,
Category: Research
Pillaiyarkuppam, Pondicherry, India
Received on: 08/09/12 2
Department of Forensic Medicine, Mahatma Gandhi Medical College and Research
Revised on:13/09/12
Institute, Pillaiyarkuppam, Pondicherry, India
E-mail of Corresponding Author: neempath@gmail.com
ABSTRACT
Objectives: The objectives of this study are to assess the knowledge, attitude and practice regarding
blood donation among various categories of health professionals and comparing them with that of the
general population. Material and method: A cross sectional descriptive study was carried out at
Pondicherry. Total 150 individuals were interviewed including doctors (n=25), nurses (n=25),
technicians (n=25) and general population of Pondicherry (n=75). All were interviewed with the help
of a pretested and semi-structured questionnaire. Results: There was a significant difference in
knowledge pertaining to blood donation between health professionals and the general population. On
the other hand there was no difference of attitude of the two groups. There was no difference in
knowledge and attitudes according to gender but most of the donors were males.
Conclusion: There is a need to increase the awareness and attitude among the paramedical staff and in
general population. There is also need to motivate females for blood donation. There is also need to
create awareness about blood safety in paramedical staff and general population.
Keywords: Attitude, Blood donation, General population, Health professionals, Knowledge, Practice.
INTRODUCTION are the hope and future of a safe blood supply in

Blood is the most donated tissue in medical the world. [1]
practice and a veritable tool in many life saving The World Health Organization (WHO) estimated
situations when used judiciously. In spite of the that donation by 1 % of a country population is the
rapid and remarkable conquest and breakthrough minimum blood required to meet a nation’s most
of medical science today, there is still no ideal basic needs for blood. [2] India needs about 6 to
substitute. Blood is manufactured by only human 7.5 million units of blood annually and every year
beings and human donation is the only way of there is gradual increase in this demand. [3] The
acquiring blood to meet emergency requirements reasons for increase in demand are because of the
in cases of road traffic accidents, complications of rise in human life expectancy and the
pregnancy and childbirth, various anaemic implementation of new and aggressive surgical
disorders and surgical emergencies. Blood and therapeutic methods requiring large quantities
donation is the act of giving one's blood, so it can of blood and blood products. [4] Donor blood
be transfused into another for therapy. It is safe procurement from voluntary, non-remunerated
and advantageous to the donor, recipient, donor has been adjudged the safest source of
community and the blood transfusion service. blood. Even though Indian law forbidden
Blood can save millions of life and young people collection of blood from paid donors, many times
health care facilities forced to accept blood from

Page 114
paid donors as there are scarcity of voluntary points indicate good knowledge. Based on total
blood donors. [5] Hence the World Health score, knowledge level on blood donation was
Organization has adopted a policy aimed at 100 % categorized into poor (≤8 points), average (9 -14
voluntary, non-remunerated donor blood points) and good (≥15 points). The participation to
procurement by the year 2020. [6] It is a well survey was on voluntary basis. All participants
known fact that in developing countries more than were given a briefing about objective of the study
50 % of blood donations are made by paid and and assured confidentiality in collection of
voluntary donors. [7, 8] Ignorance, fear and wrong personal data.
concepts about blood donation and lack of
voluntary blood donation organizations are major RESULTS
constraints in many developing countries to Table – I showed details of the demographics of
facilitate voluntary blood donation. The study was respondents. The response was gathered from a
designed to determine the behaviour of the total of 150 respondents voluntarily participated in
medical and paramedical persons and general the survey. The age of the respondents ranged
population towards blood donation by their between 17 to 54 years. The study sample
knowledge, attitude and blood donation practice consisted of 93 males (62 %) and 57 females (38
along with factors influencing blood donation and %). The mean age of males was 37 years and the
their willingness to donate the blood voluntarily. mean age of females was 26 years. The
demographics showed the mean age of the
MATERIAL AND METHOD respondents to be 32 years.
This cross sectional study was conducted among There was significant difference in knowledge
health professionals and general population of pertaining to blood donation between health
South India. Total 25 doctors, 25 nurses, 25 professionals and general population. More than
technicians and general population (75) of half 42 (56 %) of the general population had poor
Pondicherry were included as study population. A overall score regarding knowledge, attitude and
well structured validated and self administered practice of blood donation as per Table – II which
questionnaire was used to assess the knowledge, showed overall score comparison of the
attitude and practice about blood donation. The respondents.
questionnaire was pretested and verified for errors. Total 68 (45.33 %) of the respondents had good
Questionnaire consists of three sections: practice, knowledge about blood donation. About one
knowledge and attitude. Blood donation practice quarter 43 (28.67 %) had poor knowledge on what
was assessed through six questions addressing the blood donation entails. Total 62 (41.33%)
nature of donation, frequency of donation, reasons respondents had poor knowledge about the health
for not donating blood etc. Knowledge part conditions that would require blood transfusion,
contains 6 questions; knowledge on blood only 46.67% could state correctly some of the
donation was assessed through questions covering health conditions like anaemia, trauma, road traffic
benefits, requirements and restrictions of blood accidents, sickle cell anaemia and surgery. Total
donation. The attitude for blood donation was 112 (74.67 %) said they can donate blood
assessed through 6 questions with ‘yes’ and ‘no’ voluntarily as per Table – III which showed
options. A scoring mechanism was used to knowledge of respondents on blood donation.
understand overall knowledge level; a score of one More than half of the respondents, total 94 (62.67
has given for each correct response and zero for %) had never donated blood; only few of the
wrong response. Respondents with all correct respondents, total 61 (37.33 %) had ever donated
response get a maximum of 18 points, higher blood. Among those that had ever donated, males

Page 115
(85.71 %) were more than females (14.29 %). blood donation. Hossain et al. has reported similar
More than half, total 30 (53.57 %) of the blood results, 82 % of participants showed a positive
donated by the study population was for relations attitude towards voluntary blood donation. [11]
and total 19 (33.93 %) donated for friends. Very The negative attitude towards paid blood donation
few, only 11 (7.33 %) of the total respondents had reported in other studies [8, 11, 12] was also
voluntarily donated blood. Total 17 (30.35 %) reported in this study. However in this study, only
donated for emergency situations, 28 (50 %) 7.33 % of the respondents had actually donated
donated to replace blood units borrowed from the blood voluntarily. Therefore, the findings of this
blood bank as per Table – IV which showed blood study would suggest that greater knowledge about
donation practice among the respondents. blood donation does not necessarily lead to actual
blood donation practice, probably because of the
DISCUSSION mythical beliefs and wrong perceptions about
Escalating demand for safe blood and its blood donation still held by people. In this study,
availability in our country can be only ensured large number of male and female respondents
through enhancing voluntary blood donations. expressed their willingness to donate blood if they
Role of general population in voluntary blood learn more about the importance of blood
donation is crucial to meet the demand of safe donation.
blood and more over health professionals having a Blood donations among the respondents in this
better understanding on healthcare requirements of study were mostly for beneficial reasons as the
our country should come in forefront. Therefore recipients were mostly friends (33.93 %) and
understanding the various factors contributing to relatives (53.57 %) and the majority claimed
knowledge, attitude and practice of blood donation replacement from the blood bank compelled them
among health professionals and general population to donate blood. The voluntarily donated blood
is important. was scarce (7.33 %) and about two thirds of those
This study revealed that the respondents had good who had donated voluntarily, did so during
knowledge about blood donation; however, it did organizations' activity. This agrees with the
not find any significant relationship between age, findings of Olaiya that voluntarily donated blood
ethnic group and literacy level with knowledge was donated during religious week and club
about blood donation. Even though the activities. [10] Hence the need to explore the
respondents had a good knowledge of blood unions and departmental activities of tertiary
donation, poor blood donation practice was institutions in the country as a means of voluntary
observed in this study as 37.33 % had ever blood donation drive.
donated and only 7.33% had voluntarily donated The reasons given by the respondents for not
blood in the past. This finding agrees with the donating blood include lack of opportunity (26.59
study in Mmabatho where only 17.5 % had ever %) and inaccessibility of blood bank facilities,
donated blood. [9] The results of this study also inadequate information about the benefits of
revealed that almost more than two third of males voluntary blood donation to the donor, recipient
(85.71 %) while only 14.29 % of female had and community (9.57 %) as well as the fear (14.89
donated blood, which is comparable to the study %) that the process is harmful to the health of the
by Olaiya where female donors compared to males donor. Additionally, other inhibitory factors (18.08
were abysmally low (1%). [10] %) that would deter them from blood donation
It is important to note that majority of the were inadequate information about the blood
respondents 112 (74.67 %) participated in this donation process, fear of exposure to HIV/
study shown positive attitude towards voluntary Hepatitis infection and fear of fainting. This shows

Page 116
the wrong perception still held by people of the in the past. There is prime need to increase the
transmission of HIV infection. The same finding awareness and attitude among the paramedical
was seen in Mwanza, Tanzania where donors were staffs & general population. Blood donor
afraid of being infected with HIV. [13] This was education and sensitization should begin at
also a deterrent amongst the Scottish population as secondary school by blood donor organizers. It is
it adversely affected their blood donation practice. also needed to motivate females for the blood
In Australia, a study conducted among the college donation and to create awareness about blood
students showed that the reluctance was mostly safety in paramedical staffs and general
due to fear, contracting possible illness afterward population. Healthcare institutions should take all
and inconveniences of giving blood. [14] Another necessary steps to create more awareness program
study in Mexico also found that non donation was on blood donations among entire community.
mainly due to the fear of getting dizzy after blood Incentives and gift items such as T-shirts, wrist
donation. bands, haematinics and certificates can motivate
A study in Baltimore also found that the donors an altruistic spirit among the people.
would be encouraged to donate if specific
incentives were offered; the highest response was ACKNOWLEDGEMENT
for future blood credits and medical Authors acknowledge the immense help received
testing. [15] Another study in Texas also from the scholars whose articles are cited and
concluded that individuals donate in order to included in references of this manuscript. The
reduce medical risks and that earning future blood authors are also grateful to authors / editors /
credits would be a primary motivator. [16] A study publishers of all those articles, journals and books
amongst the adults in Mwanza Region, Tanzania, from where the literature for this article has been
also noted a positive attitude towards voluntary reviewed and discussed.
blood donation but the majority of the people will
do so only for an incentive. [13] In Nigeria, the REFERENCES
National blood transfusion service is making an 1. Dhingra N., World blood donor day: New
effort to retain its voluntary donors by giving blood for the world, World Health
incentives such as free blood tests (blood group, Organization., Available on
haemoglobin genotype, HIV/ hepatitis) to donors, http://www.who.int/mediacentre/news/releases
allowing the immediate family of volunteers to use /2010/blood_donor_day_20100613/en,
blood without replacement and giving gift items Assessed on 15-08-2012.
such as certificates, T-shirts, haematinics, 2. Gillespie TW, Hillyer CD, Blood donors and
refreshments and badges. [17] When assessing factors impacting the blood donation decision,
donor incentives and enablers, the study found Transfusion Medicine Reviews, 2002; 16:
that, in general, people are focused primarily on 115–130.
motivational tools, rather than rewards. This is 3. National AIDS control Organization (NACO),
critical in beginning to change the blood donation India. Voluntary blood donation programme -
culture from replacement to that of An operational Guideline, 2007. Available
volunteerism. [18, 19] from:
http://www.nacoonline.org/upload/Policies
CONCLUSION and Guidelines/29, voluntary blood
The findings of this study revealed that although donation.pdf, Assessed on 15-08-2012.
the majority of respondents had good knowledge 4. Riley W, Schwei M, McCullough J., The
of blood donation, only a few had donated blood United States potential blood donor pool:

Page 117
Estimating the prevalence of donor exclusion 12. Wiwanitkit V., Knowledge about blood
factors on the pool of potential donors, donation among a sample of Thai University
Transfusion 2007; 47: 1180–1188. students, Vox Sang, August 2002; 83(2): 97-
5. Dixit JV, Mahale AR, Kulkarni AP, et al., 99.
Impact of blood donation awareness campaign 13. Jacob B, Berege ZA., Attitudes and belief
by National Service Scheme of Government about blood donations among adults in
Medical College, Nanded., Indian Journal of Nwanza Region, Tanzania, East African
Community Medicine, Jan-Mar 2001; 26(1): Medical Journal, 1995; 72: 345-348.
12-15. 14. Namgay S, Ranabir P, Subhabrata S.,
6. Blood safety and donation: Fact sheet No. 279. Behaviour disparities toward blood donation
Jun, 2008. Available from: in Sikkim, India, Asian Journal of Transfusion
http://www.who.int/mediacentre/factsheets/fs2 Science, 2008; 2: 56-60.
79/en/. Assessed on 15-08-2012. 15. Sanchez AM, Ameti DI, Schreiber GB, et al.
7. Wake D, Cutting W., Blood transfusion in The potential impact of incentives on future
developing countries: Problems, priorities and blood donor behaviour, Transfusion Journal,
practicalities, Tropical Doctor, 1998; 28: 4-8. 2001; 41: 172-178.
8. Alam M, Masalmeh BE, Knowledge, attitude 16. Burnett JJ., Examining the profiles of the
and practices regarding blood donation among donor and non donor through a multiple
the Saudi population, Saudi Medical discriminated approach, Transfusion Journal,
Journal, 2004; 25(3): 318-321. 1982; 22: 138-142.
9. Mwaba K, Keikelame MJ, Blood donation 17. Federal Ministry of Health in Nigeria. Federal
behaviour and belief among a sample of high Ministry of Health, Policy on blood donation.
school students in Mmabatho, Curationis, Nigeria: Federal Government of Nigeria Press,
1995; 18: 2-3. Abuja, Nigeria, 2007.
10. Olaiya MA, Alakya N, Ajala A, et al., 18. Okpara RA., Attitudes of Nigerians towards
Knowledge, attitude, belief and motivations blood donation and blood transfusion,
towards blood donation among blood donors Tropical and Geographical Medicine, 1989;
in Lagos, Nigeria, Transfusion Medicine, 41: 89-93.
2003: 13-17. 19. Ottong JG, Asuquo EE, Olaniran NS, et al.
11. Hossain GM, Anisuzzaman M, Begum A., Community mobilization for blood donation
Knowledge and attitude towards voluntary in Cross-River state, Nigeria, International
blood donation among Dhaka University Journal of Gynaecology and Obstetrics, 1997;
students in Bangladesh, East African Medical 59: 119-125.
Journal, September 1997; 74(9): 549-553.

Page 118
Table 1: Details of the demographics of respondents.

Variables Frequency (%)
Age (years)
<18 11 7.33
18-25 53 35.33
25-50 70 46.67
>50 16 10.67
Total 150 100
Gender
Female 57 38
Male 93 62
Religion
Hindu 94 62.67
Islam 37 24.67
Christianity 19 12.67
Table 2: Overall score comparison of the respondents

Overall Doctors Nurses Technicians General population
score Frequency % Frequency % Frequency % Frequency %
Good 17 68 10 40 08 32 18 24
Fair 08 32 11 44 10 40 15 20
Poor 00 00 04 16 07 28 42 56
Total 25 100 25 100 25 100 75 100
Table 3: Knowledge of respondents on blood donation

Variables Frequency %
What is blood donation?
Good 68 45.33
Fair 39 26
Poor 43 28.67
Any health problem after blood donation?
Yes 41 27.33
No 109 72.67
Indications for blood transfusion?
Good 70 46.67
Fair 18 12
Poor 62 41.33
Can females donate blood?
Yes 98 65.33
No 52 34.67
Would you donate blood voluntarily?
Yes 112 74.67
No 38 25.33

Page 119
Table 4: Blood donation practice among the respondents.

