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NATIONAL JOURNAL OF
MEDICAL RESEARCH
Volume 6 │ Issue 1 │ Jan – March 2016 │ Page: 1 - 110
print ISSN: 2249 4995│eISSN: 2277 8810
NATIONAL JOURNAL OF MEDICAL RESEARCH
Official Publication of National Association of Medical Research
Print ISSN: 2249 4995
Online ISSN: 2277 8810
EDITORIAL BOARD
Chief Editor
Dr. Viren Patel MD (Pathology), USA
Associate Editor
Dr. Sunil Nayak MD (Community Medicine), Patan, Gujarat
Executive Editor
Dr. Harsh Shah, MD (Skin & VD)
Associate Executive Editor
Mr. Bhaumik M
Members
Dr. Chirag Mehta MS (ENT), Palanpur
Dr. Mehul Gosai, MD (Pediatric), Bhavanagar
Dr. Deepak Agrawal, MD (Pathology), Agra
Dr. N K Gupta, MS, MCh (CTVS), PGDHHM, Lucknow
Dr. Deepak Parchivani PhD (Biochem), Bhuj
Dr. Praful J. Dudharecha MD (Medicine), Rajkot
Dr. Deepak Shukla MD (Medicine), Surat
Dr. Rajesh Solanki, MD (TB & Chest), Ahmedabad
Dr. H. R. Jadhav, MS (Anatomy), Ahmedabad
Dr. Gunvant Kadikar MD (Ob. & Gy.), Bhavnagar
Dr. Hitendra Desai MS (Surgery), Ahmedabad
Dr. Indira Parmar, MD (Pediatric), Vadodara
Dr. Kaushik Kadia MS (Surgery), Patan
Dr. Rudresh Jarecha, DMRE, DNB (Radio.), Hydrabad
Dr. Uma Gupta, MD (Ob. & Gy.), Lucknow
Dr. Suprakash Chaudhury, MD (Psychi.), PHD, Ranchi
Dr. Shalini Srivastav MD (PSM), Greater Noida
Dr. Vani Sharma, MD (Ob. & Gy.), Himachal Pradesh
Dr. K. M. Maheriya MD (Pediatrics), Ahmedabad
Dr. Gurudas Khilani, MD (Med & Pharmac), Patan
All the views expressed in the articles are personal views of the authors and not the official views of the
National Journal of Medical Research or the Association. The Journal retains the copyrights of all material
published in the issue. However, reproduction of the published material in part or total in any form is
permissible with due acknowledgement of the source as per ethical norms.
Mr. Bhaumik M., Associate Executive Editor, NJMR
Email: [email protected], Mob: 8140975850
PUBLISHER
MedSci Publications
National Journal of Medical Research (Reg. No. 24-022-21-48410)
C-43, Umiya Bunglows,
Bhadreshwar, Hansol, Ahmedabad – 382475.
NATIONAL JOURNAL OF MEDICAL RESEARCH │ Volume 6│Issue 1│ Jan – March 2016
www.njmr.in
CORRESPONDENCE
[email protected]
The journal is indexed in Scopemed, DOAJ, WHO HINARI, IndexScholar, IndMedica, NewJour, Index
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Open Access Journal
NATIONAL JOURNAL OF MEDICAL RESEARCH
NATIONAL JOURNAL OF MEDICAL RESEARCH
Volume 6│Issue 1│Pages 1 – 110 │Jan - March 2016
Table of Content
Original Article
Study of Ocular Changes in Pregnancy
O K Radhakrishnan, Debapriya Datta, Jyoti Yadav, Priti Kumari, Vasundhara Phillips, Nimrita Nagdev ... 1
-
4
Prevalence of raised inter-arm BP difference in young healthy adults –A cross sectional study
Simmy Kurian, Manjula V D, Roshni Paul Joseph ................................................................................................. 5
-
8
Effect of Chronic Alcohol Intake on Auditory System with Changes in Auditory Brainstem Evoked
Responses
Harinder J.Singh, Sharanjit Kaur, Amandeep Kaur, Lily Walia, Anand Sharma ................................................ 9
- 12
Outcome of Chemotherapy in Lung Cancer: Our Experience At A Rural Tertiary Care Hospital in Central
India
Babaji Ghewade, Tarushi Sharma, Satyadeo Choubey, Swapnil Chaudhari ........................................................ 13 - 16
Clinical examination and foot pressure analysis of diabetic foot: Prospective analytical study in Indian
diabetic patients
Harshanand J Popalwar, Anil Kumar Gaur, Badrinath D Athani, Jayasree Ramesh ......................................... 17 - 22
Prevalence of Vitamin-A deficiency & refractive errors in primary school-going children
Rupali D Maheshgauri, Radhika R Paaranjpe, Abha Gahlot, Ami Gohil, Sonali Pote, Deepaswi Bhavsar ... 23 - 27
Effects of Tadalafil on cardiopulmonary haemodynamics in patients of chronic pulmonary diseases with
pulmonary hypertension- A pilot study
Indrajeet Sharma, Purshottam K. Kaundal, Malay Sarkar, Tulika Jha, Prakash C. Negi, Ashok K. Sahai,
Sanjeev Asotra .............................................................................................................................................................. 28 - 34
A Study on Awareness of Tobacco Use and Cancer Risk Among Medical Students
(Col) Prakash G Chitalkar, Rakesh Taran, Deepak Singla, Prashant Kumbhaj .................................................. 35 - 37
A Study to Evaluate and Compare the Efficacy and Safety of Topical Cyclosporine A 0.5% with Topical
Placebo (Artificial Tears) in Alleviating the Principal Signs Associated with Vernal Keratoconjunctivitis
Abha Gahlot, Rupali Maheshgauri, Bhargav Kotadia, Kanisha Jethwa, Gira Raninga ...................................... 38 - 41
Prevalence and risk factors of non fatal road traffic accidents in a community setting of district Dehradun
Shubham M. Sharma,Ruchi Juyal, Shaili Vyas, Jayanti Semwal ............................................................................. 42 - 44
Study on Clinico-epidemiological pattern of foreign bodies in Otorhinolaryngology and associated
morbidities
Richa Gupta, Manish Mittal ........................................................................................................................................ 45 - 47
A prospective study of comparison between Open Gastrojejunostomy and Laparoscopic Assisted
Gastrojejunostomy in patients of post corrosive ingestion pyloric stenosis
Samir M.Shah, Chirag K. Patel, Smit M. Mehta, Vikram B. Gohil ....................................................................... 48 - 50
Study of Change In Macular Volume With Uncontrolled HbA1c Levels in a Diabetic patient in absence of
Diabetic Macular Oedema
Parag Apte, Priti Kumari, Debapriya Datta, Nilesh Jagdale, Jatin Patel, Richa Naik......................................... 51 - 53
Evaluation of visual outcome of cataract surgery in rural eye-camps in the state of Maharashtra
Rupali D Maheshgauri, Abha Gahlot, Sonal Kohli, Radhika R Paaranjpe, Bhagyashree Kadam, Gira
Raninga .......................................................................................................................................................................... 54 - 57
Volume 6│Issue 1│ Jan – March 2016
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Open Access Journal
NATIONAL JOURNAL OF MEDICAL RESEARCH
Assessment of the profile of psychiatric manifestations in cannabis users: A cross sectional study
Indrajeet Sharma, Tulika Jha, Purshottam K. Kaundal .......................................................................................... 58 - 61
Effects of intrathecal Bupivacaine with normal saline versus Bupivacaine with Fentanyl in patients
undergoing surgery
Jigna R Shah, Manish Bhatt ........................................................................................................................................ 62 - 68
Scientific Validation of Disease Diagnosis System, Using Human Energy Field (Aura) For GIT Cases
Rajeev Pahwa, Uday Kumar Jejurikar, Menka Kuril, Barkha Kuril ...................................................................... 69 - 72
Evaluation of Stress urinary incontinence among non pregnant female patients in a tertiary care hospital
Shraddha Agarwal, Ashwin Vacchani, Jigisha Chauhan, Sneha .C. Halpati......................................................... 73 - 76
Incidence and Treatment Abandonment in Teen And Young Adult Cancers
(Col) Prakash.G Chitalkar, Rakesh Taran,. Prashant Kumbhaj, Deepak Singla ................................................. 77 - 79
A radiographic study of rib anomalies in patients of various chest diseases belonging to north Indian
population at a tertiary care centre
Darshan K Bajaj, Shailesh K Singh, Abhishek Dubey, Anand Srivastava, Surya Kant, Ajay K Verma,
Ved Prakash, Mona Asnani ......................................................................................................................................... 80 - 83