Variables Frequency %
Ever donated blood?
Yes 56 37.33
No 94 62.67
Total 150 100
Ever donated blood?(by gender) (N=56)
Male 48 85.71
Female 08 14.29
Types of blood donation
Voluntarily 11 7.33
Non voluntarily 45 30
Non donor 94 62.67
Reasons for blood donation (N=56)
Emergency 17 30.36
Replacement 28 50
Organization
07 12.5
activity
Free will 04 7.14
Reasons for non-donation (N=94)
No opportunity 25 26.59
No knowledge 09 9.58
Fear 14 14.89
Other reasons 17 18.08
Unfit 29 30.86

Page 120
Pushpalatha M. et al ACCESSORY SPLEEN – A CASE REPORT
ACCESSORY SPLEEN – A CASE REPORT
IJCRR Pushpalatha M., Sujana M., Sharmada K.L

Vol 04 issue 21
Section: Healthcare Department of Anatomy, Bangalore Medical College and Research Institute,
Category: Case Report Bangalore, India
Revised on:28/09/12
E-mail of Corresponding Author: mpushpalatha145@gmail.com
ABSTRACT
Accessory spleen is a common congenital anomaly. There are currently no endoscopic ultrasound
criteria for the diagnosis or differentiation of this benign splenic anomaly from pathologic disorders
including neoplasms. Accessory spleen and splenic lobulation can be misinterpreted as neoplasm by
endoscopic ultrasound. Although homogenous, they can be hyperechoic or hypoechoic [1]. Accessory
spleen has been known to rupture [2].
Keywords: Endoscopic ultrasound, neoplasms, pathologic disorders.
INTRODUCTION the blood supply from small branches arising from

An accessory spleen is a small nodule of splenic the left Gastro epiploic artery. Spleen was normal
tissue found apart from the main body of the in its position and gastrosplenic ligament was
spleen. Accessory spleens are found in present.
approximately 10% of the population [3]. They are
typically around 1 centimeter in diameter. They
form either by the result of developmental
anomalies or trauma. They may result in
interpretation errors in diagnostic imaging [4]. The
most common locations for accessory spleens are
the hilum of the spleen and adjacent to the tail of
the pancreas. They may be found anywhere along
the splenic vessels, in the gastrosplenic ligament,
the splenorenal ligament, the walls of the stomach
or intestine, the pancreatic tail [5], the greater
omentum, the mesentry or the gonads and their
path of descent [6]. Fig: 1
Case report DISCUSSION

During routine dissection for 1st year medical Anatomy text books tend to mention the
undergraduate students in Anatomy Department in infrequent presence of accessory spleens as an
BMCRI. During the routine dissection of stomach anatomic fact devoid of pathological significance.
and its relations along the greater curvature in the The Accessory spleen is an anomaly which is due
greater omentum a splenic tissue about 3cm in to development abnormalities in the embryo [7].
diameter was oval in shape. It was 7cm distal to Ten patients with the mean age of 58 years were
the cardiac end of the stomach. It was receiving evaluated 9 for pancreaticobiliary disease and 1

Page 121
Pushpalatha M. et al ACCESSORY SPLEEN – A CASE REPORT
for gastric sub mucosal mass of which 8 had an

accessory spleen [1].The developing spleen forms REFERENCES
near the urogenital ridge from which the gonads 1. Barawi M, Bekal P, Gress F. Division of
develop. The gonads may pick up some tissue Gastroenterology and Hepatology, Winthrop-
from the spleen and as they descend through the University Hospital, State University of New
abdomen they can produce either a continuous or a York at Stony Brook, Mineola, New York
broken line of deposited splenic tissue [6]. 11501, USA. 2000 Dec;52(6):769-72.
The typical size is approximately 1 centimeter, but 2. Kumar, R.: A Case of Traumatic Rupture of
sizes ranging from a few millimeters up to 2-3 cm an Accessory Spleen, Arch Dis Child. 1962
are not uncommon [6]. Apiril;37:227.
3. Moore, Keith L. Clinically Oriented Anatomy
3rd ed. Baltimore: Williams &
Wilkins.1992;p.187.
4. Grayer G; Zissin R, Apter S, Atar E, Portnoy
O, Itzchak Y. CT findings in congenital
anomalies of the spleen. British Journal of
Radiology. 2001 Aug;74(884):767-772.
5. Kin SH; Lee JM, Hun JK, Lee JY, Kim KW,
Cho KC, Choi BI. “Intrapancreatic Accessory
Spleen: Findings on MR Imaging, CT, US and
Scintigraphy, and the Pathologic Analysis”.
Korean J Radiology. 2008 Apirl;9(2):162-174.
6. Chen S-L; Kao Y-L, Sun H-S, Lin W-L.
Splenogonadal Fusion. Journal of the
Formosan Medical Association. 2008
Fig: 2
Nov;107(11):892-5.
7. Settle, E.B.: The Surgical Importance of
CONCLUSION
Accessory Spleens, Amer J Surg. 1940
Thus the presence of accessory spleen is rare
Oct;50:22-26.
findings providing knowledge for surgeons and
radiologists. They are medically significant in that
they may result in interpretation errors in
diagnostic imaging [4]. It may lead to continued
symptoms after therapeutic splenectomy [3].

Page 122
OXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS IN PATIENTS WITH TYPE 2
Al- G. Mohammed et al
DIABETES MELLITUS WITH AND WITHOUT CORONARY ARTERY DISEASE
OXIDATIVE STRESS AND ANTIOXIDANT ENZYME STATUS

IN PATIENTS WITH TYPE 2 DIABETES MELLITUS WITH
AND WITHOUT CORONARY ARTERY DISEASE
IJCRR Al- Ghonaim Mohammed I., Ramprasad N., Abdel-Ghaffar Mamdouh H.
Vol 04 issue 21
Section: Healthcare
Medical Laboratory Science Department, College of Applied Medical Sciences,
Category: Research
Shaqra University, Al- Quwayiyah, Kingdom of Saudi Arabia
Revised on:17/09/12
Accepted on:23/09/12 E-mail of Corresponding Author: ramprasad4u7@gmail.com
ABSTRACT
Background: Diabetes Mellitus (DM) is the most common disorder characterized by metabolic
abnormalities and long term complications. Patients with type 2 diabetes mellitus are more prone to
Coronary Artery Disease (CAD). Although oxygen free radicals are known to contribute to the
development of CAD and diabetes. Oxidative stress occurs as a result of increased level of lipid
peroxides and free radical intermediates, as well as the decreased in total antioxidant capacity.
Aim: In the present study, our aim was to investigate the lipid peroxidation, lipid profile and
antioxidant enzymes in diabetic patients with and without CAD. Materials and Methods: The study
was carried out in 62 patients suffering from diabetics, 59 patients suffering from diabetes with CAD
and 78 healthy controls were randomly selected. Various parameters like serum lipid profile,
Malondialdehyde used as an index of oxidative stress, antioxidant enzymes like Glutathione peroxidase
(GPx), Superoxide dismutase (SOD), and Paraoxonase (PON) were measured and compared. Results:
Increased levels of MDA concentration, total cholesterol, triglycerides, LDL-cholesterol, while
decreased levels of HDL- cholesterol, GPx, SOD and PON were significantly low (p<0.001) in
diabetes with CAD patients compared to diabetes without CAD patients. Conclusion: The hypothesis
of the current study indicates that increased concentration of lipids and lipid peroxide levels may be
contribute to decreased levels of antioxidant enzymes that are associated with increased consequences
of diabetes leading to Coronary artery disease.
Keywords: Lipid peroxidation, Lipid profile, Glutathione peroxidase, Superoxide Dismutase,
Paraoxonase.
INTRODUCTION Epidemiological surveys indicate that there could

Diabetes mellitus (DM) is a chronic disorder be 15-20 million cases of CAD in India. The
resulting from a number of factors in which an incidence is higher in urban than rural population
absolute or relative deficiency of insulin or its [3].
function occurs [1]. World health organization has Diabetes mellitus threatens to become a global
reported that global prevalence of diabetes will health crisis; treating diabetes and its
increase more than double from 135 million to 300 complications is going to dominate future health
million by 2025. India stands as the first in whole care expenditures. NIDDM accounts for about
world to have the largest number of diabetes 90% of the total diabetic population, and coronary
mainly Non Insulin Dependent Diabetes mellitus artery disease (CAD) is the most common cause of
(NIDDM) [2]. morbidity and mortality. Cardiovascular deaths are
Coronary Artery Disease (CAD) is a rising increased up to fourfold in diabetics compared
problem in developing countries like India. with their nondiabetic counterparts. The

Page 123
development of atherosclerosis is closely diseases such as cancer, diabetes and CAD. Low
associated with risk factors such as hypertension plasma levels of antioxidant as well as low intake
(HTN), obesity; smoking, dyslipidemia and of dietary antioxidants have been associated with
mainly diabetes have been identified [4]. an increased risk of atherosclerotic heart disease
Oxidative stress is defined as the interruption of [9]. Enzymatic Glutathione peroxidase (GPx),
balance between oxidants and reductants within Superoxide Dismutase (SOD) and PON play an
the body due to the excess production of peroxides important role in alleviating tissue damage due to
and free radicals. This imbalance will cause formation of free radicals. Morever, the body
damage to cellular components and tissues in the defense mechanism would play an important role
body leading to oxidative stress and as well as the in the form of antioxidants and try to minimize the
decrease in total antioxidant capacity [5]. damage adapting itself to the above stressful
Hyperglycemia, a hallmark of diabetic depletes situation.
natural antioxidant and facilitates the production Hence a systemic approach has been made in the
of reactive oxygen species (ROS) which has the present study to focus on the Diabetes and
ability to react with all biological molecules like Coronary artery disease. Oxidative stress was
lipids, proteins, carbohydrates, DNA etc and exert measured by the serum levels of MDA, which is
cytotoxic effects on cellular components. Thus as widely used as an index of the extent of oxidative
increased ROS and impaired antioxidant defense damage, stress related enzymes such as GPx, SOD
contribute for the initiation and progression of and PON were measured and compared in type 2
micro and macro vascular complications in diabetic subjects with and without Coronary
diabetes [6]. Artery Disease along with normal healthy
DM is characterized by hyperglycemia together subjects.
with biochemical alternations of glucose and lipid
peroxidation. Lipid peroxidation is a free radical MATERIALS AND METHODS
related process, which is potentially harmful The study was case controlled in design. We have
because its uncontrolled, self-enhancing process selected the patients as they are presented. The
causes disruption of membranes, lipids and other study was only male oriented. Patients included in
cell components. A lot of oxygenated compounds, the present study were all admitted to the medicine
particularly aldehydes such as Malondialdehyde unit or attending the Out Patient Department
(MDA) are produced during the attack of free (OPD) of medicine and some patients were
radicals to membranes, lipoprotein and admitted to the intensive coronary care unit
polyunsaturated fatty acids [7]. Thus lipid (ICCU) of Al- Quwayiyah Government General
peroxidation in the blood provides useful Hospitals, Shaqra University, Kingdom of Saudi
information for the prognosis of diabetes in which Arabia, during the period from October 2011 to
secondary disorders are often fatal. August 2012 were included in the study.
Serum Paraoxonase (PON) synthesized in the liver Consecutive 121 patients with type 2 diabetes
and it is High density lipoprotein cholesterol mellitus, admitted to hospital were selected for the
(HDL-C) associated enzyme that prevents study and they were between 40- 65 years. They
oxidative modification of Low density lipoprotein were further classified into two groups. 62 patients
cholesterol (LDL-C). Serum PON is responsible were diabetes mellitus without CAD and another
for the antioxidant activity of HDL- C [8]. group of 59 patients were diabetes mellitus with
Sufficient levels of antioxidants are important to CAD. The criteria for the diagnosis of type 2
live with healthy condition for human beings and diabetes was fasting blood glucose >126.0 mg/dl
most important for the prevention of chronic [10] and glycated hemoglobin (HbA1c) 6.2% [11].

Page 124
The criteria for the diagnosis of CAD was made iodophenyl 3-4- nitrophenol- 5-phenyl tetrazolium
on the basis of clinical history, history of chloride to form a red formazon dye [20]. PON
myocardial infarction, 12 leads electrocardiogram activity was estimated by using 5.5 Mm p-nitro
(ECG) and coronary angiography findings. phenyl acetate (sigma chemicals Co.,) as a
Smoking was defined as regular smoking of substrate. The change in the absorbance at 412 nm
cigarettes / Beedies (a local type of tobacco). due to the formation of p- nitro phenol was
Those patients whose body mass index (BMI) >25 measured by using ELICO spectrometer [21].
were considered as obese. Controls had 78 healthy
age matched, non diabetes, non myocardial STATISTICAL ANALYSIS
infarction, non smoking and non alcoholic healthy All values are expressed as mean ±SD. Student t-
individuals. test was used to estimate the significant difference
All diabetic patients selected for this study were between the groups. Pearson’s correlation analysis
on irregular treatment for diabetics and none of the was used to test the correlation between various
study subjects was an antioxidant supplementation parameters and considered significant when
or lipid lowering drugs. Subjects suffering from p<0.05. SPSS for windows 13.0 was used for
renal, hepatic disease and any chronic or acute statistical analysis.
inflammatory illness were excluded from the
study. RESULTS
All participants gave written informed consent and The clinical characteristic of the two groups of
this protocol was approved by the ethical and type 2 diabetes mellitus patients and control
human research committee of College of Applied subjects are presented in Table I. In present study
Medical Sciences, Shaqra University, Al- number of smokers and hypertensive were more in
Quwayiyah, Kingdom of Saudi Arabia. diabetes mellitus with CAD compared to diabetes
Fasting venous blood samples were collected from mellitus without CAD and controls.
all the study subjects after an overnight fast. Serum levels of fasting glucose, HbA1c, total
Fasting glucose levels were estimated by cholesterol, triglycerides, LDL-C were
enzymatic methods [12]. Glycemic control was significantly higher in diabetes with CAD compare
assessed by measuring glycated hemoglobin by the to controls (p<0.001), whereas decreased HDL-C
resin-ion exchange method [13]. The lipid profile (p<0.001) levels in diabetics with and without
was done by fully auto analyzer (ERBA-XL-300). CAD patients as compared to controls Table II.
The concentration of serum Cholesterol was Antioxidant enzymes such as GPx, SOD and PON
estimated by CHOD- PAP method [14], were significantly decreased (p<0.001) in diabetics
Triglycerides level was estimated by GPO without CAD and further decreased in diabetes
(trinder) method [15], while HDL-C estimation with CAD as compared to controls (p<0.001).
was done by Phosphotungestic method [16] and Whereas MDA levels were significantly increased
LDL-C levels were estimated by enzymatic (p<0.001) in diabetes with CAD compared to
methods [17]. Serum levels of MDA, a marker of diabetes without CAD and controls as shown in
lipid peroxidation were measured by thiobarbutric Table III.
acid (TBA) method [18]. The haemolysate In order to ascertain any relationship between
prepared from the red cells was used for the HbA1c levels with various antioxidant enzymes
estimation of antioxidant enzyme activities. GPx and stress factors, linear correlation analysis was
was measured by the method of Paglia and carried out. Results revealed that GPx, SOD and
Valentine [19]. SOD estimation was based on the PON activities were negatively correlated with
reaction between superoxide radicals and 2-4- HbA1c level. Whereas MDA concentration was

Page 125
positively correlated with HbA1c levels in neutralizing the atherogenic effects of oxidized
diabetics without CAD and diabetics with CAD as LDL [28].
shown in Table IV. MDA is a natural product of lipid peroxidation and
reflects the oxidant status of the biological
DISCUSSION systems. It has been demonstrated that high MDA
Type 2 (Non-Insulin-Dependent) Diabetes is levels are associated with high oxidative stress in
associated with a marked increase in the risk of diabetes mellitus and CAD [29]. Several authors
coronary heart disease. It has been debated have reported increased levels of lipid
whether patients with diabetes who have not had peroxidation in diabetic patients [30, 31] while a
myocardial infarctions should be treated as few could not find any significant increase in lipid
aggressively for cardiovascular risk factors as peroxidation in diabetes [32, 33]. Few authors
patients who have had myocardial infarctions have reported increased levels of MDA in CAD
[22]. patients [6, 34]. In our study also, increased levels
Although it has been apparent for some time that of MDA in diabetic patients and further increased
coronary heart disease (CHD) is the major cause in diabetic with CAD patients compared to
of morbidity and mortality in patients with type 2 controls, because at a time two diseases have a still
diabetes. Framingham study demonstrated a direct greater degree of oxidative stress.
association between diabetes and heart failure Earlier studies on the relationship between the
[23]. CAD occurs due to a number of factors in lipid peroxides and glycemic controls have yielded
diabetics; both insulin resistance and elevated lipid conflicting results. Kesavulu et al [35] and Losada
levels, common in diabetics primarily triggers et al [36] have shown a positive correlation
atherogenic injury. It is also suggested that between MDA and the measure of blood glucose
endothelium in diabetic arteries is more prone to control such as HbA1c, while several authors
atherogenic injury due to decreased production of could not [37]. Similarly, positive correlation
endothelial nitric oxide, known to be between the MDA concentrations versus HbA1c
antiatherogenic, and increased production of levels was observed in the present study. The
plasminogen activator inhibitor [24]. estimation of lipid peroxidation in the diabetes and
Tobacco Smoking is one of the most powerful CAD patients is very useful as it may serve as a
modifiable risk factor for the development of CAD useful monitor to judge the prognosis of the
and diabetes patients [25]. Our data showed that patients.
prevalence of smoking was significantly higher in Free radicals scavenging enzymes such as GPx
diabetes with CAD patients as compared to and SOD are the first line of cellular defense
controls. Like other studies [26, 27] in our study against oxidative injury, which are involved in the
also, hypertension and obesity was found to be disposal of superoxide anions and hydrogen
significantly high in diabetic patients and further peroxide [28]. One of the most important
increased in diabetic with CAD patients. antioxidant enzymes found in the humans is GPx;
Atherosclerosis is a process for which there is it protects the cell damage by catalyzing the
substantial evidence of a role for oxidative stress. reduction of lipid hydroperoxides and also protects
Hypercholesterolemia and triglyceridemia are the heart from damage by oxidative stress due to
independent risk factor that alone or together can oxygen free radicals through its antioxidant effect
accelerate the development of CAD and [38]. A few authors have reported increased GPx
progression of atherosclerotic lesions. HDL may activity in the RBC of type 2 diabetes [39]. In
be protective by reversing cholesterol transport, contrast, some reports have described a decreased
inhibiting the oxidation of LDL and by activity of erythrocyte GPx in diabetic patients

Page 126
[35] and CAD patients [40]. Similarly in the significantly lowered in patients with diabetes
present study also, it was found significantly mellitus and CAD. Lower serum PON activity has
decreased activity of GPx in diabetic patients due been associated with increased susceptibility to
to decreased activity of glucose-6- phosphate atherosclerosis, neuropathy, retinopathy and other
dehydrogenase in erythrocytes [28]. However complications in diabetic population compared
hypercholesterolemia is also one of the reasons for with healthy controls. In the present study also, a
the decreased GPx activity in CAD patients. So decreased PON activity was observed in diabetes
we have observed further decreases in diabetic and this further decreased in diabetes with CAD
with CAD patients. Another one of the important patients. Thus there was a significant negative
antioxidant enzymes present in human body is correlation between HbA1c and serum PON
SOD. Some studies reported reduced levels of activity.
SOD activity in diabetes [41] and Suresh Chari et There were some limitations in the present study,
al [42] says decrease in the activity of SOD in sample size was small and it was a hospital based
CAD patients. On the other hand jain et al [43] study, so can’t represent whole population. There
reported on increased levels of SOD in diabetes is need to perform such studies on larger and
and MM Kesavulu et al [44] revealed that there is community based population.
no change in the activity SOD in CAD patients,
but Sree hari babu et al [45] says decreased levels CONCLUSION
of SOD activity in diabetic patients, Whereas in It is very clear from this study that there are
the present study decreased activity of erythrocyte abnormalities in lipid profile, lipid peroxide levels
SOD was observed in diabetic without CAD and antioxidant enzymes in diabetic patients with
patients and further decreased in diabetic with and without CAD. We hypothesized that reduced
CAD patients because of superoxide is the main antioxidant enzyme activities and increased MDA
reactive oxygen species which react with nitric levels may contribute to the increased
oxide radical and forms peroxynitrite thereby susceptibility for the development of insulin
causing oxidative stress, cellular damage and also resistance and CAD in patients with NIDDM. The
increased levels of lipid peroxidation and present study illustrates that reduced consumption
conjugated dienes [46]. This would seem of alcohol, smoking, animal saturated fat and
unexpected because in a disease with elevated increased consumption of n-3 fatty acids, intake of
oxidative compounds, a compensatory increase in fruits and vegetables, tree nuts, natural of
antioxidant enzymes would be desirable. antioxidants, supplementation of trace elements,
It was tested whether there was a correlation physical activity and maintenance of healthy body
between HbA1c levels and SOD, GPx activity and weight and secondary measures like control of
our results showed a significant negative hyperglycemia and HTN are the measures to
correlation between HbA1c versus GPx and SOD mitigate the devastating consequences of diabetes
levels, which suggest that the enzymes could be which further may lead to cardiovascular diseases.
glycated. Similarly Faure et al [47] and Nath et al Thus, further investigations of therapeutic
[48] revealed that there was a significant negative strategies to prevent or delay the progression of
correlation between HbA1c versus SOD and GPx diabetic cardiovascular complications are needed.
level.
In recent studies, reduced serum PON activity has ACKNOWLEDGEMENT
been reported to be associated with increased risk We thank the Deanship of Scientific Research,
of insulin resistance [49]. Mackness et al [21] and College of Applied Medical Sciences, Al-
Leviev et al [50] reported the PON activity was Quwayiyah, Shaqra University, Kingdom of Saudi

Page 127
Arabia. Authors acknowledge the immense help patients with non insulin dependent diabetes
received from the scholars whose articles are cited mellitus. Metab 1998; 47: 598- 602.
and included in references of this manuscript. The 9. MS Van der Gaag, R Van den Berg, H Van
authors are also grateful to authors / editors / den berg et al. Moderate consumption of Beer,
publishers of all those articles, journals and books red wine and spirits has counteracting effects
from where the literature for this article has been on plasma antioxidants in middle- aged men.
reviewed and discussed. Eur of Clin Nutrition 2000; 54: 586- 591.
10. Trinder P. Blood sugar estimation by GOD-
REFERENCES POD method. Ann Clin Biochem 1969; 6: 24-
1. King H, Aubert RE and Herman WH. Global 27.
burden of diabetes, 1995-2025. Prevalence, 11. Trivelli, LIA.et al Glycosylated Hemoglobin
numerical estimates and projection. Diabetes estimation by Ion Exchange Resin Method.
care 1988; 21: 1414- 1431. New Eng J Med 1971; 284:353.
2. Taylor SI. Deconstructing type 2 diabetes. 12. Hayvarinen, A. and Nikkila, E. Specific
Cell 1999; 97: 9- 12. determination of blood glucose with ortho-
3. Srikrushna Mahaptra, Kashinath Padiary, toluidine. Clin Chim Acta 1962; 7:140- 143.
Trinath Kumar Mishra, et al. Study on Body 13. Eross, J., Kreutzmann, D., Jimenez, M., Keen,
Mass Index, Lipid Profile and Lipid R., Rogers, S., Colwell .C et al. Colorimetric
Peroxidation status in Coronary Artery measurement of Glycosylated protein in whole
Disease. J Indian Med Assoc 1998; 96: 2: 40 - blood red cells, plasma and dried blood. Ann
42. Clin Biochem 1984; 21: 519-522.
4. Enrique Z Fisman, Alexander Tenenbaum. A 14. Richmond W. Preparation and properties of
cardiologic approach to Non- insulin cholesterol oxides from nocardia sp. and its
antidiabetic Pharmacotherapy in patients with application to the enzymatic assay of total
heart disease. Cardiovascular Diabetology cholesterol in serum. Clin Chem 1973;
2009; 10: 1186: 1475- 2840- 8- 38. 19:1350-6.
5. L. E. Pavlova, V. M. Savov, H. G. Petkov, and 15. McGowan MW, Artiss JD, Strandbergh DR,
I. P. Charova. Oxidative stress in patients with Zak B. A peroxidase-coupled method for the
Beta Thalassemia major. Prilozi 2007; 28: 1: colorimetric determination of serum
145- 154. triglycerides. Clin Chem 1983; 29: 538-42.
6. Shivaprakash T.M, Purnima Dey Sarkar, 16. Rifal N, Warnick GR editors. Laboratory
Tripti Sharma, Ramprasad. N and R. measurement of lipids, lipoproteins and
Maheshwari. Oxidative Stress and apolipoproteins. Washington DC: American
Paraoxonase status for Coronary Artery Association of Clinical Chemistry (AACC)
Disease in NIDDM patients. Biomedical press; 1994 p. 21 – 42.
Research 2007; 18: 2: 19- 23. 17. Pissani T, Gebski CP, Leary ET, et al.
7. Mahbood, M .F and Rahman P.G. Serum lipid Accurate direct determination of low density
Peroxidation and antioxidant enzyme levels in lipoprotein cholesterol using an immune
male and female diabetic subjects. Singapore separation reagent and enzymatic cholesterol
Med J 2005; 46: 322- 324. assay. Arch Pathol Lab Med 1995; 119: 1127-
8. Ikeda Y, Suehiro T, Nakauchi Y, Morita T and 1135.
Arii K. Serum PON activity and its 18. Yagi K. Lipid peroxides and Human diseases.
relationship to diabetic complications in Chem Phys lipids 1987; 45: 337-351.

Page 128
19. Paglia DE, Valentine WN. Studies in the 29. Jung HH, Choi DH, Lee SH. Serum
qualitative and quantitative characterization of Malondialdehyde and Coronary artery disease
erythrocytic glutathione peroxidase. J Lab in hemodialysis patients. Am J Nephrol 2004;
Clin Med 1967; 70: 158- 169. 24: 537- 542.
20. Arthur JR, Boyne R. Superoxide dismutase 30. Mooradian AD. Increased serum conjugated
and glutathione activities in neutrophils from dienes in elderly diabetic patients. J Am
selenium deficient and copper deficient cattle. Geriatric Soc 1991; 39: 571- 574.
Life sciences 1985; 36: 1569- 1575. 31. Griesmacher A, Kindhauser M, Andert SE,
21. Mackness MJ, Harty D, Bhatnagar D, Schrenier W, Toma C, et al. Enhanced serum
Winocour PH and Arrol S. Serum PON levels of thiobarbituric acid reactive
activity in familiar hypercholesterolemia and substances in diabetic mellitus. Am J Med
insulin dependent Diabetes mellitus. 1995; 98: 469- 475.
Atherosclerosis 1991; 86: 193- 198. 32. Velazquez E, Winocour PH, Kesteven P,
22. Steven. M. Haffner, M.D SeppoLehto, M. D., Alberti KG and Laker MF. Relation of lipid
et al. Mortality from Coronary Heart disease peroxides to macrovascular disease in type 2
in subjects with and Type 2 diabetes and in diabetes. Diabet Med 1991; 8: 752- 758.
non diabetic subjects with and without prior 33. Sklodowska M, Gromadzinska J and
Myocardial infraction. N Eng J Med 1998; Wasowicz W. Lipid peroxidation
339: 229- 234. concentration, selenium level and glutathione
23. Saxena KK. Congestive Heart Failure in peroxidase activity in blood of type 2 diabetic
Diabetes. Cardiology Today 2002; 2: 71- 76. elderly people. J Clin Biochem Nutr 1989; 7:
24. Purnima dey Sarkar, Shivaprakash. T. M, B. 35- 41.
Madhusudhan. Association between PON 34. Sharma Anitha, Sharma Ashish, Agarwal
activity and Lipid levels in patients with Apurva. Correlation of Homocysteine with
premature coronary artery disease. Clinica MDA and Lipid parameters in CAD patients.
Chimica Acta 2006; 373: 1:2: 77- 81. IJCRR 2012; 4: 14: 44- 48.
25. Pias P, Pogue J, Gstein H et al. Risk factors 35. Kesavulu MM, Giri R, kameshwara Rao B and
for AMI in Indians: a case- control study. Apparao C. H. Lipid peroxidation and
Lancet 1996; 348: 358- 363. antioxidant enzyme levels in type 2 diabetics
26. Chen L, Chester M, Kaski JC. Clinical factors with microvascular complications. Diab Metab
and angiographic features associated with 2000; 26: 387- 392.
premature coronary artery disease. Chest 36. Losada M and Alio JL. Malondialdehyde
1995; 108: 364- 49. serum concentration in type 1 diabetes with
27. Zimmerman FH, Cameron A, Fisher LD. and without retinopathy. Doc Opthalmol
Myocardial infraction in young adults: 1996- 97; 93:223- 229.
angiographic characterization, risk factors and 37. Freitas JP, Filipe PM, and Rodrigo FG. Lipid
prognosis. J Am Coll Cardiol 1995; 26: 654- peroxidation in type 2 normo lipdemic
61. diabetic patients. Diabet Res Clin Prac 1997;
28. K. Kaviarasan, M.M. Arjunan, K.V. 36: 71- 75.
Pugalendi. Lipid Profile, oxidant- antioxidant 38. Q. Shazia, Z H Mohammad, Taibur Rahman,
status and glycoprotein components in and Hossain Uddin Shekar. Correlation of
hyperlipidemic patients with/ without diabetes. oxidative stress with Serum Trace Element
Clin Chim Acta 2005; 362: 49- 56. Levels and Antioxidant Enzyme Status in Beta
Thalassemia major patients: A Review of the

Page 129
Literature. Anemia 2012; Hindawi Publishing 45. B. Sree Hari Babu, D. Lakshmi Lalitha, P.K
Corporation: Article ID 270923: 7 pages: doi: Behera, D.S.S.K Raju. Study of serum
10.1155/ 2012/ 270923. Adenosine deaminase as an effector of
39. Rema M, Mohan V, Bhaskar A, and oxidative stress in diabetes mellitus type 2.
Shamugasundram KR. Does oxidative stress IJCRR 2012; 4: 16: 108- 115.
play a role in diabetic retinopathy?. Ind J 46. S. Filiz, O. Gulyuz, K. Sabri, E. Deniz, and H.
Opthalmol 1995; 43: 17- 21. Alev. “Oxidant and Antioxidant status in beta
40. Purnima Dey Sarkar, Ramprasad N, Indranil Thalassemia major patients”. Journal of
Dey Sarkar, and Shivaprakash TM. Study of Ankara University faculty of Medicine 2005;
oxidative stress and trace element levels in 58: 1: 34-38.
patients with Alcoholic and Non Alcoholic 47. Faure P, Benhamou PY, Petard A, Halini S
Coronary Artery Disease. Indian J Physiol and Roussel AM. Lipid peroxidation in insulin
Pharmacol 2007; 51: 2: 141- 146. dependent diabetic patients with early retina
41. Vucic M, Gavella M, Bozikov V, Acroft SJ degenerative lesions: effects of an oral zinc
and Rocic B. Superoxide dismutase activity in supplementation. Eur J Clin Nutr 1995; 49:
lymphocytes and polymorphonuclear cells of 282- 288.
diabetic patients. Eur J Clin Chem Biochem 48. Nath N, Chari and Rathi B. Superoxide
1997; 35: 517- 521. dismutase in diabetic polymorphonuclear in
42. Suresh Chari and Madhur Gupta. Proxidant diabetic polymorphonuclear leucocytes.
and Antioxidant status in patients of type 2 Diabetes 1984; 33: 586- 589.
diabetes mellitus with IHD. Ind Jour Clin 49. Polat Dursun, Ezgi Demirtas, Ahmet Baayrak
Biochem 2006; 21: 2: 118- 122. and Hakan Yarali. Decreased serum
43. Jain AP, Mohan A, Gupta OP, Jajoo UN and Paraoxonase 1 activity: an additional risk
Kalantri. SP. Role of oxygen free radicals in factor for atherosclerotic heart disease in
causing endothelial damage in diabetes patients with PCOS?. Human Reproduction
mellitus and its microvascular complications. J 2006; 21: 104- 108.
Diab Assoc India 1998; 38: 51- 54. 50. Leviev I, Kalix, Brulhart, Meynet MC, and
44. MM Kesavulu, B Kameswara rao, R Giri, J James RW. The PON 1 promoter
Vijaya, G Subramanyam, et al. Lipid polymorphism C (-107) T is associated with
peroxidation and antioxidant enzymes status in increased serum glucose concentration in non
type 2 diabetics with Coronary Heart Disease. diabetic patients. Diabetol 2001; 44: 1177-
Diab Res and Clin Prac 2001; 53: 33- 39. 1183.
Table 1. Clinical details of the study subjects

Particulars Controls Diabetes without CAD Diabetes with CAD
(n=78) (n= 62) (n= 59)
Mean ±SD Mean ±SD Mean ±SD
Age (yrs) 47.6 ± 7.9 50.2 ± 12.3 53.8 ± 11.4 *
BMI (kg/m2) 22.7 ± 8.1 25.2 ± 3.5 28.0 ±4.2 *
HTN % 7% 59 % 70 % *
Smokers % 9% 62 % 72 % *
* P<0.001, Highly significantly compared to controls. BMI= Body mass Index, HTN= Hypertension,
CAD= Coronary Artery Disease.