Study of clinical profile and complications of Dengue fever in Tertiary care hospital of Puna City
Pradnya Mukund Diggikar, Prasanna Kumar Satpathy, Gaurav Dinesh Bachhav, Kanishka Dinesh Jain,
Anuja Mukesh Patil, Prafull Chajjed .......................................................................................................................... 84 - 86
A study of visual problems in children scoring low grades and those with lack of concentration at school in
Pune city
Radhika Ramchandra Paranjpe, Rupali Darpan Maheshgauri, Shraddha Ramadhar Yadav, Bhargav
Jitendra Kotadia, Nimrita Gyanchand Nagdev, Kanisha Girish Jethwa .............................................................. 87 - 88
A Study on Comparison of Intravenous Butorphanol with Intravenous Fentanyl for Premedication in
General Anesthesia
Hemangini M Patel, Bansari N Kantharia ................................................................................................................ 89 - 91
Comparison of haemodynamic fluctuation of intravenous Ketamine with intravenous Propofol – Fentanyl
combination in short surgical procedure
Madhavi S Mavani, Sudevi Desai ............................................................................................................................... 92 - 94
Trends of Nosocomial Infections in A Private hospital of Surat, Gujarat
Latika N Purohit, Prashant V Kariya......................................................................................................................... 95 - 97
Review Article
Using the methodology of wavelet analysis for processing images of cytology preparations
Vyacheslav V Lyashenko, Asaad Mohammed Ahmed abd allah Babker, Oleg A Kobylin............................... 98 - 102
Case Report
Acute disseminated encephalomyelitis in chicken pox
Arijit Sinha, Suvrendu Sankar Kar, Tirtha Pratim Purkait, Uttam Kumar Pandit .............................................. 103 - 104
Retrocaval /circumcaval ureter: rare congenital anomaly of ureter or inferior vena cava
Samir M Shah, Chirag K Patel, Smit M. Mehta, Vikram B Gohil ......................................................................... 105 - 107
Mesenteric Panniculitis- A Case Report
Amol Jagdale, Saurav Mittal, Krutik Patel, Azhar Shaikh....................................................................................... 108 - 110
Volume 6│Issue 1│ Jan – March 2016
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NATIONAL JOURNAL OF MEDICAL RESEARCH
print ISSN: 2249 4995│eISSN: 2277 8810
ORIGINAL ARTICLE
STUDY OF OCULAR CHANGES IN PREGNANCY
O K Radhakrishnan1, Debapriya Datta2, Jyoti Yadav3, Priti Kumari2, Vasundhara Phillips2, Nimrita Nagdev2
Author’s Affiliations: 1Professor; 2PG Resident; 3Senior Resident, Department of Ophthalmology, Dr D. Y. Patil Medical College, Pimpri, Pune
Correspondence: Dr Debapriya Datta Email: [email protected]
ABSTRACT
Introduction: In pregnancy, women undergo a tremendous number of systemic and ocular changes. Physiological changes occur in the cardiovascular, hormonal, metabolic, hematologic and immunologic systems.
Hormonal changes are among the most prominent systemic changes in pregnant women with the placenta,
maternal endocrine glands and the fetal adrenal glands combining their productivity to make a high-powered
hormone factory.
Aims: To evaluate the various ocular changes taking place in pregnancy in women with no other co-morbid
ocular or systemic diseases and to compare ocular changes in three trimesters of pregnancy with controls of
non pregnant women.
Materials and Methods: The ocular changes occuring in varying stages of pregnancy in 225 pregnant
women were studied and compared with 75 healthy non pregnant women.
Results: Age was similar in the pregnant and non pregnant women studied. Headache was significantly more
common among pregnant women when compared to non pregnant women. Diplopia was not significantly
different between pregnant and non pregnant women. Intraocular pressure was significantly less among the
pregnant women as compared to non pregnant women. Occurrence of conjunctival pigmentation was significantly more in pregnant women when compared to non pregnant women. There was no difference in corneal
thickness when pregnant and non pregnant women were compared. Krukenberg’s spindles were seen more
commonly among pregnant women when compared to non pregnant women.
Conclusion: Various ocular changes occur during a normal pregnancy. Knowledge of these changes can help
to differentiate the physiological changes occurring in a normal pregnancy from ocular manifestation of systemic diseases.
Keywords: Pregnancy, Diplopia, Krukenberg’s spindle
INTRODUCTION
Pregnancy is a physiological situation which places
abnormal stress and demands on a pregnant
woman’s body.1 The physiological, hematological,
hormonal, immunological and metabolic changes in
the body of a pregnant woman merit special consideration, as also the eye. The maternal endocrine system and the placenta (the hormone factory) cause
ocular abnormalities which are reversible and rarely
permanent.2
The ocular effects of pregnancy may be physiological
or pathological or may be modifications of preexisting conditions.3 Physiological changes include
increased pigmentation of the lids, ptosis, changes in
cornea and refractive status and decreased intraocular pressure. 4 These usually resolve post partum. Preexisting diseases such as Graves’ disease, Retinitis
NJMR│Volume 6│Issue 1│Jan – Mar 2016
pigmentosa and Optic neuritis should be monitored
due to their relapses in pregnancy. There may be
worsening of Diabetic retinopathy and Central serous chorio-retinopathy with increased risk of retinal
detachment. Conditions like glaucoma and non infectious uveal inflammatory disorders may even improve transiently. Pre-eclampsia and eclampsia could
result in hypertensive retinopathy, exudative retinal
detachment and cortical blindness. Neuroophthalmological disorders such as venous sinus
thrombosis, benign intracranial hypertension, pituitary adenoma, meningioma and optic neuritis should
be kept in mind as differential diagnosis in pregnant
women presenting with visual acuity loss, visual field
loss, persistent headaches or oculomotor
sies.5 Use of ophthalmic drugs can affect foetal
health during pregnancy.
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Knowledge of ocular changes in pregnancy can help
to differentiate the physiological changes from ocular
manifestation of systemic disease and diseases pertaining to the eye in a pregnant woman.4
AIMS: The aim of the study was to evaluate the
various ocular changes taking place in pregnancy in
women with no other co-morbid ocular or systemic
diseases and to compare ocular changes in three trimesters of pregnancy with controls of non pregnant
women.
MATERIALS AND METHODS
It was a cross sectional observational study carried
out jointly in the Department of Ophthalmology and
Department of Obstetrics and Gynaecology of a tertiary care centre in Western Maharashtra from July
2012 to September 2014. The study included 225
pregnant women and 75 non pregnant women. Ethics Committee Clearance was obtained before starting the study.
Written and informed consent was obtained from all
women participating in the study.
Inclusion Criteria: Pregnant women between the
age of 19-40 years in the 1st, 2nd and 3rd trimester
of pregnancy and non pregnant women with no ocular or systemic co-morbidity were included in the
study.
Exclusion Criteria: Pregnant women with any preexisting co-morbidity like Diabetes and Hypertension; and Pregnant women with any pre-existing ocular morbidity like Cataract, Uveitis, Glaucoma, Retinal and Optic nerve disorders were excluded from
the study..
The selected patients were divided into 4 groups:
-
Group A: 75 pregnant women in 1st trimester
with no other ocular and systemic co-morbidity.