Page 130
Table 2: Biochemical details of study subjects

Parameters Controls Diabetes without Diabetes
(n=78) CAD with CAD
Mean ±SD (n= 62) (n= 59)
Mean ±SD Mean ±SD
Fasting Blood Glucose (mg/dl) 90.3 ± 13.5 189.0 ± 17.9 * 223.0 ± 21.2*
HbA1c % 5.1 ± 0.6 7.9 ± 0.8* 8.2 ± 0.7*
Total Cholesterol (mg/dl) 146.0 ± 17.5 181.0 ± 18.4* 287.0 ± 28.1*
Triglycerides (mg/ dl) 111.2 ±15.8 122.0 ±16.3* 230.0 ±22.2*
HDL-C (mg/ dl) 50.1 ±5.0 46.0 ±5.3* 32.2 ±5.9*
LDL-C (mg/ dl) 72.0 ±21.8 90.0 ±24.2* 192.0 ±30.2*
* P<0.001, Highly statistically significantly vs controls. CAD= Coronary Artery Disease, HbA1c= Glycated Haemoglobin,
HDL-C= High density lipoprotein cholesterol, LDL-C= Low density lipoprotein cholesterol.
Table 3: Activities of erythrocyte Antioxidant enzymes and MDA Concentration in study subjects
Parameters Controls Diabetic Diabetic with CAD
(n=78) without CAD (n= 59)
Mean ±SD (n= 62) Mean ±SD
Mean ±SD
GPx (U/gHb) 36.2 ± 13.1 25.2 ± 3.7* 19.5 ± 2.8*
SOD (U/gHb) 8.9 ± 1.9 7.0 ± 0.86* 5.6 ± 0.46*
Serum PON (U/ml) 196.1 ± 17.8 160.1 ± 16.2* 130.2 ± 10.2*
MDA (nmoles/ml) 3.6 ± 0.5 6.8 ± 0.40* 8.7 ± 1.3*
*P<0.001, Highly statistically significantly compared to controls. GPx=Glutathione peroxidase,
SOD= Superoxide dismutase, PON= Paraoxonase, MDA= Malondialdehyde.
Table 4: Correlation Analysis of HbA1c levels between Diabetics with and without CAD patients
Diabetes without Diabetes with
CAD CAD
‘r’ ‘r’
HbA1c / GPx - 0.62* - 0.69*
HbA1c / SOD - 0.73* - 0.79*
HbA1c / PON - 0.88* - 0.92*
HbA1c / MDA 0.80* 0.89*
*significant at p<0.05, r= correlation coefficient, GPx=Glutathione peroxidase, SOD= Superoxide dismutase,
PON=Paraoxonase, MDA= Malondialdehyde, HbA1c=Glycated Haemoglobin.

Page 131
Sanjay Kumar et al ANTIEPILEPTICS AND PREGNANCY: A REVIEW
ANTIEPILEPTICS AND PREGNANCY: A REVIEW
Sanjay Kumar1, Biswa Bhusan Mohanty2, Divya Agrawal2, Pramila Nayak1,

IJCRR Shantilata Patnaik1, Jyotsna Patnaik1, Susanta Kumar Mahapatra3
Vol 04 issue 21
1
Section: Healthcare Dept. of Pharmacology, IMS and SUM Hospital, SOA University, Bhubaneswar, India
2
Category: Review Dept. of Anatomy, IMS and SUM Hospital, SOA University, Bhubaneswar, India
3
Received on: 1/09/12 Dept. of O and G, IMS and SUM Hospital, SOA University, Bhubaneswar, India
Revised on:13/09/12
Accepted on:25/09/12 E-mail of Corresponding Author: dska27@yahoo.co.in
ABSTRACT
Epilepsy in a pregnant woman is a serious and potentially life-threatening condition for both mother
and child. Most pregnant women with epilepsy will need to take at least one antiepileptic drug. The
goal for all concerned is a healthy, seizure-free mother and an undamaged child. However, epilepsy as
well as antiepileptic drugs cause some serious effect on the fetus. So, for epileptic women it is
important to obtain appropriate information about possibility to have children and about risks
connected with their pregnancy. Every physician should be informed about risk to the fetus that is
associated with seizures and drugs used for treatment during pregnancy. Drugs used in girls and young
women should be chosen with the respect to the future reproduction, because the use of antiepileptic
drugs (AED) in women with epilepsy is in fact a balance between seizure control and adverse effects of
drugs. The purpose of this review is to provide an update on management of Women with Epilepsy
(WWE) prior to and during epilepsy.
Keywords: Epilepsy, antiepileptic drugs, pregnancy, women with epilepsy (WWE)
INTRODUCTION increased risk is around three-fold. The babies of

Epilepsy is the tendency to have recurrent women with epilepsy (WWE) are also at
unprovoked seizures. It is universal, with no age, increased risk of neonatal problems, including
sex, geographical, social class or racial hemorrhagic disease of the newborn and
boundaries. Epilepsy imposes a large economic „abstinence syndrome‟ In addition to these effects
burden on health care systems of countries. There of epilepsy and anti-epileptic medication on the
is also a hidden burden associated with stigma and progress of pregnancy, the pregnancy may also
discrimination against the patient and even his/her influence the progress of epilepsy, with an
family in the community, workplace, school and increase in seizure frequency in around a third of
home. Many patients with epilepsy suffer severe women and altered metabolism of anti-epileptic
emotional distress, behavioral disorders and drugs. During pregnancy, the clinician faces the
extreme social isolation. dual challenge of maintaining seizure control, yet
Epilepsy is one of the most common chronic minimizing teratogenic risk.
illnesses encountered by obstetricians, affecting What is epilepsy?
around 1 in 200 women attending antenatal Epilepsy can be defined as “the occurrence of
clinics. Epilepsy itself is associated with a risk of transient paroxysms of excessive or uncontrolled
giving birth to a malformed child around 25% discharges of neurons, which may be due to a
higher than for pregnant women generally (in number of different causes leading to epileptic
whom the risk is 2-3%) and, for women with seizures”. The actual presentation or
epilepsy who are taking anti-epileptic drugs, the manifestation differs among individuals,

Page 132
depending upon the location of the origin of the symptomatic seizures early in the course of
epileptic discharges in the brain and their spread. infection. For example, in patients with viral
A person should only be diagnosed as having encephalitis and early seizures, the risk of
“epilepsy” if there are recurrent manifestations i.e. epilepsy is 10% by 5 years and 20% by 10 years
(7)
there should be at least two or more unprovoked . Degenerative CNS diseases are associated with
similar episodes in 24 hours. Hence, the first an increased risk of epilepsy. Alzheimer‟s disease
episode of a seizure is called “single seizure” and increases the risk by 10 fold and 10% of long term
not epilepsy. Alzheimer‟s disease survivors eventually develop
Prevalence of epilepsy epilepsy (6). Up to 5% of patients with multiple
Approximately 50 million people are affected by sclerosis develop epilepsy (8). Mental retardation
epilepsy globally. About 40 million or 80% are (MR) and cerebral palsy (CP) are important risk
assumed to live in developing countries. Multiple factors for the development of epilepsy in children
studies worldwide indicate that the prevalence of and young adults. Prematurity and birth
epilepsy globally is in the range of 5 to 8 per one complications are risk factors for both CP and
thousand populations. MR, but pre or perinatal events themselves are not
Risk factors for epilepsy independent risk factors for epilepsy when
There are well recognized risk factors for the children with CP or MR are excluded (9). Finally,
development of epilepsy. Febrile seizure occur in patients with a first degree relative with epilepsy
2% to 4% of otherwise healthy children younger have a twofold to four fold risk of developing
than age 5 years; however a history of a complex epilepsy (10).
febrile seizure or a neurodevelopmental Reproductive function and fertility in WWE
abnormality or a family history of epilepsy may Increased rates of sexual dysfunction are reported
increase the risk of developing epilepsy by 2% to among both men and WWE. This may arise from
4% (1). A history of significant head trauma also is both neuroendocrine disturbances related to
a risk factor. Studies of Vietnam War veterans seizure activity, as well as the alteration of
showed a risk of 50% after a penetrating head endogenous sex steroid metabolism in the
trauma (2). Head trauma with loss of presence of enzyme-inducing AEDs (11).
consciousness, amnesia or a skull fracture Hypothalamic amenorrhoaea, hyperprolactinemia
increases the 5 year risk to approximately 2%; and premature menopause are over-represented
however the risk is increased with severe head among WWE, thought partly because of
injuries, with 12% of survivors developing interference with normal hypothalamic and
epilepsy (3). Vascular lesions are a significant pituitary function by tempero-limbic discharges
cause of epilepsy. commonly involved in epilepsy (12). An increase in
Epilepsy develops in 6% to 44% of individuals anovulatory cycles and polycystic ovarian
with arteriovenous malformations (4). Cavernous syndrome (PCOS) has also been observed in
malformations commonly present as seizures (5) WWE (12, 13). While this may partly relate to
and cerebrovascular disease is the major cause of disturbance of the Hypothalamic-pituitary-adrenal
epilepsy in elderly (6). Brain tumours account for (HPA) axis, AEDs may also play a role in this (13).
approximately 4% of cases of epilepsy (1) and Enzyme-inducing (EI) AEDs increase serum sex
seizures is often the presenting feature of brain hormone binding globulin (SHBG) levels,
tumours. CNS infections can also increase the risk resulting in decreased levels of biologically active
of developing epilepsy, particularly in children estradiol and testosterone. In addition, valproic
and in elderly. The risk is further increased with acid (VPA) is associated with an increased rate of
certain types of infection and if there are hyperandrogenism, ovulatory dysfunction and

Page 133
PCOS, particularly among young (<26 years) Effect of epilepsy on pregnancy

women (14). The birth rate was lower in WWE Over 90% of pregnant women with epilepsy have
than the population without epilepsy, (hazard ratio uneventful pregnancies (22). During labour, there is
0.83, 95% CI 0.83–0.93) (15). Differences between a three-fold rise of seizure breakthrough due to
treated and untreated women (16) suggesting that drug default; lack of sleep, fasting, dehydration
while women may have a mild reduction in and concomitant medication, 1% may have status
fertility associated with epilepsy, the use of AEDs epilepticus. Nelson and Ellenberg (23) reported an
does not significantly impact further. Pregnancy increase in the incidence of pre-eclampsia,
has a variable effect on the frequency of seizures. perinatal mortality, cesarean delivery and preterm
In some women there is no change; up to a quarter birth among epileptic women, as well as increased
of women may experience a reduction in the incidence of low birth weight, congenital
number of seizures, whilst in up to one third of malformations, seizures, mental retardation in
women their seizure frequency will increase. A Women with Epilepsy. Maternal epilepsy is
study by Hollingsworth and Resnik (17) which associated with a two-fold increase in the
included 2385 pregnancies showed increased incidence of congenital anomalies in children
seizure frequency in 35%, decreased frequency in born to women with epilepsy. Some of this
15% and no change in 50%. The more frequent increase in the incidence of congenital anomalies
the seizures, before conception, the more likely do appears to occur even in the absence of
these increases in frequency during pregnancy. anticonvulsant medication. The conventional
Seizure exacerbation may occur at any time, but is drugs i.e. phenytoin, carbamezapine,
most frequently encountered at the end of the first phenobarbitol, valproate are all appropriate in
and at the beginning of the second trimester (18). pregnancy. The main practical issue is the
The apparently higher risk of seizures among teratogenecity of these drugs. Anticonvulsant
women treated with oxcarbazepine prompts therapy does appear to further increase the
further studies on pharmacokinetic changes of the incidence of congenital abnormalities in children
drugs (19). Subtherapeutic levels are caused by: (a) of epileptics, particularly with polypharmacy. In
Nausea and vomiting leading to skipped doses. (b) general, the risk of congenital defects is low (2-
Decreased gastrointestinal motility and use of 3%) in overall population of pregnant women
antacids decrease drug absorption. (c) Expanded which increases to 4-5% in women taking
intravascular volume lowers serum drug levels. anticonvulsants (24). Recent pregnancy databases
(d) Induction of hepatic, plasma and placental have suggested that valproate is significantly
enzymes increases drug metabolism. (e) Increased more teratogenic than Carbamazepine and the
glomerular filtration hastens drug clearance (20). (f) combination of valproate and lamotrigine is
Non-compliance. particularly teratogenic (25).
Seizure threshold is lowered by Exhaustion from Obstetric complications associated with
sleep deprivation and Hyperventilation during epilepsy
labour. Some WWE may experience seizure only There is an increased risk of vaginal bleeding,
during pregnancy which is termed gestational anemia, hyperemesis gravidarum, abruption
epilepsy; such women would be seizure free placentae, eclampsia, premature labour,
between pregnancies. Another subgroup spontaneous abortions and fetal congenital
(Gestational onset Epilepsy) may have their first malformations.
seizure during pregnancy and thereafter may Effect of antiepileptics on pregnancy
continue to get spontaneous recurrent seizures (21). The first report of a malformation associated with
AEDs was described in a child exposed to