-
Group B: 75 pregnant women in 2nd trimester
with no other ocular and systemic co-morbidity.
-
Group C: 75 pregnant women in 3rd trimester
with no other ocular and systemic co-morbidity
-
Group D: 75 non pregnant women with no
other ocular and systemic co- morbidity.
Evaluation of the patient included the following
in each case:
Demographic factors like age, sex, occupation and
address were recorded. Complete ophthalmic history
and medical history was taken. The measurement of
the uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) was done. Intraocular
pressures were recorded using Goldmann applanation tonometer. Anterior segment of both eyes were
examined under the slit lamp biomicroscope. Corneal thickness was measured using Pachymeter. Fundus evaluation of both eyes was done through dilated
pupils using direct ophthalmocope , slit lamp biomicroscopy with a 90D lens and indirect ophthalmoscopy. Keratometry was done using Bausch and
Lomb Keratometer. Perimetry was done using
Humphrey’s visual field analyzer.
RESULTS
In all group 75 women included in each. Thus total
225 womenr participated. The mean age was analyzed quantitatively within groups as shown in table
1. The P value was >0.05, which was statistically not
significant.
Table 1: Comparison of Age in Study Groups
Group
Group A
Group B
Group C
Group D
Women
75
75
75
75
Mean Age (yrs)
24.75
25.03
24.96
24.64
p-Value
>0.05
Group A: Pregnant in 1st rimester; Group B: Pregnant in 2nd
Trimester; Group 3: Pregnant in 3rd Trimester; and Group 4:
Non pregnent
Table 2: Comparison of Ocular Problems in Study Groups and its Statistical Significance
Ocular problems
Headache
Diplopia
IOP Mean (mm Hg)
Conjunctival pigmentation
Corneal thickness Mean(microns)
Krukenberg’s spindles
Group A (%)
30 (40.0)
0
15.03
20 (26.67)
548.89
10 (13.33)
Group B (%)
34 (45.33)
2 (2.67)
13.05
19 (25.33)
551.96
14 (18.67)
Group C (%)
28 (37.33)
0
11.07
16 (21.33)
553.48
6 (8.0)
Group D (%)
5 (6.67)
0
15.33
1 (1.33)
547.77
0
p-Value
<0.0001
>0.05
<0.0001
<0.001
>0.05
<0.05
Group A: Pregnant in 1st rimester; Group B: Pregnant in 2nd Trimester; Group 3: Pregnant in 3rd Trimester; and Group 4: Non pregnant
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Table 3: Comparison of ocular changes between pregnant and non pregnant women and its statistical significance
Ocular Problem
Headache
Diplopia
Conjunctival Pigmentation
Krukenberg’s spindle
Groups
Pregnant
Non Pregnant
Pregnant
Non Pregnant
Pregnant
Non Pregnant
Pregnant
Non Pregnant
Present
92
5
2
0
55
1
30
0
DISCUSSION
Pregnancy is a natural state of physiological stress for
the body. Each organ system of the body in a pregnant women behaves differently from that of a body
in a non-pregnant state. The present study was conducted to evaluate the various ocular changes taking
place in pregnancy in women with no other comorbid ocular or systemic diseases. Headache was
more commonly seen among pregnant women as
compared to non pregnant women in the study.
Within group comparison showed that all cases in
1st, 2nd and 3rd trimester had significantly more
headache as compared to non pregnant women. Increase in headaches is caused by surge of hormones
in pregnancy along with an increased volume of
blood circulating throughout the body.6
Diplopia was not seen to be a significant problem
among the pregnant women studied. In a study of
240 normal pregnant women, it was found that 12
pregnant women developed Idiopathic Intracranial
Hypertension during their pregnancies. Ten were
found to have headaches, five were found to have
transient visual obscuration, four were found to have
visual field loss, four were found to have reduced
visual acuity and three had diplopia. Bilateral papilledema of varying severity was seen in all 12 women.
7,8 Intraocular pressure was found to be significantly
less among pregnant women as compared to non
pregnant women in this study. Within group comparison showed that intraocular pressure in 2nd and
3rd trimester pregnant women was significantly less
as compared to non pregnant women. Similar finding
was also observed in a study conducted by Ebeigbe
JA, Ebeigbe PN and Ighoroje ADA (2012) who
found that there was a fall in intraocular pressure
across the trimesters and this was very significant
(P<0.0001). 9,10
The prevalence of Conjunctival pigmentation was
more commonly seen among the pregnant women as
compared to non pregnant women in the study.
Within group comparison also showed that in 1st
2nd and 3rd trimester of pregnancy, conjunctival
pigmentation was more commonly seen as compared
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Absent
133
70
223
75
170
74
195
75
Odds Ratio (CI)
9.68 (3.76 - 24.92)
P value
<0.0001
1.69 (0.08 - 35.58)
>0.05
23.94 (3.25 - 176.28)
<0.001
23.56 (1.42 - 390.14)
<0.05
to non pregnant women (P<0.0001). A study conducted by Gaikin AV and Vavilis D et al reported
similar findings where conjunctival pigmentation was
found to be more common in pregnant women. Authors felt that an increase in conjunctival pigmentation is due to elevated estrogen levels associated with
normal pregnancy which resolves post partum. 11
Corneal thickness was not significantly different between pregnant and non pregnant women in our
study. Weinreb RN, Lu A, Beeson C. (1988) measured central corneal thickness in 89 pregnant
women.They found that there was no significant difference (P = .79) in corneal thickness between the
nongravid and postpartum women. A study by Huna
Baron R et al done in 2002 found that corneal thickness increased by 16 micron (P = .01) in the pregnant women when compared to the control eyes of
18 non gravid and 17 postpartum women. Authors
mentioned that in pregnancy, there is a measurable
increase
in
corneal
thickness
due
to
edema.12 Krukenberg’s spindles on the cornea was
more common among the pregnant women as compared to non pregnant women in our study
(P<0.0001). Study by Riss B, Riss P showed similar
results of increase in Krukenberg’s spindles in pregnant women in comparison with non pregnant
women. Newly developed Krukenberg’s spindles on
the cornea have been observed early in pregnancy
and they tend to decrease in size during the third
trimester and during the postpartum period.13 The
mechanism presumably is related to hormonal
changes such as low progesterone levels. However,
by the third trimester, an increase in progesterone
and aqueous outflow often result in decreased or absence of Krukenberg’s spindles.14
CONCLUSIONS
Pregnancy produces numerous changes in the organ
systems of a pregnant women’s body. Headache was
a common symptom reported by pregnant women.
Decreased intra ocular pressure and conjunctival
pigmentation were seen during pregnancy. Krukenberg’s spindles were more common among pregnant
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NATIONAL JOURNAL OF MEDICAL RESEARCH
women when compared to non pregnant
women.The occurrence of diplopia and a change in
corneal thickness was not different between pregnant
and non-pregnant women.
REFERENCES
1. Garg P et al. Ocular changes in pregnancy. Nepal J Ophthalmol.2012;4(7):150- 61.
2. Sunness J.S. The pregnant woman's eye. Surv Ophthalmol.1988;32:219–238.
3. Gary F, Kenneth J, Steven L, et al. Williams Obstetrics
Twenty-third Ed 2010;8:195.
4. Sushil C, Tarun C, Jairam Y, et al. Ophthalmic considerations in pregnancy. Med J Armed Forces India. Jul
2013;69(3):278– 84.
5. Erkkila H, Raitta C, Iivanainen M, et al.Optic neuritis during
lactation. Graefes Arch Clin Exp Ophthalmol 1985; 222:134.
6. Carlin A, Alfirevic Z. Physiological changes of pregnancy
and monitoring. Best Pract Res Clin Obstet Gynaecol.
2008;22:801–23.
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7. Tang RA, Dorotheo EU, Schiffman JS, et al. Medical and
surgical management of idiopathic intracranial hypertension
in pregnancy. Curr Neurol Neurosci Rep 2004; 4:398.
8. Huna-Baron R, Kupersmith MJ.Idiopathic intracranial hypertension in pregnancy. J Neurol 2002;249:1078.
9. Ebeigbe JA, Ebeigbe PN and Ighoroje ADA. Intraocular
Pressure in Pregnant and Non-Pregnant Nigerian Women.
African Journal of Reproductive Health December 2011;
15(4):20.
10. Pitta Paramjyothi, Lakshmi A.N.R, Surekha D. Physiological
Changes of Intraocular Pressure (IOP) in the Second and
Third Trimesters of Normal Pregnancy. Journal of Clinical
and Diagnostic Research. 2011 October ; 5(5):1043-45.
11. Gaikin AV.Condition of the microcirculatory bed of the bulbar conjunctiva in physiological and pathological pregnancies. Arkh Anat Gistol Embriol 1985;89:36.
12. Weinreb RN, Lu A, Beeson C. Maternal corneal thickness
during pregnancy. Am J Ophthalmol 1988;105:258.
13. Riss B, Riss P. Corneal sensitivity in pregnancy. Ophthalmologica 1981;183:57-62.
14. Duncan TE: Krukenberg spindles in pregnancy. Arch Ophthalmol 1974; 91:355.
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ORIGINAL ARTICLE
PREVALENCE OF RAISED INTER-ARM BP DIFFERENCE IN
YOUNG HEALTHY ADULTS –A CROSS SECTIONAL STUDY
Simmy Kurian1, Manjula V D2, Roshni Paul Joseph3
Author’s Affiliations: 1Assistant Professor; 3Tutor, Department of Physiology, Govt Medical college
lam; 2Professor, Department of Community Medicine, Govt Medical College Idukki, Kerala.
Correspondence: Dr Simmy Kurian Email: [email protected]
ABSTRACT
Background: Inter-arm difference (IAD) in blood pressure (BP) has been observed in various general populations and in individuals with increased risk of cardio vascular disease and peripheral vascular disease. The
prevalence of raised IAD in BP in young healthy adults has not been well addressed in most prior studies.
Objectives: To estimate the prevalence of raised IAD in BP in young healthy adults, to find the gender difference in mean IAD and mean arterial BP, to find the difference in mean arterial BP according to the presence of IAD in BP.
Methods: A cross sectional study was carried out among 284 medical students. BP was measured twice in
each arm, using an automatic device that was calibrated according to the manufacturer’s recommendations
and the values were averaged. IAD in BP is defined as difference between average BP in right arm and average BP in left arm.
Results: Prevalence of raised IAD in BP in the study group was 16.5% (47). None had IAD in BP ≥ 20 mm
of Hg. Mean systolic IAD in BP was 5.915(±3.81) mm of Hg and mean diastolic IAD in BP was 3.18 (±2.44)
mm of Hg. The mean values of systolic and diastolic IAD in BP were almost similar in males and females ,
but the mean values of mean arterial BP in both arms were significantly different (P<0.05) in males and females. Mean values of Mean arterial BP in both arms were higher in those with raised IAD in BP and this was
statistically significant (P<0.05).
Interpretation & conclusion: Significant IAD in blood pressure (≥ 10 mm of Hg) is common in young
healthy adults. The clinical significance of raised IAD in BP in young healthy adults requires long term follow
up.
Key words: Inter-arm difference in blood pressure, mean arterial blood pressure, cardio vascular disease, peripheral vascular disease.
INTRODUCTION
Inter–arm BP difference (IAD) has received increasing attention recently since it has been found to be
associated with peripheral vascular disease1 and is
identified as a risk factor for cardiovascular morbidity2. A difference in BP readings between arms can
be observed in various general populations, healthy
women during antenatal period and in population
with an increased risk of cardiovascular disease
(CVD), such as people with hypertension, diabetes
mellitus, chronic renal disease or peripheral vascular
disease. The prevalence of IAD in young healthy
adults is not well addressed in most of the studies
although the prevalence in older adults and hypertensives are well documented. WHO has predicted
that by 2030 almost 23.6 million people will die from
CVD, mainly from heart disease and stroke3. Over
NJMR│Volume 6│Issue 1│Jan – Mar 2016
80 % of CVD deaths occur in low and middle income countries. Most of the risk factors for cardiovascular diseases are high in young adults4 which
supports the fact that nearly half of the deaths due to
CVD are occurring in young and middle aged individuals .
A recent study5 found that participants with higher
inter-arm Systolic BP (SBP) difference were at much
higher risk for future CVD than those with less than
10 mm difference between arms. The prevalence of
raised IAD in BP in young adults is not well addressed since only few studies,,6,7 were performed in
this population. . The prevalence of systolic IAD ≥
10mm of Hg was 12.6% in a study done on young
healthy adults.7
IAD differences ≥ 20 mm of Hg systolic and/ or 10
mm of Hg diastolic warrant specialist referral.
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Hence prevalence of raised IAD in BP in young
adults should be identified. If IAD in BP is high, it
should be investigated.
Operational Definitions used
Aims & Objectives: The primary objective was to
estimate the prevalence of raised IAD in BP in
young healthy adults. Second objective was to find
the gender difference in mean IAD in BP as well as
gender difference in right and left mean arterial BP
.Third objective is to find the difference in mean arterial BP according to the presence of inter-arm difference in BP.
Raised diastolic inter-arm BP difference- ≥ 10 mm of
Hg difference between average diastolic BP in right
arm and average diastolic BP in left arm
MATERIALS AND METHODS
A medical institution based cross- sectional study
was conducted among MBBS students in a tertiary
care centre in central Kerala during the period July
2015 to November 2015, after approval by the institutional ethics committee. The study population consisting of 300 MBBS students enrolled for the course
during the academic years 2013, 2014 and 2015.
Sample size was estimated using the formula n= 4 x
p x q / d2. n=sample size, P = the prevalence, q =
100 – p, d=the relative precision .
The calculated sample size was 265 , but annual intake of students of this institution is 100 and it was
decided to cover three batches of medical students(300 students).
Exclusion criteria: The exlcusion criteria for the
study were students less than eighteen years of age,
with any major illness, on any regular drugs and
found to have hypertension on clinical examination
were excluded. On clinical examination, 9 students
were found to have hypertension and were hence excluded.7 students did not participate in the study.
Total 284 students participated in the study and response rate was 94%. Height and weight were measured using standard equipments. BP measurement
was done in a quiet room with subject in sitting position following at least five minutes of rest. The subject was refrained from taking food or drinks half
hour before BP measurement. The apparatus was
kept at the level of heart and hands were supported
during BP measurement. BP was measured twice in
each arm .BP was measured first in the arm first presented without prompting , using an automatic device (OMRON –Model-HEM-7130) that was calibrated according to the manufacturer’s recommendations and the values were averaged. Cuff was then
swapped to the other arm and two readings were
taken with five minutes interval. Inter-arm BP difference is defined as difference between average BP in
right arm and average BP in left arm.
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Raised systolic inter-arm BP difference - ≥ 10 mm of
Hg difference between average systolic BP in right
arm and average systolic BP in left arm
Statistical Methods: The data was coded and entered in Microsoft excel and analysed using SPSS
version 16.0. Prevalence of raised inter- arm BP difference would be expressed as percentage. Continuous variables were summarised as arithmetic mean
and standard deviation. Difference in mean IAD and
mean arterial BP in males and females were tested
using student t test. For all statistical analysis the significance level was set at p < 0.05.
RESULTS
Systolic inter-arm difference in BP ≥ 10 mm of Hg
was present in 15.4%(44) subjects. Diastolic interarm difference ≥ 10 mm of Hg was present in 1.7%
(5) subjects.(Table 1)
Prevalence of raised inter-arm difference in BP in the
study group was 16.5%(47). None had inter-arm BP
difference ≥ 20 mm of Hg.
Descriptives of anthropometric parameters and BP
are described in table 2.