Page 134
mephenytoin in utero who had microcephaly, cleft be used. It should not exceed 1000 mg/day in
palate, a speech defect and an IQ of 60 (26). Infants divided doses. Breastfeeding is considered
of mothers with epilepsy after exposure to AEDs compatible with valproate therapy. Valproate
in utero are twice as likely to have birth defects as concentrations in breastfed babies are low.
infants not exposed to these drugs. Meador et al Phenytoin - The primary site of action appears to
reported that the rate of total congenital be the motor cortex where spread of seizure
malformations was significantly higher for activity is inhibited. It promotes sodium efflux
polytherapy (9.84%; 95% CI = 7.82, 11.87) than from neurons and tends to stabilize the threshold
for monotherapy (5.3%; 95% CI = 3.51, 7.09) (27). against hyperexcitability caused by excessive
In addition to the direct effect of AEDs, there may stimulation or environmental changes capable of
be contribution from toxic AED metabolites, reducing membrane sodium gradient. This
reduced folate availability, hypoxic injury includes the reduction of post tetanic potentiation
associated with seizures and genetic at synapses. Loss of post tetanic potentiation
predisposition (28). Malformation rates in the prevents cortical seizure foci from detonating
general population range from 2-3 %. Reports of adjacent cortical areas. Phenytoin reduces the
malformation rates in various population of maximal activity of brain stem centers responsible
exposed infants range from 1.25% to 11.5% (29- 36). for the tonic phase of tonic-clonic (grand-mal)
The precision of risk estimation with any seizures. The use of phenytoin during pregnancy
individual AED is imperfect as there is a paucity has been associated with a 2-3 fold increased risk
of controlled data, and an uncertain impact of (6-15%) for malformations, including heart
potential confounders, such as type of epilepsy, defects, microcephaly and cleft lip and palate. A
seizure frequency, and family history of birth characteristic pattern of abnormalities, called
defects, socio-economic factors, nutrition and “Fetal Hydantoin Syndrome”, has been reported
exposure to additional teratogens (37). in about 10% of infants born to women who took
Valproic Acid (VPA) – Valproate has been phenytoin during pregnancy. Features of this
associated with a distinctive pattern of anomalies syndrome include a unique facial appearance,
called “Fetal Valproate Syndrome”. This involves abnormalities of fingers, toes and nails, growth
poor growth, small head circumference, delay and developmental delay/disability. Also it
characteristic facial features, heart defects, cleft produces cardiac anomalies such as atrial septal
lip/palate, and limb anomalies (particularly absent defects and ventricular septal defects.
radius). A variety of developmental issues have Diazepam - Diazepam is prescribed as a
also been reported, including developmental tranquilizer, muscle relaxant, preoperative
delay, decreased IQ scores, hyperexcitability, medication, and as an adjunct to anticonvulsant
behavior problems, autism spectrum disorders and therapy. There is a no consistent pattern of
neurological dysfunction. Numerous small studies malformations observed in infants exposed to
have suggested cognitive and language diazepam. Some neonatal behavior problems have
impairment and an increase in autistic spectrum been noted in exposed infants.
disorder in children who have been exposed to Phenobarbital - Chronic use of phenobarbital
antiepileptic drugs in utero (38). Recent reports late in pregnancy has been associated with
suggest that these problems may be highest in transient neonatal sedation or withdrawal
children who have been exposed to valproate. symptoms in infants. Features seen in these
Valproate should therefore be avoided in infants include hyperactivity, irritability and
reproductive women wherever possible. When it tremors. Perinatal or neonatal hemorrhage has
is unavoidable, the lowest effective dose should been observed occasionally in infants of women

Page 135
who took phenobarbital late in pregnancy. This lamotrigine fall early in pregnancy, so dose
has been attributed to drug-induced suppression of increase may be necessary to control seizures. A
the synthesis of vitamin K-dependent clotting trough plasma lamotrigine concentration before
factors. pregnancy, at the onset of the second trimester of
Carbamazepine (CBZ) - The use of pregnancy and every two months during
carbamazepine during pregnancy has been pregnancy may help to guide any necessary
associated with an increased risk for spina bifida increase in lamotrigine dose. Postpartum, the
of up to 1% (1/100), as compared to the general lamotrigine concentration rises within a few days
population risk of 1/1000. It is also associated and prompt dose reduction may be required to
with a unique facial appearance and the prevent toxicity (49).
underdevelopment of the fingers, toes, and nails. Levetiracetam
Similarly, malformations have been reported in There have been small case series suggesting an
6/248 (2.4%) of patients receiving oxcarbazepine increase in low birth weight among infants of
in pregnancy (39) and 2/44 (4.5%) of patients WWE receiving Levetiracetam (50). There appears
receiving gabapentin (40). Vigabatrin is associated to be a substantial increase in clearance during
with acquired visual field defects and its safety is pregnancy and an associated fall of blood
not established in pregnancy (41). The cause of this concentrations (51). Although Levetiracetam is
teratogenecity could be due to direct drug toxicity, secreted into breast milk, recent data suggest that
drug-induced folate deficiency or genetically the neonatal concentrations are low.
determined lack of epoxide hydrolase or free Neurocognitive defects
radicals (42). The role of the hepatic mixed In addition to structural malformations associated
function oxidase system may be especially with AEDs, there has been increasing concern
important in conferring teratogenic risk. However, regarding the potential adverse effect of AEDs on
systems such as epoxide hydrolase, glutathione fetal cognitive development. While structural
reductase, hyperoxide dismutase and other toxin malformation risk is essentially confined to the
scavenging systems may be important modifiers first trimester, cognitive effects of AEDs have the
that lower the risk. Knowledge is also potential to impact throughout gestation. Animal
accumulating on the interactions of AEDs with studies suggest that these cognitive effects may be
molecular targets such as histone deacetylase and mediated by AED-induced neuronal apoptosis (52).
peroxisomes proliferator activator receptors that Several investigators have reported an increase in
may play important roles in teratogenesis (43). educational requirements (53, 54), poorer
Lamotrigine neuropsychological performance and reduced
It remains uncertain whether lamotrigine is verbal IQ among children exposed prenatally to
associated with an increased risk of facial clefting VPA (55).
(44, 45, and 46)
. However, The North American AEDS and neural tube defect
Pregnancy Register has reported that exposure to Valproate and carbamazepine have been
lamotrigine in the first trimester may cause an independently associated with the development of
increased risk of oral clefts (a rate of 8.9 per 1000, neural tube defects (NTDs). NTDs are anomalies
as compared to 0.37 per 1000 in the reference of central nervous system and its membranes
population) (47). Significant dose related resulting from abnormal development of neural
teratogenesis with lamotrigine exceeding 200 tube. They are classified as either open defects
mg/day has been reported (48). Lamotrigine lacking a covering of overlying skin, or closed
clearance increases steadily through to 32 weeks defects that are covered with skin. Robert and
of pregnancy. Plasma concentrations of Guibaud (56) were the first to make the association

Page 136
between VPA and CBZ and the development of increase in the volume of distribution of the drug
NTDs. More recent studies have revealed an (this effect is least for carbamazepine) (66). This
association between CBZ exposure in utero and drop in total blood levels is partially counteracted
NTDs (57, 58, and 59). Other investigators have by the fact that free (and, therefore, active) drug
identified spinabifida aperta as the specific NTD levels may increase due to a normal decrease in
associated with VPA & CBZ exposure (60). the concentration of serum protein that occurs in
Pathophysiology of NTDs pregnancy. Some of this reduction is related to the
NTDs are uncommon malformations occurring in reduction in serum protein in pregnancy, meaning
6/10,000 pregnancies. Spina bifida and that the total drug concentration is lower, but the
anencephaly are the most commonly reported unbound (active) concentration is stable. This is
NTD and affect nearly 2500 to 3000 births in the particularly relevant for highly protein bound
United States each year (61, 62). The types of NTD drugs, such as VPA and phenytoin (67, 68). As noted
associated with AED exposure are primarily above, a clinically significant reduction in plasma
myelomeningocele and anencephaly, which are concentrations of both lamotrigine and
the result of abnormal neural tube closure between oxcarbazepine occurs in pregnancy (69, 70) as well
the third and fourth week of gestational age. In as Levetiracetam (66, 67, and 68). There is a paucity of
previous thinking about NTDs, the fusion of the data on the pharmacokinetics of the newer AEDs,
neural tube was visualized as a process in which such as gabapentin, topiramate and zonisamide
(67)
the lateral edge met in the middle and fused both . Therefore, for any given total drug level there
rostrally and caudally. Recent studies have is likely to be freer drug available during
suggested that there are multiple sites for neural pregnancy than there would be in a nonpregnant
tube closure (63, 64) and that different etiologies individual. Because of the difficulty in
may result in different types of abnormality. interpreting serum drug levels of anticonvulsants
There are four different sites along the neural tube during pregnancy, it is advisable to check total
where neurulation develops. The first is serum drug levels if available monthly in pregnant
midcervical. The second is at the cranial junction women and adjust their dose accordingly. It is
of the prosencephalon and mesencephalon. The best to use the least number of drugs at the lowest
third is at the site of the stomodeum. This region dose possible to prevent seizures.
fuses in caudal direction only. VPA appears to In WWE, the goal of therapy is to maintain
have species differential effects, being associated seizure control using the lowest effective AED
with spina bifida in humans and exencephaly in dose. The International League against Epilepsy
mice (65). position paper recommends that drug
Management of anticonvulsant therapy in concentrations be determined during pregnancy
pregnancy (68)
. It is recommended that – prior to pregnancy –
Women with epilepsy who are considering an individual „therapeutic level‟ during a period of
pregnancy should be treated with the least optimal seizure control should be determined,
teratogenic but most efficacious antiepileptic drug which can then serve as a „target level‟ for
for their particular type of epilepsy at the lowest pregnancy (66, 68). Among patients with good
effective dose. If a pregnant woman is maintained control, serum concentration should be performed
on the same dose of an anticonvulsant throughout each trimester, but more frequent (for example,
pregnancy, total blood levels of the anticonvulsant monthly) levels may be required in patients with
will tend to go down during the pregnancy due to complicated epilepsy, breakthrough seizures,
a pregnancy related increase in hepatic and renal significant side effects and those WWE requiring
clearance of the drug and a pregnancy related lamotrigine and oxcarbazepine where highly

Page 137
variable and more clinically significant variation of requirements by individual women

fluctuations in drug concentration have been has led some to call for higher folate
observed (66, 68). supplementation on the order of 0.5-0.6 mg/day
(76)
Can a woman breastfeed her baby if she is . Women with epilepsy, like all women of child
taking AEDs? bearing age should take folate supplementation
All anticonvulsants are excreted in breast milk but the dosage recommended by Center for Disease
levels are exceedingly low and not a cause for Control and Prevention (CDC) but 0.4 mg/day
concern. Women are encouraged to feed in a may not be high enough for many women who do
secure position. Possible effects of anti-epileptic not metabolize folate effectively (77). Stopping
drugs in breast milk include drowsiness and anti-epileptic treatment may be appropriate if the
feeding difficulties with the baby. These are more epilepsy produces a single type of seizure and the
common with barbiturate anti-epileptic drugs. woman has been free from seizures for the
Other side-effects are rare. previous 2 years and EEG and neurological
How a WWE be looked after in pregnancy? examination are normal. This must always be
The risk of malformation in the baby caused by discussed with the doctors who look after her
anti-epileptic drugs is highest during early epilepsy. Stopping anti-epileptic medications in
pregnancy, so counseling before pregnancy is pregnancy without medical advice can be very
essential. If anti-epileptic drugs are needed, harmful to the woman and her baby in the womb
normally the most effective single drug should be if severe seizures occur. All pregnant women with
given at the lowest possible dose that controls the epilepsy should be offered detailed ultrasound
seizures. To further minimize this risk, high dose scanning for fetal abnormality. The use of enzyme
(5 mg) folic acid is generally recommended for at inducing AEDs may induce fetal hepatic enzyme
least 1 month preconceptually and throughout the activity culminating in vitamin K deficiency and
first trimester (71). Enzyme inducing AEDs and increased risk of neonatal bleeding and that
valproate are known to interfere with folic acid vitamin K should be administered to such women
metabolism (72) and Kjaer et al. reported fewer in late pregnancy to minimize this risk (25). During
congenital malformations in women taking AEDs the last month of pregnancy vitamin K 10 mg/day
with folic acid, compared to those not given by mouth is recommended for pregnant woman on
additional supplementation (73). Dansky et al (74) certain anti-epileptic therapies and in such
found significantly lower blood folate circumstances it is usually recommended that the
concentration in WWE with abnormal pregnancy baby should be given 1 mg vitamin K
outcomes. Treatment of mice with folic acid, with intramuscularly or intravenously. Maternal oral
or without vitamins and amino acids, reduced vitamin K1, for example 10 mg/day for one month
malformation rates and increased fetal weight and prepartum, has been recommended when enzyme-
length in mouse pups exposed to phenytoin in inducing antiepileptic drugs are prescribed
utero (75). In the general population the utility of because the drugs may potentially predispose the
folate supplementation in reducing the risk for baby to haemorrhagic disease of the newborn (78).
NTDs is clearly established. Whether risk will be
reduced for WWE taking AEDs is unclear. The CONCLUSION
recommended daily allowances of folate have Labour and delivery is a relatively high risk time
been increased to 0.4mg/day for non-pregnant for seizure recurrence. The reasons for this are
women, 0.6 mg/day for pregnant women and 0.5 multifactorial including poor bioavailability and
mg/day for lactating women. The increased folate compliance with AEDs, sleep deprivation, anxiety
catabolism during pregnancy, coupled with and hyperventilation in labour. All centers

Page 138
delivering obstetric care should therefore be ACKNOWLEDGEMENT

mindful of the increased risk of seizure in labour, Authors acknowledge the immense help received
and manage WWE accordingly (25, 79, and 80). from the scholars whose articles are cited and
Most AEDs are compatible with breast feeding. included in references of this manuscript. The
The optimal method of estimating drug exposure authors are also grateful to authors / editors /
is to measure the milk drug concentration and publishers of all those articles, journals and books
multiply it by the estimated daily intake. from where the literature for this article has been
Typically, a value 10% of the weight-based reviewed and discussed.
therapeutic drug dose is considered safe. The
estimated levels for carbamazepine, phenytoin REFERENCES
and VPA are 3–5% of therapeutic dose and are 1. Annegers JF, Hauser WA, Shirts SB, Kurland
considered safe. Estimates for lamotrigine and LT. factors prognostic of unprovoked seizures
Levetiracetam are approximately 10% and after febrile convulsions. N Eng J Med
Gabapentin approximately 12% (81, 82). During 1987;316:493-8
their postnatal stay, WWE and all their maternity 2. Salazar A M, JabbariB, Vance SC, et al.
care providers should be aware of the risk of epilepsy after penetrating head injury. I.
postpartum seizures, particularly in the setting of Clinical correlates. A report of the Vietnam
sleep deprivation. Ensuring such women get Head Injury Study. Neurology 1985;35:1406-
adequate sleep and attention to medication 14
compliance is of the utmost importance. Although 3. Annegers JF, Grabow JD, Groovers RV, et al.
the risk to the infant from maternal seizures is seizures after head trauma: a population
generally low, women with juvenile myoclonic study. Neurology 1980;30: 683-9
epilepsy are a particular concern, since myoclonic 4. Crawford PM, West CR, Chadwik DW, Shaw
jerks tend to be more frequent in the early MD. Arteriovenous malformation of the
morning, often around the time of infant waking brain; natural history in unoperated patients. J
(83)
. To minimise the risk of harm if a seizure Neurol Neurosurg Psychiatry 1986;49: 1-10
occurs, changing or feeding the baby on the floor 5. Casazza M, Broggi G, Franzini A, et al.
is recommended, the use of baby slings should be Cavernous angiomas and epileptic seizures:
avoided, stair climbing should be minimised preoperative course and post operative
where possible and bathing the baby should be outcome. Neurosurgery 1996;39: 26-32
avoided when alone (25,83). The chances of 6. Hauser WA, Annegers JF, Kurland LT.
perinatal problems such as difficult labour, incidence of epilepsy and unprovoked
prematurity and low birth weight are a little seizures in Rochester, Minnesota: 1935-1984.
higher in the case of pregnancies of women with Epilepsia 1993; 34:453-68.
epilepsy than in normal pregnancies. The risk of 7. Annegers JF, Hauser WA, Beghi E, et al. the
jaundice during the neonatal period could also be risk of unprovoked seizures after encephalitis
higher in these children. Congenital and meningitis. Neurology 1988;27:729-33
malformations in newborns are sometimes 8. Kinnunen E, Wikstrom J, prevalence and
associated with pregnant women who have been prognosis of epilepsy in patients with multiple
treated for epilepsy with anti epileptic drugs such sclerosis. Epilepsia 1986;27:729-33
as phenobarbitol, valproic acid, phenytoin and 9. Nelson KB, Ellenberg JH. Antecedents of
carbamazepine. seizure disorders in early childhood. Am J Dis
Child 1986;140:1053-61