Table 1: Prevalence of Raised Inter-arm BP difference
Gender
Male
Female
Total
Inter-arm Difference
Present (%) Absent (%)
15 (17.6)
70 (82.4)
32 (16.1)
167 (83.9)
47 (16.5)
237 (83.5)
Total
85
199
284
Table 2: Descriptives of anthropometric parameters and BP of study subjects
Clinical/Anthropometric
Mean (±SD)
Measures
(n=284)
Height
162.97 ( ±10.386 )
Weight
54.43 ( ±11.752)
BMI
20.249 ( ±3.094)
LSBA
105.4 ( ±10.774)
RSBA
109.121 (±11.85)
LDBA
67.54 ( ±6.49)
RDBA
69.02 (±6.88)
SIAD
5.915 (±3.81)
DIAD
3.18 (±2.44)
BMI-Body Mass Index; LBSA-Left arm Systolic BP Average; RSBA-Right arm Systolic BP Average; LDBA-Left
arm Diastolic BP Average; RDBA-Right arm Diastolic BP
Average; SIAD-Systolic Inter-arm Difference in BP;
DIAD-Diastolic Inter-arm Difference in BP.
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NATIONAL JOURNAL OF MEDICAL RESEARCH
All variables were normally distributed.
Mean systolic inter-arm difference in BP was
5.915(±3.81) mm of Hg and mean diastolic inter-arm
difference in BP is 3.18 (±2.44) mm of Hg.
Mean BP recorded from 284 subjects were 109.12
(±11.85) / 69.09 (±6.88) mm of Hg in Right arm and
105.04 ( ±10.77) / 67.5 (±6.4) mm of Hg in left arm.
The mean values of systolic and diastolic inter-arm
BP differences were comparable in males and fe-
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males and the slight difference observed was not statistically significant. But the mean values of mean arterial BP in both arms were higher in males than females and this difference was statistically significant
(P=0.001 in both arms).) Similarly when subjects
were grouped based on presence and absence of
IAD, those with presence of IAD had higher mean
values of mean arterial BP in both arms .This was
also statistically significant.(Left arm-P=0.02 ,Right
arm –P=0.01) (Table 3).
Table 3: Comparison of means of IAD and mean arterial BP according to
gender and presence of raised IAD
Parameter
SIAD
Factors
Mean±SD
p-Value
Males
5.62(±4.39)
0.40
Females
6.04(±3.53)
DIAD
Males
3.27(± 2.15)
0.67
Females
3.14(±2.56)
LAM
Males
83.76(±5.99)
0.001
Females
78.19(±7.36)
RAM
Males
86.12(±7.02)
0.001
Females
80.50(± 8.96)
LAM
Raised IAD present ( n=47)
82.01(±7.26)
0.02
Raised IAD absent (n=237)
79.43(±7.39)
RAM
Raised IAD present ( n=47)
88.2(±8.2)
0.01
Raised IAD absent (n=237)
80.98(±8.4)
IAD-Inter- Arm Difference in BP; DIAD-Diastolic Inter-Arm Difference in BP; SIADSystolic Inter-Arm Difference In BP.LAM-Left Arm Mean arterial BP, RAM-Right Arm
Mean arterial BP.
DISCUSSION
The present study done in young healthy adults
showed the prevalence of raised IAD in BP as
16.5%. In a similar study done in young healthy
adults7 , the prevalence was 12.5%.Both studies used
sequential method for BP estimation which may
have resulted in higher prevalence rates. Mean systolic inter-arm difference in BP is 5.915(±3.81) mm
of Hg and mean diastolic inter-arm difference in BP
is 3.18 (±2.44) mm of Hg in this study. This result
was almost similar to values obtained in other studies,8,9 Many previous studies 10,11 have shown that
mean IAD was unrelated to gender . Similarly, in the
present study mean values of systolic and diastolic
IAD does not vary much in males and females.
In our study BP in right arm tended to be higher
than BP in left arm which was similar to the observation in a study by Adam J Singer11.This may be due
to the right handedness of majority of subjects. The
larger muscle mass in right arm is less easily compressed by blood pressure cuff. This might not have
occurred if direct intra arterial blood pressure monitoring was performed. In a study by Kimura
etal 12 done in Japan, there is considerable difference
in measured BP in left and right arm and systolic BP
in right arm was slightly lower than the left arm
.Large difference in absolute systolic BP was associNJMR│Volume 6│Issue 1│Jan – Mar 2016
ated with risk factors of atherosclerosis like hypertension, hypercholesterolemia and obesity in the
above study. According to a study by Rajiv Agarwal13
, every 10mm difference in systolic BP between arms
conferred mortality hazard of 1.24(95% CI:1.01 1.52) after adjusting for average BP. Also his observation was that BP difference between arms are reproducible and carry prognostic information. In our
study systolic IAD was present in 15.4%(44) of subjects which may also have prognostic significance .
They have to be followed up as coronary artery disease development later is observed5 in a community
based cohort and documented in those with raised
IAD in BP. Also greater than 10 mm Hg of IAD in
BP was independently associated with future cardiovascular risks in a recent study.14
The mean values of mean arterial BP were significantly different in males and females in the present
study. The mean values were higher in males than
females. Mean values of mean arterial BP in both
arms were high in those with raised IAD in BP .
Mean arterial pressure is a major independent predictor of cerebrovascular events 15 .Raised IAD along
with high values of mean arterial pressure in these
subjects warrants their follow up for future cardio
vascular events development.
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LIMITATIONS
The study used sequential method for estimation of
raised IAD in BP which might have resulted in
higher prevalence rate .Influence of mid arm circumference on IAD in BP was not considered in the
study.
CONCLUSION
and cardiovascular disease in Framingham Heart Study. The
American Journal of Medicine. 2014;127(3).
6.
Martin D.Fotherby, Barnabas Panayiotou and John F Potter.Age related difference in simultaneous inter-arm BP
measurements. Postgrad Med J 1993;69:194-196.
7.
Alon Grossman, Alex Prokupetz , Barak Gordon, Nira
MoragKoren, Ehud Grossman. Interarm BP difference in
young healthy adults. The Journal of clinical Hypertension
Aug 2013;.vol(15)/No 8.
8.
Arnett D K, Tang W, Province M A,etal .Interarm difference
in seated systolic and diastolic BP;The Hypertension Genetic
Epidemiology Network study.J Hypertension 2005;23:11411147.
Bilateral upper extremity blood pressure determined
by automated indirect measurements has wide degree
of inter-arm variation. So in a primary care setting
9. Verberk W J,Kessel A G,Thien T. BP measurement method
blood pressure should be measured routinely in both
and inter arm difference: A metaanalysis . Am J Hypertenarms to prevent under estimation of hypertension.
sion 2011; 24(11) :1201-1208.
Individuals with raised inter-arm difference in BP 10. Lane D, Beevers M, Barnes N, Bourne J etal .Inter-arm difrequire long term follow up.
ference in blood pressure:When are they clinically significant?.J Hypertens.2002 Jun;20(6):1089-95.
REFERENCES
1.
2.
3.
4.
5.
Clark C E, Campbell J L, Powell R J, Thompson J F. The
inter-arm BP difference and peripheral vascular disease:Cross
sectional study-Fam Pract 2007;24:420-426.
Clark C E ,Taylor R S, Shore A C,etal. Association of a difference in systolic blood pressure between arms with vascular disease and mortality;a systematic review and meta analysis.Lancet 2012;379;905-914.
Global Atlas on Cardiovascular Disease Prevention and Control. Whorld Health Organisation Geneva 2011.Available at
http://www.world-heart federation .org/fileadmin/user.../
Global – CVD-Atlas.PDF.Accessed on 15 th January 2015.
Simmy Kurian, Manjula V.D, Annamma , Jaimol Zakariah.A
study on cardiovascular risk factor profile of medical students in a tertiary care hospital in central Kerala.National
Journal of Medical Research 2015 Jan-March;5(1):11-17.
Ido Weinberg, Philimon Gons, Christophem J .O Donnel
etal.The systolic Blood Pressure Difference Between Arms
NJMR│Volume 6│Issue 1│Jan – Mar 2016
11. Adam.J.Singer, Judd . E. Hollander. Blood Pressure Assessment of Inter arm difference. Arch Intern Med. 1996;156(17)
: 2005-2008.
12. Kimura A, Hashimoto J , Watabe D, Takahashi H, et al . Patient characteristics and factors associated with interarm difference of BP measurement in a general population in
Ohasama , Japan.J Hypertens. 2004 Dec;22(12):2277-83.
13. Rajiv Agarwal, Zerihuu Bunaye, Dagis M . Bekele.Prognostic
significance of between arm BP difference.Hypertension
2008;51:657-662.
14. Takanori Tokitsu , Eiichiro Yamamoto, Yoshihiro Hirata,
Koichi Sugamura et al.Relationship between future cardiovascular events in coronary artery disease.J Hpertens
2015,33:1780-1790.
15. Verdecchia P. Schillaci G,Reboidi G, Franklin SS.Different
prognostic impact of 24 hour mean BP and pulse pressure
on stroke and coronary artery disease in essential hypertension.Circulation.2001;103:2579-2584
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print ISSN: 2249 4995│eISSN: 2277 8810
ORIGINAL ARTICLE
EFFECT OF CHRONIC ALCOHOL INTAKE ON AUDITORY
SYSTEM WITH CHANGES IN AUDITORY BRAINSTEM
EVOKED RESPONSES
Harinder J.Singh1, Sharanjit Kaur2, Amandeep Kaur3, Lily Walia4, Anand Sharma5
Author’s Affiliations: 1Associate Professor, 4Professor & Head; 5Professor, Dept. of Physiology; 2Associate Professor,
Dept. of Pharmacology, MMMC&H, Solan; 3Medical Officer, NHM, Ludhiana
Correspondence: Dr Harinder J.Singh E-mail: [email protected]
ABSTRACT
Objective: Alcohol affects the auditory threshold, processing of tones and frequency change at different levels of auditory processing system.1 ABR is the sensitive tool for identifying the various changes in auditory
processing unit.
Material and Methods: A total of 52 subjects were divided in group 1 with 26 non-alcoholics males and
Group 2 (in lower case) with 26 alcoholic males. Chronic alcoholics who were taking alcohol for more than 8
years (300ml/day) without the history of any neurological and audiological problem and none of them were
taking any medication that was oto-toxic were included in our study. Brainstem auditory evoked potential was
performed on these subjects and results were analyzed statistically.
Results: There was a significant increase in latency of wave V in alcoholics (5.678 ± 0.2271 ms) as compare
to non-alcoholics (5.874 ± 0.2969 ms). (p = 0.0102) The mean value of inter peak latency for I-V in group -1
(non-alcoholics) was 3.88 ± 0.26 ms and in group 2 (alcoholics) was 4.19 ± 0.42 ms which showed a statistically significant increase in group 2. (p =0.0020). There was also a statistically significant increase in inter peak
latency for III-V in group 2 (2.495 ± 0.389 ms) as compared to group 1 (2.228 ± 0.35 ms). (p= 0.0119) but
there was no significant result noted for changes in other waveform pattern and inter peak latency I-III.
Key words: Alcoholism, Brainstem auditory evoked potential, latency waves, inter peak latency.
INTRODUCTION
Chronic alcohol intake is one of the most popular
abused substance to affect the hearing mechanism. It
is known to cause increase in the hearing threshold
by altering the central auditory processing particularly at level of summation of auditory signals. Initially this temporary threshold shift in hearing
mechanism may become permanent if alcohol taken
over a period of time.1, 2 The mechanism of alcohol
toxicity is because of increase in fluidity of neuronal
cell membrane and change in neurotransmitters.3 Chronic intake of alcohol affects auditory
brainstem responses and causes delay in neurotransmission time, which reflects damage to central auditory pathways in the form hearing loss.4
Brainstem auditory evoked potentials (BAEPs) are a
common non-invasive objective method to evaluate
the integrity of central auditory pathways. It is one of
the best measure used for the identification of cochlear and retrocochlear disorders and for threshold
testing. Calibrated clicks are delivered to one ear, and
NJMR│Volume 6│Issue 1│Jan – Mar 2016
electrical events are recorded in the form of seven
waves (I-VII) that appear at certain latent period of
time. Any delay or absence of the peaks can locate
the brainstem lesions. So this is an sensitive objective
tool to measure the function and abnormalities
through the entire auditory pathway from cochlea to
cortex.5, 6 There was a study conducted in patients
with sensorineural deafness due to alcoholism and
the results showed prolongation of wave I in 57% of
cases and prolongation of inter peak latency I-V in
43% of cases.6 Certain studies showed significantly
delay in appearance of wave V and inter peak latencies III-V and I-V.7 The current study was designed
to evaluate the abnormalities in Auditory brainstem
response (ABR) waves in chronic alcoholics to detect
early changes in auditory processing unit.
METHODOLOGY
This study was conducted in Department of Physiology, M.M. Medical College and Hospital, KumarhatPage 9
NATIONAL JOURNAL OF MEDICAL RESEARCH
ti, Solan. Himachal Pradesh. The study protocol was
duly approved by institutional ethics committee. Our
study was conducted to observe the effects of alcohol on brainstem auditory evoked potentials. 26 nonalcoholics males as controls (Group 1) and 26 chronic alcoholic male subjects (Group 2) as cases were
included in our study. All the subjects were of the
age group of 25 to 55 years with a mean age of 43.00
± 10.131in group I and 46.370 ± 8.367 in group 2 (p
> 0.05). The subjects were randomly selected from
the general population of Solan, Himachal Pradesh
and surrounding areas of Solan district.
Inclusion criteria: Alcoholics who have been consuming more than 300 ml of alcohol daily for more
than 8 years and absteince of alcohol for 10 days
prior to this study were included in our study. These
patients were recruited from college staff only giving
this above history. All alcoholics were without the
history of any neurological and audiological problem
and none of them were taking any medication that
was oto-toxic. The subjects were free from symptoms of Wernick’s encephalopathy like nytagmus and
ataxia.
Exclusion criteria: All the subjects having history
of clinical auditory abnormality, subjective symptoms
of hearing loss, diabetes mellitus or hypertension
were excluded from our study.
All the subjects were interviewed on a proforma
which include clinical history for each subject. The
subjects were explained about the study and informed consent was taken before their participation.
The test performed on these subjects was short latency auditory evoked potential using Neuro- Perfect
2-channel EMG NCV EP PC based machine in Physiology Department.
print ISSN: 2249 4995│eISSN: 2277 8810
BAEP Recording Procedure: The subjects were
seated in front of machine. High quality EEG electrodes were used. Spots were marked on scalp of
subjects and these spots were rubbed with acetone to
remove oil. The electrodes were dipped in conductive jelly and pressed on each spot with adhesive
tape. The ground electrode was placed on midline
point on forehead. The active electrodes were placed
on left mastoid and on right mastoid region. Reference electrode was placed on vertex of skull. The
impedence of electrodes was kept below 5 ohm. Filter setting was kept at 10 Hz as low filter and at
3000Hz as high filter. 2000 clicks were given at the
rate of 11.1 per second with intensity of 60 decibels
above normal hearing threshold. A series of 5 waves
were recorded during first 10 milliseconds of both
right and left ears and its latencies and inter peak latencies were noted. Then we take the average of
these 2000 sweeps using computer techniques. The
mean wave latency I, II, III, IV, V and inter peak latencies I-III, I-V and III-V of auditory brainstem response (ABR) were measured.8,9 The data was analysed statistically between group 1 and group 2.
RESULTS
Our study compared the latencies and interpeak latencies between alcoholics and non-alcoholics. The
mean latency V in group 1(non-alcoholics) was 5.678
± 0.2271 ms and in group 2 (alcoholics) was 5.874 ±
0.2969 ms. There was a significant increase in latency
of wave V in alcoholics as compare to non-alcoholics
(Table 1) (p = 0.0102).