Page 139
10. Ottman R, Annegers JF, Hauser WA, Kurland 21. Commission on classification & terminology
LT. seizure risk in offsprings of parents with of International League against epilepsy 1989
generalized virsus partial epilepsy. Epilepsia proposal for revised clarrification of
1989; 30:157-61. epilepsies and epileptic syndromes. Epilepsia
11. Luef GJ. Epilepsy and sexuality. Seizure 1989; 30:389-99.
2008; 17:127–30. 22. Richmond JR, Krishnamoorthy P, Andermann
12. Herzog AG. Disorders of reproduction in E, Epilepsy and Pregnancy; an Obstetric
patients with epilepsy: primary neurological perspective. Am J Obstet Gynecol 2004; 190:
mechanisms. Seizure 2008; 17:101–10. 371-79
13. Isojarvi J. Disorders of reproduction in 23. Nelson KB, Ellenberg JH: Maternal seizure
patients with epilepsy: antiepileptic drug disorders, outcome of pregnancy and
related mechanisms. Seizure 2008; 17:111–9. neurologic abnormalities in children.
14. Morrell MJ, Hayes FJ, Sluss PM, Adams JM, Neurology 1982; 32: 1247.
Bhatt M, Ozkara C, et al. Hyperandrogenism, 24. Ropper Allan H, Brown Robert H. Epilepsy
ovulatory dysfunction, and polycystic ovary and other seizures disorders. Adam‟s and
syndrome with valproate versus lamotrigine. Victor‟s Principles of Neurology, 8th edition.
Ann Neurol 2008; 64:200–11. McGraw Hill, 2005, pp 296.
15. Artama M, Isojarvi JIT, Raitanen J, Auvinen 25. Crawford P. Best practice guidelines for
A. Birth rate among patients with epilepsy: a management of women with epilepsy.
nationwide population-based cohort study in Epilepsia 2005; 46 (Suppl 9): 117-24.
Finland. Am J Epidemiol 2004; 159:1057– 26. Mullers – Kuppers Von M. embryopathy
63. during pregnancy caused by taking
16. Artama M, Isojarvi JIT, Auvinen A. anticonvulsants. Acta Paedopsychiatr 1963;
Antiepileptic drug use and birth rate in 30:401-5
patients with epilepsy – a population-based 27. Meador K, Reynolds MW, Crean S, Fahrbach
cohort study in Finland. Hum Reprod 2006; K, Probst C. Pregnancy outcomes in women
21:2290–5. with epilepsy: a systematic review and
17. Hollingsworth DR, Resnik R. Medical metaanalysis of published pregnancy
counselling before pregnancy. NewYork, registries and cohorts. Epilepsy Res 2008;
Churchill Livingstone, 1988, pp 415. 81:1–13.
18. Browne T R, Gregory L, Holmes G L, 28. LaJoie J, Moshe SL. Effects of seizures and
Montouris G D. Special considerations their treatment on fetal brain. Epilepsia 2004;
inWomen. In: Browne T R, Holmis G L (eds), 45(Suppl 8):48–52.
Handbook of Epilepsy, 3rd edition. Lippincott 29. Fedrick J. Epilepsy and pregnancy: a report
Williams & Wilkins, 2004 pp. 216. from the Oxford Record Linkage study. Br
19. Christensen J, Sabers A, Sidenius P. Med J 1973;2:839-43
Oxcarbazepine concentrations during 30. Kelly TE. Terratogenicity of anticonvulsant
pregnancy: A retrospective study in patients drugs. 1; review of literature. Am J Med
with epilepsy. Neurology 2006; 67 (8): 1497- Genet 1984;19:413-34
99. 31. Nakane Y, Oltuma T, Takahashi R et al. Multi
20. Morrell MJ. Maximising of women with institutional study on the teratogenecity and
epilepsy: Science and ethics in new drug fetal toxicity of anticonvulsants: a report of a
development. Epilepsia 1997; 38 (Suppl 4): collaborative study group in Japan. Epilepsia
S32-S41. 1980;21:663-80

Page 140
32. Battino D, Binellis, Caccamo ML et al. 43. Vinten J, Adab N, Kini U, Gorry J, Gregg J,
Malformation in offspring of 305 epileptic Baker GA; Liverpool and Manchester
women: a prospective study. Acta Neurol Neurodevelopment Study Group
Scand 1992; 85:204-7 Neuropsychological effects of exposure to
33. Philbert A, Dam M. The epileptic mother and anticonvulsant medication in utero.
her child. Epilepsia 1982;23: 85-99 Neurology 2005; 64:949-54.
34. Stiggers – Theunissen RP, Reiner WO, Borm 44. Holmes LB, Baldwin FJ, Smith CR, Habecker
GF et al. Factors influencing the risk of F, Glassman L, Wong SI, et al. Increased
abnormal pregnancy outcomes in epileptic frequency of isolated cleft palate in infants
women. A multicenter prospective study. exposed to lamotrigine during pregnancy.
Epilepsy res 1994;18: 261-9 Neurology 2008;70:2152–8
35. Jick SS, Terries BZ. Anticonvulsants and 45. Dolk H, Jentink J, Loane M, Morris J, de
congenital malformations. Pharmacotherapy Jong-van den berg LTW. Does lamotrigine
1997;17: 561-4 use in pregnancy increase orofacial cleft risk
36. Kaneko S, Battino D, Andermann E et al. relative to other malformations? Neurology
Congenital malformations due to antiepileptic 2008; 71:714–22.
drugs. Epilepsy Res 1999;33: 145-58 46. Meador K, Penovich P. What is the risk of
37. Artama M, Auvinen A, Raudaskoski T, orofacial clefts from lamotrigine exposure
Isojarvi I, Isojarvi J. Antiepileptic drug use of during pregnancy? Neurology 2008; 71:706–
women with epilepsy and congenital 7.
malformations in the offspring. Neurology 47. R. Sankar. Terotagenicity of Antiepileptic
2005; 64:1874–8. drugs: Role of Drug Metabolism and
38. Tomson T, Perucca E, Battino D. Navigating Pharmacogenomics. Acta Neurologica
toward fetal and maternal health: the Scandinavica 2007; 116 (1): 65-71.
challenge of treating epilepsy in pregnancy. 48. Holmes LB, Wyszynski DF, Baldwin EJ,
Epilepsia 2004; 45:1171–523. Habecker E, Glassman LH, Smith CR.
39. Eisenschenk S. Treatment with oxcarbazepine Increased risk for non-syndromic cleft palate
during pregnancy. Neurologist 2006; 12:249– among infants exposed to lamotrigine during
54. pregnancy (abstract). Birth Defects Res A
40. Montouris G. Gabapentin exposure in human Clin Mol Teratol 2006; 76:318.
pregnancy: results from the gabapentin 49. Morrow J, Russell A, Guthrie E, Parsons L,
pregnancy registry. Epilepsy Behav 2003; Robertson I, Waddell R, et al. Malformation
4:310–7. risks of antiepileptic drugs in pregnancy: a
41. Sorri I, Herrgard E, Viinikainen K, prospective study from the UK Epilepsy and
Paakkonen A, Heinonen S, Kalviainen R. Pregnancy Register. J Neurol Neurosurg
Ophthalmologic and neurologic findings in Psychiatry 2006; 77:193-8.
two children exposed to vigabatrin in utero. 50. Ten Berg K, Samren EB, Van Oppen AC,
Epilepsy Res 2005; 65:117–20. Engelsman M, Lindhout D. Levetiracetam use
42. Vajda FJ, O'Brien TJ, Hitchcock A, Graham and pregnancy outcome. Reprod Toxicol
J, Cook M, Lander C, et al. Critical 2005;20:175–8
relationship between sodium valproate dose 51. Pennell PB. Antiepileptic drug
and human teratogenecity: results of the pharmacokinetics during pregnancy and
Australian register of anti-epileptic drugs in lactation. Neurology 2003; 61:S35-S42.
pregnancy. J Clin Neurosci 2004; 11:854-8.

Page 141
52. Meador KJ, Baker G, Cohen MJ, Gaily E, 64. Golden JA, Chernoff GF. Multiple sites of
Westerveld M. Cognitive/ behavioural anterior neural tube closure in humans:
teratogenetic effects of antiepileptic drugs. evidence from anterior neural tube defects
Epilepsy Behav 2007; 11:292–302. (anencephaly). Pediatrics 1995; 95: 506-10
53. Adab N, Jacoby A, Smith D, Chadwick D. 65. Seller MJ. Recent development in the
Additional educational needs in children born understandings of the etiology of neural tube
to mothers with epilepsy. J Neurol Neurosurg defects. Clin dysmorphol 1995;4:93-104
Psychiatry 2001; 70:15–21. 66. Tomson T, Battino D. Pharmacokinetics and
54. Viinikainen K, Eriksson K, Heinonen S, et al. therapeutic drug monitoring of newer
The effects of valproate exposure in utero on antiepileptic drugs during pregnancy and the
behavior and the need for educational support puerperium. Clin Pharmacokinet 2007;
in school-age children. Epilepsy Behav 2006; 46:209–19.
9: 636–40. 67. Brodtkorb E, Reimers A. Seizure control and
55. Vinten J, Adab N, Kini U, Gorry J, Gregg J, pharmacokinetics of antiepileptic drugs in
Baker GA. Neuropsychological effects of pregnant women with epilepsy. Seizure 2008;
exposure to AED medication in utero. 17:160–5.
Neurology 2005; 64:9 49–54. 68. Patsalos PN, Berry D, Bourgeois BFD, Cloyd
56. Robert E, Guibaud P. Maternal valproic acid JC, Glauser TA, Johannessen SI, et al.
and congenital neural tube defects [abstract] Antiepileptic drugs-best practice guidelines
Lancet 1982;2:937 for therapeutic drug monitoring: a position
57. Rosa F. Spina bifida in infants of women paper by the subcommission on therapeutic
treated with carbamazepine during pregnancy. drug monitoring, ILAE Commission on
N Engl J Med 1991;324:674-7 Therapeutic Strategies. Epilepsia 2008;
58. Kallen B. Maternal carbamazepine and infant 49:1239–76.
spina bifida. Reprod Toxicol 1994;8:203-5 69. Ohman I, G Tomson T. Effects of pregnancy
59. Little BB, Santos- Ramosr, Newell JF, and contraception on lamotrigine disposition:
Maderry MC. Megadose carbamazepine new insights through analysis of lamotrigine
during the period of neural tube closure. metabolites. Seizure 2008; 17:199–202.
Obstet Gynecol 1993;83 (4 suppl 2): 705-8 70. Christensen J Sabers a, Sidenius P.
60. Linghout D, Omtzigt JG,Cornel MC. Oxcarbazepine concentrations during
Spectrum of neural tube defects in 34 infants pregnancy: a retrospective study in patients
prenatally exposed to anti epileptic drugs. with epilepsy. Neurology 2006; 67:1497–9.
Neurology 1992;42 (4 suppl 5):111-8 71. Tomson T, Hiilesnaa V. Epilepsy in
61. Mulinare J, Erickson D. Prevention of neural pregnancy. BMJ 2007; 335: 769–73.
tube defects. Teratology 1997;56: 17-8 72. Kampman MT. Folate status in women of
62. Honein MA, Paulozzi LJ,M athews TJ, child-bearing age with epilepsy. Epilepsy Res
Erickson JD, Wong LY. Impact of folic acid 2007; 75:52–56.
fortification of the US food supply on the 73. Kjaer D, Horvath-Puho´ E, Christensen J, et
occurance of neural tube defects. JAMA al. Antiepileptic drug use, folic acid
2001;285: 2981-6 supplementation and congenital
63. Van Allen MI, Kalousek DK, Chernoff GF, et abnormalities: a population-based case-
al. evidence for multi site closure of the control study. BJOG 2008; 115:98–103.
neural tube in human. Am J Med Genet 1993; 74. Dansky LV, Andermann E, Andermann F,
47: 723-43 Sherwin AL, Kincha RA. Maternal epilepsy

Page 142
and congenital malformations: correlation Children in Primary and Secondary Care.

with maternal plasma anticonvulsant levels Clinical guideline 20. October 2004.
during pregnancy. In : Janz D, Dam M, 80. Robinson JN, Clearly-Goldman J.
Richens A, Bossi L, Helge H, Schimdt D, eds. Management of epilepsy and pregnancy: an
Epilepsy; pregnancy and the child. New York; obstetrical perspective. Int Rev Neurobiol
Raven Press, 1982: 251-8 2008; 83:273– 82.
75. Zhu MX, Zhou SS. Reduction of teratogenic 81. Pennell PB, Gidal BE, Sabers A, Gordon J,
effects of phenytoin by folic acid and a Perucca E, for the international AED
mixture of folic acid, vitamins and amino pharmacology work group for the health
acids: a primary trial. Epilepsia 1989; 30: outcomes in pregnancy and epilepsy forum.
246-51 Pharmacology of antiepileptic drugs during
76. Oakley GP, Folic acid preventable spina pregnancy and lactation. Epilepsy Behav
bifida and anencephaly. Bull World Health 2007; 11: 263–9.
Organ 1998; 76 (suppl 2): 116-7 82. Ohman I, Vitols S, Tomson T.
77. Centres for Disease Control and Prevention. Pharmacokinetics of Gabapentin during
Recommendations for the use of folic acid to delivery, in the neonatal period, and lactation:
reduce the number of cases of spina bifida and does a fetal accumulation occur during
other neural tube defects. MMWR Morb pregnancy? Epilepsia 2005; 46:1621–4.
Mortal Wkly Rep 1992; 41 (RR-14): 1-7 83. Fox C, Betts T. How much risk does a woman
78. Choulika S, Grabowski E, Holmes LB. Is with active epilepsy pose to her newborn
antenatal vitamin K prophylaxis needed for child in the puerperium? A pilot study.
pregnant women taking anticonvulsants? Am Seizure 1999; 8:367–9.
J Obstet Gynecol 2004; 190:882-3.
79. The Epilepsies: The Diagnosis and
Management of the Epilepsies in Adults and

Page 143
COMPARISON OF POST 24 HOURS EFFECT OF COOLING AND SUSTAINED PASSIVE
Shilpa Khandare et al STRETCHING AS TREATMENT TECHNIQUES FOR REDUCTION OF SPASTICITY IN
HEMIPLEGICS USING H-REFLEX
COMPARISON OF POST 24 HOURS EFFECT OF COOLING AND

SUSTAINED PASSIVE STRETCHING AS TREATMENT
TECHNIQUES FOR REDUCTION OF SPASTICITY IN
IJCRR HEMIPLEGICS USING H-REFLEX
Vol 04 issue 21
Section: Healthcare Shilpa Khandare, Tushar J. Palekar
Category: Research
Received on: 06/09/12 Padmashree Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune, M.S., India
Revised on: 15/09/12
Accepted on: 26/09/12 E-mail of Corresponding Author: shil287@yahoo.co.in
ABSTRACT
Background: Studies have shown that alpha motor neurons ( MN) serving skeletal muscles are
hyperexcitable in presence of spasticity and can be activated by inputs that would normally evoke a
response. There is activation of gamma motor neurons (gMN) for the degree of MN activation thus to
analyze its effect on spasticity, H reflex is used. Various modalities are used to reduce spasticity,
cooling and sustained passive stretching is two of them. Studies have been conducted to find out
efficacy of each but a comparative study to find out post 24 hours effect of them has not been
performed. Objectives: To find out Post 24 hours effects of application of cooling and sustained
passive stretch on reduction of spasticity using H reflex and comparing the two techniques to find out
which is more effective. Method: Thirty patients (male=21, female=09) were selected between the age
group 40-70 years with spastic hemiplegia due to cerebrovascular accident. The average time since the
onset of hemiplegia was 9.23 8.36 months and the patients were selected for the study from the OPD
of physiotherapy department, they were divided into two groups with 15 patients in each group The
affected side of the patient was considered as Study group A Cooling was given and Study group B
Sustained Passive Stretching was given along with routine rehabilitation. H reflex was used as outcome
measure to test spasticity in all the patients at pre and post 24hrs. Results: Our study did not find any
statistically significant difference between cooling and sustained passive Stretching for reducing the
hypertonicity in triceps surae muscles (p<0.05). Conclusion: It is concluded that Cooling and
Sustained passive stretching both are equally effective in reducing spasticity of tricep surae muscles in
patient with hemiplegia.
Key words: Spasticity, Cooling, Sustained Passive Stretching, H-reflex.
INTRODUCTION million (84%) will be in the developing country.