Table 1: Comparative evaluation of latencies of ABR waves in group 1 (non-alcoholics) and group 2
(alcoholics)
ABR latency
waves (in milliseconds)
Group 1
Group 2
p-value
I (ms)
Mean ±S.D.
II(ms)
Mean ±S.D.
III(ms)
Mean ±S.D.
IV(ms)
Mean ±S.D.
V(ms)
Mean ±S.D.
1.795 ± 0.2246
1.688 ± 0.2725
0.1263 *
2.730 ± 0.2032
2.698 ± 0.2084
0.5739 *
3.450 ± 0.2240
3.380 ± 0.2431
0.2854*
4.716 ± 0.2446
4.740 ± 0.2561
0.7328*
5.678 ± 0.2271
5.874 ± 0.2969
0.0102 **
* Non significant, ** significant, ABR= Auditory brainstem response, SD = Standard deviation
Table 2: Comparative evaluation of inter-peak latencies of ABR waves in group 1 (non-alcoholics)
and group 2 (alcoholics)
ABR INTERPEAK LATENCY
(in milliseconds)
Group 1
Group 2
p- value
I-III(ms)
Mean ±S.D.
1.654 ± 0.3597
1.692 ± 0.3514
0.7011*
I-V(ms)
Mean ±S.D.
3.883 ± 0.2579
4.199 ± 0.4225
0.0020***
III-V(ms)
Mean ±S.D.
2.228 ± 0.3485
2.495 ± 0.3892
0.0119**
* Non significant, ** significant, *** highly significant, ABR= Auditory brainstem response, SD = Standard deviation.
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The inter peak latency I-III, I-V and III-V in group 1 (non-alcoholics) was 1.654 ± 0.3597 ms, 3.883 ±
0.2579 ms and 2.228 ± 0.3485 ms and in group 2 (alcoholics) was 1.692 ± 0.3514 ms, 4.199 ± 0.4225 ms
and 2.495 ± 0.3892 ms respectively. The inter peak
latency I-V showed statistically significant increase in
group 2 as compared to group 1 (Table 2) (p
=0.0020). Also the inter peak latency III-V showed
significant increase in group 2 as compared to group
1 (Table 2) (p = 0.0119).
Our results revealed that ABR latency V; inter peak
latency I-V and III-V has statistical significant prolongation in group 2 when compared to group 1
(Table 2) (p < 0.05) showing that chronic alcoholism
affects the central auditory pathway with prolongation of transmission of nerve impulse in chronic alcoholics. Data was analysed using student’s unpaired‘t’ test comparing the means and standard deviation between group 1 and group 2. The differences between the means was considered significant
when p < 0.05.
DISCUSSION
Chronic alcohol intake was related to hearing loss
due to neuronal degeneration as suggested by few
researchers like Sandra Beatriz et al, Nordahl et al,
Golabeck et al.10, 11, 12 but some contradicted this relation like studies done by Propelka et al and Itoh et
al who found no association between alcohol consumption and hearing loss.13, 14 Previous studies also
showed that chronic alcoholism was a known cause
of hearing loss of the sensorineural type at high frequencies (4000 – 8000 Hz). 15
Auditory threshold (AT) measurement method is a
standard behavioural procedure for measuring auditory sensitivity. Verma et al. in their study had shown
to affect the auditory threshold in alcohol-dependent
patients for higher frequencies.1 The studies done in
past show the effects of alcohol on brain auditory
evoked potentials with variable results. Our result
mostly correlates with other studies which show delay in latencies of ABR waves II, III, IV and V in alcoholics.[7] In a study conducted in 2002, the authors
have shown that 57% patients with hearing loss due
to chronic alcoholism have latency prolongation of
wave I and 43% patients with hearing loss due to
chronic alcoholism shows latency prolongation of
wave V, showing that auditory pathways were involved in sensorineural hearing loss.6 Our observations also showed the increase in latency V and increase in inter-peak latency I-V and III-V in alcoholic group.
The wave V originates from inferior colliculus.13 The
statistical comparison in our study showed the increasing trend of wave latency V in alcoholics as
compared to non-alcoholics. The possible reason for
NJMR│Volume 6│Issue 1│Jan – Mar 2016
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this increase in latency V is because of demyelination
of auditory pathways. 16 Our study was also in
agreement with a previous study showing the prolongation of III-V wave. The prolongation of III-V
wave suggests alcoholic cerebellar degeneration.17
There were also prolonged I-V and I-III inter peak
intervals in patients of Wernicks–korsakoff syndrome group in another study.18 Our study also
shows the increase in inter peak latency I-V showing
the disturbances in neurological functions in chronic
alcoholics.
The results observed in alcoholics could be explained
due to degeneration in auditory pathway. It can also
be due to peripheral hearing loss due to auditory
nerve atrophy which can lead to increase in latencies
and increase in inter peak latencies.19 Another reason
for these changes is change in membrane transmission, neuronal loss, death of axons and demyelination of nerves which produces delay in absolute latencies in alcoholics.16 The chronic alcohol consumption leads to depletion of vitamin B12 stores in liver
and greater vitamin B12 intake would be required to
preserve cochlear functioning.20 In our study as a
limitation of this study, we could not demonstrate
the causal association between vitamin B12 and hearing loss.
CONCLUSION
Chronic alcohol consumption can lead to brainstem
damage, resulting in hearing degradation depending
upon the quantity of alcohol ingested and time duration for this intake. Deviations from normal wave
pattern or delay in peak latencies and inter peak latencies can detect various pathologies in auditory
processing unit.
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1.
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worried? Am J Otolaryngol 2006 Jul-Aug;27(4):225-8.
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Kähkönen S, Marttinen Rossi E, Yamashita H. Alcohol impairs auditory processing of frequency changes and novel
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Melgaard B. The neurotoxicity of ethanol. Acta Neurologica Scandinavica 1983;67(3)131–142.
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Smith, E.S. & Riechelmann, H. Cumulative life-long alcohol
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Weber BA. Patient specific normative values of Auditory
brainstem response audiometry. AJA 1992 Nov; 24-26.
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Zhelyazkova Z, Benchev R. Auditory evoked Brainstem
response (ABR) of Patients with hearing loss, suffering
from chronic alcoholism. Balkan Journal of Otology and
Neuro-Otology 2002; 2(1):26-29.
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7.
Begleiter H, Porjesz B and Chou CL. Auditory brainstem
potentials in chronic alcoholics. Science 1981;211:1064-6.
8.
Rosenhamer H, Lindstrom B, Lundborg T. On the use of
click-evoked electric brain stem responses in audiological
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Audiol 1981;10: 3-1 1.
9.
Jewett D, Romano M, Williston J. Human auditory evoked
potentials: possible brain stem components detected on the
scalp. Science 1970;167:1517-8.
10.
Ribeiro SBA, Jacob LCB, Alvarenga KDF, Marques JM,
Campelo RM, Tschoeke SN. Auditory assessment of alcoholics in abstinence Rev. Bras. Otorrinolaryngol.
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11. Legatt AD. Arezzo IC, Vaughan HG Jr. The anatomic and
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12. Golabek W, Niedzielska G. Audiological investigation of
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BE, Klein R, Nondahl DM. Moderate alcohol consumption
and hearing loss: a protective effect. J Am Geriatr Soc
2000;48:1273 -78
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14. Itoh A, Nakashima T, Arao H, Wakai K, Tamakoshi A,
Kawamura T et al. Smoking and drinking habits as risk factors for hearing loss in the elderly; epidomological study of
subjects undergoing routine health checks in Aichi, Japan.
Public Health 2001;115(3):192 – 6.
15. Pearson P, Dawe LA, Timnay B. Frequency selective effects
of alcohol on auditory detection and frequencydiscrimination thresholds. Alcohol and alcoholism.1999;34(5):741749.