The Global Burden of disease study described a The global population aged over 65 year is
measure that integrates the sum of life-year lost increasing by 9 million a year. By 2025 there will
due to premature mortality and year lived with be more than 800 million people over 65 year of
disability adjusted for severity, the so-called age in the world; two-third of them will be living
disability –adjusted life years (DALY). In 1999 in developing countries. Many people had to live
cerebrovascular disease accounted for 50 million with disability developed with spasticity3. Jun
DALY worldwide, representing 3.5% of all Kimura (1983)4 reported that direct evaluation of
DALY1,2. Projection to year 2020 show that 61 tone is subjective and erroneous, thus an indirect
million DALY are likely to be lost due to method using H reflex can be used. They
cerebrovascular disease each year, and of these 52 considered the amplitude of H and M and a ratio

Page 144
of maximum amplitude of H to maximum Exclusion criteria:

amplitude of M wave (Hmax/Mmax ratio) as a Unconscious patients.
measure of excitability of the motor neuron pool. Acute flaccid paralysis.
The purpose of the study was to find which Any Orthopaedic abnormalities
treatment technique helps in longer reduction of Study Design: Comparative Study
Spasticity, Cooling or Sustained passive
stretching. Various modalities are used to reduce METHODS
spasticity, Cooling and sustained passive Thirty patients (21 males and 9 females) were
stretching are two of them. Studies have been selected between the age group 40-70 years with
conducted to find out efficacy of each but a spastic hemiplegia due to cerebrovascular
comparative study has not been performed on post accident. They were divided into two groups with
24 hour’s effect of them. Thus at our Institute we, 15 patients in each group. One group received
undertook this study to compare the effects of cooling where as other group received sustained
cooling and Sustained passive stretching. passive stretching along with routine
Aim and objective: To find out the Post 24 Hours rehabilitation. The affected side of the patient was
Effect of Cooling and Effects of Sustained passive considered as study group. H-reflex was measured
Stretching as Treatment Techniques for reduction at Pre and Post 24 hours of treatment in both the
of Spasticity in Hemiplegics groups.
The patients were selected for the study from the
METHODOLGY OPD of physiotherapy department. The patients
Materials were those with spasticity in lower extremity.
Electro diagnostic EMG machine (RMS EMG Thirty patients showed grade 1+ spasticity and 17
EPMK ) was used to Study the M wave and H patients showed grade 2 spasticity on Modified
reflex. Surface electrodes were used as pick up, Ashworth Scale.
Stimulating and earth electrodes. Ice cubes The skin resistance overlying the soleus muscle
wrapped in a thin cloth were used to cool the and tendo Achilles was made as minimal
surface of the calf. Goniometer was used to as possible by shaving the area and cleaning it
measure the range of motion. Dynamic ankle with alcohol. The procedure to elicit the H-reflex
splint was used to stretch the Tendo Achilles. usually involves applying a percutaneous electric
stimulus to a mixed nerve, which was applied to
Inclusion criteria: the posterior tibial nerve in the popliteal fossa.
Sample: 30 Hemiplegics patients (21 males Continuing to increase the stimulus intensity
and 9 Females) beyond that required for an H-reflex result in
Age group: 40 - 70 years direct stimulation of the motor axons and the
Onset of hemiplegia: more than 6 months presence of an M-wave, Hmax and Mmax were
All had either internal capsule or MCA also considered.
territory Infarct.
All had moderate to severe spasticity (1+ to 2 STATISTICAL ANALYSIS
on modified ashworth scale) For finding the efficacy of each technique, paired t
Patients with unilateral hemiplegia were -test was applied. To compare these two
included. techniques unpaired t test was used. A level of
Triceps surae was chosen as muscle for study. significance was set at p<0.05.
Affected side was considered as study group.

Page 145
RESULTS p<0.01 which is highly significant. M latency was

In present study both the group showed significant t=0, p>0.05 which is not significant.
reduction of spasticity in triceps surae muscle as Similarly, highly significant reduction of spasticity
measured by H reflex. Our study found out highly in triceps surea muscle at pre and post sustained
significant reduction in pre and post 24 hours passive Stretching was found: H amplitude was
cooling given in study group. H amplitude was t=11.98, p<0.01 which is highly significant. M
t=11.98, p<0.01 which is highly significant. M amplitude was t=10.31, p<0.01 which is highly
amplitude was t=10.31, p<0.01 which is highly significant. H latency was t=12.23, p<0.01 which
significant. H latency was t=12.23, p<0.01 which is highly significant. Hmax/Mmax ratio was t=8.9,
is highly significant. Hmax/Mmax ratio was t=8.9, p<0.01 which is highly significant. M latency was
t=0, p>0.05 which is not significant.
Table 1: Comparison of pre and post treatment effect of Cooling

Pre Post
Mean SD MEAN SD
H amplitude 4.34 0.69 2.73 0.64
M amplitude 13.33 0.97 10 1.30
H latency 36.86 34.70 34.70 0.49
M latency 0 0 0 0
Hmax/Mmax 0.62 0.087 0.57 0.49
Table 2: Comparison of pre and post treatment effect of sustained passive stretching
Pre Post
Mean SD Mean SD
H amplitude 4.34 0.65 2.73 0.64
M amplitude 13.33 0.91 10 1.30
H latency 36.86 0.42 34.70 0.49
M latency 0 0 0 0
Hmax/Mmax 0.62 0.087 0.57 0.94
Table 3: Between group comparison of cooling and sustained passive stretching

Mean SD Mean SD t-Value P Result
H AMPLITUDE 5.12 0.65 5.12 0.65 0 P>0.05 N.S
M amplitude 13.33 0.97 13.33 0.97 0 P>0.05 N.S
H latency 36.86 0.40 36.86 0.40 0 P>0.05 N.S
M latency 0 0 0 0 0 P>0.05 N.S
Hmax/Mmax 0.62 0.087 0.62 0.087 0 P>0.05 N.S
DISCUSSION decrease spasticity, two mechanisms are proposed

Our study has shown that cooling and sustained to act sequentially to produce this effect: first, a
passive Stretching used, as treatment techniques decrease in gamma motor neuron activity and,
for reduction of Spasticity both are highly later, decrease in afferent spindle and Golgi tendon
effective in temporarily reducing the hypertonicity organ activity. A decrease in the integrated
in triceps surae. Cryotherapy can temporarily electromyography (EMG) activity has been

Page 146
observed within a few second of the application of correlation was found in the present study in
cold to the skin, these change are thought to be muscle tone. We believe that the H/M ratio is a
related to decrease in the activity of the gamma neurophysiological expression, but the others
motor neurons as a reflex reaction to stimulation (passive range of motion) may be influenced by
of the cutaneous cold receptors5,6. Price R et al7 the elasticity of the muscle. (Nishikawa T, 2002)10
(1993) concluded that cold facilitates alpha- triceps surae can improve the range of motion of
motoneurons and inhibits gamma-motoneurons. the ankle joint and the motor neuron excitabilities.
Consequently, for these effects to result in Jun Kimura (1983) reported that direct evaluation
spasticity reduction, the net effect of gamma of tone is subjective and erroneous, thus an
inhibition must exceed that of alpha facilitation. If indirect method using H reflex can be used. They
these mechanisms operate simultaneously, considered the amplitude of H to maximum
spasticity tests, which incorporate muscle spindle amplitude of M wave Hmax/Mmax ratio as a
activation, would be sensitive to gamma inhibition measure of excitability of the motor neuron pool.
and would reveal cold-induced spasticity He found that the ratio increased with spasticity,
reduction, H-reflex tests of the monosynaptic thus H reflex was used to measure the spasticity
reflex arc that bypass the spindles would detect the indirectly. Similar results were shown by our study
alpha facilitation, resulting in elevated H- Hmax/Mmax ratio increased with spasticity and
reflexes4,8,9. Krause BA et al (2000) their study showed significant reduction after use of both the
showed that cold application reduces spasticity. treatment techniques2. This is a safe and
Patients with UMN lesion were taken, as sample economical method for treating stroke patients.
showed reduction in clonus and spasticity with ice However, this treatment standing for a long time
water immersion at 15 c after 10 minutes of may not be suitable for all patients.
cooling and his study found there was facilitation
of motor neurone pool6. The effect of Sustained CONCLUSION
passive stretching could be on the Ib afferent fiber It is concluded that Cooling and Sustained passive
and the Golgi tendon organ would be fired while stretching are equally effective in reducing
the calf muscle is stretched. Then the impulse spasticity in hemiplegics.
would be transmitted by the type Ib afferent fiber
through the interneuron thus, inhibiting the MN. ACKNOWLEDGEMENT
Another possibility is the type II afferent fiber: in Author would like to thank Dr. D. Y. Patil
this case, the muscle spindle of the calf muscle Vidyapeeth, Pune, for funding this research.
would be fired while the muscle is stretched. The Authors also acknowledge the immense help
impulse would be transmitted by the type II received from the scholars whose articles are cited
afferent fiber through the spinal cord, thus, and included in references of this manuscript.
inhibiting the neuron excitability of MN. An
obvious decrease of spasticity was observed after a REFERENCES
single session of passive stretching treatment. 1. The World health reports 2004: Deaths by
Similarly, H/M ratio was measured in our study cause, sex and mortality stratum in WHO
showed increased in it prior to Cooling and regions, estimates for 2002. Geneva: World
Sustained passive Stretching given in both study Health Organization.
groups and there was highly significant reduction 2. Senelick Richard C., Rossi, Peter W.,
in H/M ratio after treatment. Comparing the H/M Dougherty, Karla (1994). Living with
ratio of the triceps surae in study group significant

Page 147
Stroke: A Guide For Families. 7. Pierrot-Deseilligny E, Mazevet D. The

Contemporary Books, Chicago. monosynaptic reflex: a tool to investigate
3. Nathaniel H. Mayer. Clinicophysiologic motor control in humans: interest and limits.
Concepts of Spasticity and Motor Neurophysiol Clin 2000; 30:67–80.
Dysfunction in Adults with an Upper 8. Capaday C. Neurophysiological methods for
Motoneuron Lesion. Muscle and Nerve studies of the motor system in freely moving
1997. DOI: 10.1002/(SICI)1097-4598. human subjects. J Neurosci Methods
4. Jun Kimura: Electrodiagnosis of Diseases of 1997;74: 201–218.
Nerve and Muscle. Principles and Practice. 9. R. D. Adams, M Victor: Principles of
1st ed, 1983, F. A. Davis Neurology. 5thed, 1991, McGraw-Hill Book
5. Krause BA, Hopkins JT, Ingersoll CD, Co.
Cordova ML, Edwards JE. The relationship 10. Nishikawa T, Takuma Ozaki, Kosaku
of ankle cooling and rewarming to the Mizuno, Grabiner MD. Increased reflex
human soleus H reflex. J Sport Rehabil activation of the peroneus longus following
2000;9:1–10. application of an ankle brace declines over
6. Price R, Lehmann JF, Boswell Bassette S et time. Journal of Orthopaedic Research 2002;
al. Influence of cryotherapy on spasticity at 20 (6):1323-6.
the human ankle. Arch Phys Med Rehabil
1993;74(3):300-4.

Page 148
LOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL PROFILE AND
Supriya Panda et al
ANTIBIOGRAM PATTERN
LOWER RESPIRATORY TRACT INFECTION- BACTERIOLOGICAL

PROFILE AND ANTIBIOGRAM PATTERN
IJCRR Supriya Panda, B. Prema Nandini, T.V.Ramani

Vol 04 issue 21
Section: Healthcare Dept. of Microbiology, Maharajah’s Institute of Medical Sciences, Nellimarla,
Category: Research Vizianagaram, Andhra Pradesh, India
Revised on: 14/09/12 E-mail of Corresponding Author: drsupriyapanda@gmail.com
Accepted on: 23/09/12
ABSTRACT
Objective: A study was conducted to know bacteriological profile and antibiogram pattern of lower
respiratory tract infection (LRTI) in a rural setup. Methods: Sputum samples from 95 patients with
symptoms of LRTI and endotracheal aspirates from 5 patients admitted to intensive care unit (ICU)
were processed for culture and antibiotic sensitivity test was done to commonly used antibiotics.
Results: Aetiological diagnosis was possible in 83 patients. Sixty five patients were culture positive for
single pathogen and 18 patients were culture positive for two pathogens. Males (n=63) were found
more at risk to LRTI than females (n=37).LRTI was found more prevalent in 51-60 year age group
(n=24). K.pneumoniae (31.3%) was the commonest single pathogen isolated followed by Coagulase
positive Staphylococci (26.5%), Streptococcus pneumoniae (15.6%) and Pseudomonas aeruginosa
(3.6%). Str. pneuminiae strains were sensitive to ciprofloxacin (95%) and erythromycin (89%), but
resistant to ampicillin (31.5%). K.pneumoniae and Pseu.aeruginosa strains were sensitive to ofloxacin
(95-100%) ; and cefotaxime and ceftriaxone(67-100%). Conclusion: The present study reveals that
K.pneumoniae is the emerging pathogen of LRTI in rural setup with a low prevalence of antibiotic
resistance among the pathogens.
Key words: Lower respiratory tract infection, sputum culture.
INTRODUCTION complicated by the increasing prevalence of

Infections of the Lower respiratory tract are resistance among bacteria causing LRTI (5).
responsible for 4.4% of all hospital admissions and
6% of all general practitioner consultations AIM OF THE STUDY
(1).They account for 3 to 5% of deaths in adults The objective of the present study is to find out the
(2).The problem is much greater in developing bacteriological spectrum and antibiotic
countries where pneumonia is the most common susceptibility pattern of Lower Respiratory Tract
cause of hospital attendance in adults(3). Infection among the patients attending MIMS
Since the etiological agents of Lower respiratory General Hospital, Nellimarla, a village situated 8
tract infections(LRTI) can not be determined kilometer away from Vizianagaram town.
clinically , microbiological investigation is
required for both treatment and management of MATERIALS AND METHODS
individual case and epidemiological purposes(4). STUDY GROUP: After taking the approval from
But routine laboratories in the rural set up are not institutional review committee, 100 consecutive
able to perform sputum culture for various patients between the age group of 21-90 years
reasons. Therefore, antimicrobial therapy is with productive cough and fever for more than two
frequently empirical and presumptive, which is weeks presented to outpatients department of

Page 149
Supriya Panda et al
ANTIBIOGRAM PATTERN
Medicine and TB chest; and admitted to Medicine Cefotaxime-30mcg, Tetracycline-30mcg,

ward and intensive care unit(ICU) were included Amikacin-30mcg, Gentamycin-10mcg,
in the present study. Ofloxacin-5mcg, Ceftriaxone-30 mcg and
STUDY PERIOD: For a period of 8 months from Chloramphenicol-30mcg.
January 2011-August 2011.
EXCLUSION CRITERIA
Colonies of Staph.aureus on milk agar
Patients with pulmonary tuberculosis, congestive agar
heart failure, pulmonary infarction, AIDS and
those receiving Immune suppressive therapy
were excluded from the study.
LABORATORY INVESTIGATION
Two sets of sputum samples from each patient
and endotracheal aspirates from patients on
ventilator were collected after taking informed
consent from them and from close relatives for
the unconscious patients and processed within
2 hours. The samples were subjected to the
following investigations :-
1. Gram stained smears were examined to see the
character of exudates, number and type of
organisms. Specimens containing more than
25 polymorphonuclear leucocytes and less Tube coagulase test
than 10 epithelial cells per low power field
were included in the study (6).
2. Culture of sputum was done on Blood agar
with a streak of Staphylococcus aureus,
chocolate agar and Mac Conkey agar. Blood
agar and chocolate agar were incubated in
candle jar at 37 degree centigrade.
** Any bacteria showing heavy growth on culture
or a moderate or light growth along with Gram
stain report compatible with the culture results
were considered to be the causative agents(4).
3. Identification of bacterial isolates were done
by the relevant biochemical tests.
4. Antibiotic sensitivity test was done by
modified Kirby Bauer’s method for Gram
positive organisms to Ampicillin+Sulbactam-
10mcg,Amoxyclav-10mcg,Vancomycin-
30mcg,Ceftazidime-30mcg, Ampicillin-
10mcg, Netilmicin-30mcg, Ciprofloxacin-
5mcg and Cefazolin-30mcg ; and for Gram
negative organisms to Ampicillin +
Sulbactam- 10mcg, Amoxyclav- 10mcg,

Page 150
Supriya Panda et al
ANTIBIOGRAM PATTERN
Alpha haemolytic colonies of Str.pneumoniae on

blood agar
Bile solubility test for Streptococcus pneumoniae
Tube method Plate method
Optochin sensitivity of Str. pneumoniae

Page 151
Supriya Panda et al
ANTIBIOGRAM PATTERN
Beta haemolytic Streptococcus and its Bacitracin sensitivity
RESULTS
Out of 100 patients presented clinically as LRTI, Table 2 : culture for pathogens (n=100)
culture
aetiological diagnosis could be possible in 83 Culture positive
negative
cases(65 for single pathogen and 18 for mixed male female total
infections)in the present study(table no.2). for single pathogen 42 23 65
Maximum number of cases were males (n=63) and for mixed infection 11 07 18
from 51-60 years (n=24)of age group(table no total 53 30 83 17
1&3).A total of 101 isolates of pathogenic bacteria
Table 3: distribution of cases age wise
were isolated from these 83 culture positive
Age in years No. of cases
cases.Commonest organism isolated was 21-30 12
K.pneumoniae both as single pathogen and in 31-40 22
mixed infection.(table no 4 &5). Out of 40 isolates 41-50 19
51-60 24
of K.pneumoniae, 29 isolates were from inpatients
61-70 19
and 19 isolates were from 51-70 year of age 71-80 2
group(table no 4&6).Fourteen isolates of 81-90 2
K.pneumoniae(n=40)and 3 isolates of total 100
Pseu.aeruginosa(n=3) were resistant to ampicillin
Table 4 : Number of organisms isolated
+sulbactam combination,30 isolates of coagulase total no. mal fem
positive Staphylococcus(n=34) and 6 isolates of Organism IP OP
isolated e ale
Str.pnuminiae(n=19) were resistant to K.pneumoniae 40 29 11 27 13
ampicillin.(table7-10) Coag.+ve Staph. 34 18 16 21 13
Str.pneumoniae 19 06 13 11 08
Pseu.aeruginosa 03 03 0 03 0
Table 1: Total No. of patients Group A beta Strept. 03 01 02 01 02
No. of cases male female Prot.mirabilis 02 02 0 01 01
Inpatients 55 40 15 Total 101 59 42 64 37
Outpatients 45 23 22
Total 100 63 37

Page 152
Supriya Panda et al
ANTIBIOGRAM PATTERN
Table 5 : culture positive for mixed infections Table 6: Age distribution of K.pneumoniae isolates
Mixture of organisms Male Female Total Age No. of isolates
Coag.+ve 6 2 8 21-30 yrs 5
Staph+K.pneumoniae 31-40 yrs 9
Coag.+ve staph. +Str. 1 3 4
41-50 yrs 5
pneumoniae
Str.pneumoniae+ 2 0 2 51-60 yrs 9 47.5%
K.pneumoniae 61-70 yrs 10
K.pneumoniae +beta haem 1 1 2 71-80 yrs 1
strept.
81-90 yrs 1
K.pneumoniae + Prot. 1 1 2
mirabilis total 40
total 11 7 18
Table 7: Antibiotic sensitivity pattern.

K.pneumoniae Coag.+ve staph. Str.pneumoniae Ps.aeruginosa Pr.mirabils
(n=40) (n=34) (n=19) (n=03) (n=02)
S R S R S R S R S R
Ampicillin NA 04 30 13 06 NA NA
Ampicillin+sulbactam 26 14 28 06 18 01 0 03 02 0
Amoxyclav 06 34 28 06 15 04 01 02 02 0
Amikacin 40 0 NA NA 03 0 02 0
Cefazolin NA 26 08 17 02 NA NA
Cefotaxime 34 06 NA NA 02 01 02 0
Ceftazidime NA 31 03 18 01 NA NA
Ceftriaxone 36 04 NA NA 02 01 02 0
Ciprofloxacin NA 27 07 18 01 NA NA
Chloramphenicol 30 10 NA NA 01 02 02 0
Erythromycin NA 31 03 17 02 NA NA
Gentamycin 37 03 NA NA 03 0 02 0
Netilmycin NA 34 0 19 0 NA NA
Ofloxacin 37 03 NA NA 03 0 02 0
Tetracycline 26 14 NA NA 02 01 0 02
Vancomycin NA 34 0 19 0 NA NA
DISCUSSION from different areas reported an aetiological

In the present study, LRTI is more common in diagnosis between 45% to more than 80%.( 8)
males than a female which is consistent with other The major single pathogen causing LRTI are
studies from India (7). This is due to more Klebsiella pneumonia (31.3%), Coagulase positive
prevalent associated risk factors (eg. Smoking, staphylococci (26.5%), Streptococcus pneumonia
chronic alcoholism, COPD) of pneumonia in (15.6%) and Pseudomonas aeruginosa (3.6%) in
Indian males than females (8). Maximum number this study.This is comparable with a report from
of patients(24%) were from older age group (51- Nigeria(10) where commonest organism isolated
60years).This is in accordance with a study from was K.pneumoniae accounting for 38% of the
Finland, the rate of pneumonia increased for each isolates. A higher prevalence of Klebsiella
year of age over 50 years.(9).Microbiological pneumonia has also been reported from India in
diagnosis was possible in 83% of cases. Studies last two decades. (11,12,13)

Page 153
Supriya Panda et al
ANTIBIOGRAM PATTERN
K.pneumoniae is the commonest organism causing sensitivity to ofloxacin and 67 to 100 % sensitivity
LRTI in inpatients whereas among outpatients to cefotaxime and ceftriaxone.
,S.aureus is the commonest organism causing All the strains of Gram positive cocci and Gram
LRTI in the present study. All the 3 isolates of negative bacilli were senisitive to netilmycin and
Pseudomonas aeruginosa were from ICU patients amikacin respectively although Staph. aureus
with ventilator and isolated as single pathogen. strains have shown 88% resistance to ampicillin .
Nidhi Goel et al also reported this organism as the Resistance to Beta lactamase resistant antibiotics
commonest cause of ventilator associated were 100 % for Pseudomonas aeruginosa, 85 %
pneumonia (14). All 2 isolates of Proteus mirabilis for Klebsiella pneumoniae,21% for
were also from ICU patients with ventilator, but as Streptococcus pneumoniae and18% for
mixed infection along with Klebsiella Coagulase positive Staphylococi.
pneumoniae.
Isolation rate of K.pneumoniae both as single CONCLUSION
pathogen & in mixed infection is 48.2% in our In the present study commonest organism isolated
study; and 72.5% of these isolates were from from patients with LRTI was Klebsiella
inpatients and 47.5% were from age group 51-70 pneumonia (48.2%) both as single pathogen & in
yrs. Patients in the older age group are more mixed infection. Incidence of drug resistance
susceptible to gram negative pneumonia because among the strains was less. The most effective
of waning immunity and pulmonary defense antibiotics for Gram negative bacilli causing LRTI
mechanisms, underlying chronic diseases and was Amikacin and for Gram positive cocci was
silent aspiration. Institutional care also makes the Netilmicin in the present study. Cephalosporins
patients more susceptible to gram negative may be started before culture report can be
pneumonia (4)..In the present study, incidence of generated. However resistance to Beta lactamase
mixed infections was 21.7% which is consistent antibiotics requires further evaluation by more
with the fact that incidence of mixed infections standardized method.
does not usually exceed 30% (15).Identification of
polymicrobial infection is very important for ACKNOELEDGEMENT
treatment strategies. We acknowledge the immense help received from
We got 3 isolates of Beta hemolytic Group-A the scholars whose articles are cited and included
Streptococcus in the age group 61-70 years. It can in references of this manuscript. The authors are
cause pneumonia by the spread of infection from also grateful to authors/ editors/ publishers of all
the pharyngeal mucosa(16).There are reports those articles, journals and books from where the
regarding increasing prevalence of drug resistance literature for this article has been reviewed and
among the strains of Streptococcus pneumoniae discussed.
from India (17).Among our strains of Str.
pneumoniae ,although 31.5% resistance was noted REFERENCES
for ampicilin, they have shown high degree of 1. Anderson.H,Esmail A,Hollowell J,Littlejohns
sensitivity to ciprofloxacin(95%) and P, Strachen D.Epidemeologically based needs
erythromycin(89%). assessment,Lower respiratory diseases, DHA
There are also reports from India regarding Project Research programme.1993; p 6-12.
increase prevalence of drug resistance among 2. Editorial.Antibiotics and respiratory
gram negative bacilli strains from LRTI (14,18). illness.Br.Med.J.1994;3:1
But in the present study,K.pneumoniae and Pseud. 3. Mac Farlance J.Community acquired
aeruginosa strains have shown 95 to 100 % pneumonia.Br J Dis Chest 1987;81:p116-27.

Page 154
Supriya Panda et al
ANTIBIOGRAM PATTERN
4. Fang Gd , Fine M,orloff J, Arisumi D 12. Kulpati Das, Kumar A.Flexible fibreoptic
etal.New and Emerging etiologies for bronchoscopy in lower respiratory infection.
community acquired pneumonia with Indian J Chest Dis Allied Sci,1980;22: p39-46.
implication for therapy ,a prospective multi 13. Sharma TN,Jain NK,Nanavati V,Mangal
center study of 359 cases HN,Sarkar SK,Singh
.Medicine(Baltimoore) 1990;69:p307-16 V.Transbronchofiberoptic bronchial aspiration
5. Guthrie R. Community acquired lower in lower respiratory tract infection.Indian J
respiratory tract infections: aetiology and Chest Dis Sci.1981;23:p73-80.
treatment.Chest.2001;20:p2021-34 14. Nidhi Goel, Uma Chaudhary,Riru Aggrawal,
6. Murray,P.R and Washington ,J(1975):A Kiran Bala.Antibiotic sensitivity pattern of
microscopic and bacteriological analysis of gram negative bacilli isolated from lower
expectorated sputum.Mayo clin.proc,50,p339- respiratory tract of ventilated patients of
44. intensive care unit. Research
7. Aroma Oberoi,Aruna Article.2002;13:p148-51
Aggrawal.Bacteriological profile,serology and 15. deRoux A, Ewig S,Garcia E,Marcos
antibiotic sensitivity pattern of microorganisns MA,Mensa J,Lode H etal. Mixed community
from community acquired pneumonia.JK acquired pneumonia in Hospitalised
SCIENCE ,2006;8:p-79-82. patients.Eur.Respir.J.2006:27:795-800.
8. S.Bansal,S.Kashyap,L.S.Lal and 16. Harrison’s principle of internal medicine.15 th
A.Goel.Clinical and bacteriological profile of edition.2003,p903
community acquired pneumonia in 17. Kiran Chawla, Bimala Gurung, Chiranjay
Shimla,Himachal Pradesh. Indian J Chest Dis Mukhopadhyay,Indira Bairy.Reporting
& Allied Sci,2004;46:p17-22 emerging resistance of Streptococcus
9. Barlett JG,Dowell SF,Mandell pneumoniae from India. J of Global Infectious
LA,etal.Practice guidelines for the Disease,2010;2:p10-14
management of community acquired 18. P Gauchan, B Lekhak,J B Sherchand..The
pneumonia in adults. Cli. Infect prevalence of LRTIs in adults.J of Institute of
Dis,2000;31:P347-82 Medicine. Tribhuban University;
10. A.O.Okesola&OM Ige. Trends in vol.28(2):p10-14
bacteriological pathogens of lower respiratory
tract infections.Indian J of Chest Dis & Allied
Sci,2008;50:p269-72.
11. Madhu SV,Gupta U, Guleria JS, Talwar V.
Clinical and bacteriological profile of
hospitalized community acquired
pneumonia:A preliminary study.Indian J Chest
Dis Allied Sci,1990;32:p95-100.

Page 155

Antiepileptics IJCRR

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Antiepileptics IJCRR

Uploaded by

Copyright:

Available Formats

ISSN: 2231-2196 (Print)

ISSN: 0975-5241 (Online)

“Let the Science be your passion”

International Journal of Current Research and Review

Vol 04 / Issue 21 / November 2012

1 International Journal of Current Research and Review

Indexed in: ScopeMed, Google Scholar, Index Copernicus, Science Central,

About the editors:

IJCRR Award for Best Article:

Administrative Office: Radiance Research Academy, 148, IMSR Building, Near

2 International Journal of Current Research and Review

Prelimanary Study of Lung Functions in

3 International Journal of Current Research and Review

Does Thermal Stress Alters the

Vol 4 / Issue 21 / Nov 2012

4 International Journal of Current Research and Review

PRELIMANARY STUDY OF LUNG FUNCTIONS IN

INTRODUCTION pulmonary change following training.Wasserman

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

climatic conditions that is it may be related to conducted in Dept of Physiology, GMC,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Runners.Ind.j.physiol.pharmac.1994; Nonathletes.Ind J Physiol Pharmac:

Multiple bar diagram showing comparison of age in runner and non

Runner Non runner

Table 2: Comparison of FVC in runner and non runner group

Multiple bar diagram showing comparison of FVC in runner and non

Runner Non runner

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Table 5: Comparison of height in runner and non runner group

Parameter Runner Non runner Z P Value

Runner Non runner

Table 6: Comparison of weight in runner and non runner group

Multiple bar diagram showing comparison of weight in runner and

Runner Non runner

Medgraphics Body Plethysmograph Machine

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

COMPARITIVE STUDY OF CONVENTIONAL AND ULTRASOUND-

IJCRR B.R Ashwini1, Vernekar Sunita2, Kulkarni Mohan H3, T. Kiran4

INTRODUCTION between benign and malignant lesions

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

FacUnivPalacky Olomouc Czech Repub Can Be Left Alone? AJR Am J Roentgenol

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Fig 1: [A]: Mixed echoic lesion with specks of

Fig 2: [A]: Single well circumscribed hypoechoic

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

PHYSICOCHEMICAL AND BIOLOGICAL PROPERTIES OF

INTRODUCTION fascinating group of pteridophytes is distributed in

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

History Pharmacological Actions and Uses in Unani

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

isoadiantol-B; 3-methoxy-4-hydroxyfilicane and Salmonella arizonae, Salmonella typhi and

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

pharmacological studies have reported the Division, Lucknow: National botanical

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

Table 1: Fluorescence analysis of the powdered drug

Int J Cur Res Rev, Nov 2012 / Vol 04 (21) ,

DIAGNOSTIC DILEMMA DUE TO DIVERSE PRESENTATION