16. F Diaz, F Cadaveirs and C Grau. Short and middle latency
auditory evoked potentials in abstinent chronic alcoholics:
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Neurophysiology 1990;77:145-50.
17. Chu N, Squires K, Starr A. Auditory brainstem response in
chronic alcoholics. Electroencephalogr Clin Neurophysiol
1982;54:418-25.
18. Chan YW, Mcleod JG, Tuck RR, and Feary PA. Brainstem
auditory evoked response in chronic alcoholics. Journal of
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19. Matas CG, Filha VA, Okada MM and Resque JR, Auditory
evoked potentials in individuals over 50 years. Pro Fono R
Atual Cient 2006 Sep-Dec;18(3).
20.
Halsted CH, Villanueva JA, Devlin AM, Chandler CJ.
Metabolic interactions of alcohol and folate. J Nutr 2002;
32:2367S–2372S.
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ORIGINAL ARTICLE
OUTCOME OF CHEMOTHERAPY IN LUNG CANCER: OUR
EXPERIENCE AT A RURAL TERTIARY CARE HOSPITAL IN
CENTRAL INDIA
Babaji Ghewade1, Tarushi Sharma2, Satyadeo Choubey3, Swapnil Chaudhari2
Author’s Affiliations: 1Professor; 2Junior Resident; 3Associate Professor, Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Wardha
Correspondence: Dr Babaji Ghewade Email: [email protected]
ABSTRACT
Background: It is well known that lung cancer is one of the leading causes of mortality worldwide. In the
treatment of lung cancer, chemotherapy has become a generally accepted and widely applied therapeutic modality. In present study we find out the outcome of chemotherapy, variations in outcome due to various factors, its effect on quality of life of patients, common complications due to it and various reasons of default
among these patients.
Materials & Methods: A total of 42 cases diagnosed histopathologically as lung cancer and treated with
chemotherapy over the year were analyzed.
Results: A total of 42 patients were included in the study. There were a total of 24 males (57.2%) and 18 females (42.8%) among them .7(16.6%) patients were below the age of 50 years and 35(83.4%) were more than
50 years in age. A total of 16(38%) patients diagnosed with lung carcinoma were smokers and the rest (62%)
were nonsmokers. NSCLC was found to be more common than SCLC in non-smokers, while SCLC was
more common among smokers. Only 30.95% of patients completed the full course of chemotherapy and thus
were assessed for improvements in quality of life following chemotherapy treatment. It was found that SCLC
patients showed more improvement in scores than NSCLC patients. 29 (69.05%) of the total patients left
chemotherapy in between. The main reason for this was found to be financial problems followed by switching
to alternate forms of medicine.
Conclusions: Lack of funds to procure chemotherapy was the major factor responsible for default among
patients. In patients completing the chemotherapy, significant improvements were seen in Quality of Life.
Key words: Lung cancer, Chemotherapy,
INTRODUCTION
Worldwide, lung cancer is one of the most commonly diagnosed oncological diseases and the leading
cause of cancer-related death in men. In women,
lung cancer ranks number four with regard to incidence but number two in terms of mortality.1
There are two major types of lung cancer: non-small
cell lung cancer (NSCLC) and small cell lung cancer
(SCLC). Non-small cell lung cancer is much more
common and accounts for 85% of all lung cancer
cases (2). There are three main types of NSCLC,
which are named for the type of cells in which the
cancer develops: squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. Only 17.3% of
the people who develop non-small cell lung cancer
survive for 5 years.2
Small cell lung cancer also called “oat cell cancer,”
accounts for 14% of all lung cancers.2 This type of
lung cancer grows more quickly. Small cell lung cancer is mainly attributable to smoking. Only 6.2 % of
the people who develop small cell lung cancer survive for 5 years.2 Only 20-30% of patients present
NJMR│Volume 6│Issue 1│Jan – Mar 2016
with an operable disease, while most of the patients
present in an advanced stage II and III.
According to demographic data available from various Indian studies the ratio of small cell carcinoma
to non small cell carcinoma was 2.7:1 in India (19862001).3 Most patients are diagnosed at an advanced
stage without curative treatment options. In this situation, systemic palliative treatment has only limited
effect on survival. Consequently, to maintain or improve patients’ quality of life (QOL) represents a
main treatment goal.4
Chemotherapy for non-small cell lung cancer
Depending on the stage of non-small cell lung cancer
(NSCLC), chemo may be used in different situations:
1) Before surgery (sometimes along with radiation
therapy) to try to shrink a tumor. This is known
as neoadjuvant therapy.
2) After surgery (sometimes along with radiation
therapy) to try to kill any cancer cells that may
have been left behind. This is known as adjuvant
therapy.
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NATIONAL JOURNAL OF MEDICAL RESEARCH
3) As the main treatment (sometimes along with radiation therapy) for more advanced cancers or for
patients who aren’t healthy enough for surgery.
Chemotherapy cycles generally last about 3 to 4
weeks. It is often not recommended for patients in
poor health, but advanced age by itself is not a barrier to getting chemotherapy.5
Most often, treatment for NSCLC uses a combination of two chemo drugs. If a combination is used, it
often includes either cisplatin or carboplatin plus one
other drug. Sometimes combinations that do not include these drugs, such as gemcitabine with vinorelbine or paclitaxel, may be used.
For people with advanced lung cancers who meet
certain criteria, a targeted therapy drug such as bevacizumab or cetuximab may be added to treatment.
For advanced cancers, the initial chemo combination
is often given for 4 to 6 cycles. If the initial chemo
treatment for advanced lung cancer is no longer
working, the doctor may recommend second-line
treatment with a single drug such as docetaxel or
pemetrexed. Again, advanced age is no barrier to receiving these drugs as long as the person is in good
general health.5
Small cell lung cancer chemotherapy
Chemotherapy is usually the main treatment for
small cell lung cancer (SCLC). Doctors give chemo
in cycles, with a period of treatment (usually 1 to 3
days) followed by a rest period to allow the body to
recover. Each cycle generally lasts about 3 to 4
weeks, and initial treatment is typically 4 to 6 cycles.
It is given as a combination of 2 drugs at first. If the
cancer progresses (get worse) during treatment or
returns after treatment is finished, other chemo
drugs may be tried. The choice of drugs depends to
some extent on how soon the cancer begins to grow
again. If cancer returns more than 6 months after
treatment, it might respond again to the same chemo
drugs that were given the first time, so these can be
tried again.
Drugs/combinations used in treatment of lung
cancer
Drugs used in NSCLC
Cisplatin
Carboplatin
Paclitaxel
Albumin-bound paclitaxel
Docetaxel
Gemcitabine
Vinorelbine
Irinotecan
Etoposide
Vinblastine
Pemetrexed
Drugs used in SCLC
Cisplatin and etoposide
Carboplatin and etoposide
Cisplatin and irinotecan
Carboplatin and irinotecan
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If the cancer comes back sooner, or if it keeps growing during treatment, further treatment with the
same drugs isn’t likely to be helpful. If further chemo
is given, most doctors prefer treatment with a single,
different drug at this point to help limit side effects.
Topotecan, which can either be given into a vein
(IV) or taken as pills, is the drug most often used,
although others might also be tried.
Aims and objectives
The objectives of this research were to study the
outcome of chemotherapy in histopathologically diagnosed lung cancer patients; to assess and compare
the variations among them in relation to age, sex,
histological type, staging of carcinoma & no. of chemotherapy cycles; to study the outcome of chemotherapy in form of Survival & Quality of life; to study
the pattern of complications among these patients;
and to find out cause of default of chemotherapy.
METHODOLOGY
The study was conducted at Acharya Vinobha Bhave
Rural Hospital, Sawangi (Meghe) in indoor patients
of Lung Cancer. This was an interventional, prospective, longitudinal study. The data was collected from
patients receiving chemotherapy at AVBRH from
September 2013 to September 2014.
Inclusion Criteria: All histopathologically diagnosed
patients of lung cancers who had taken at least one
cycle of chemotherapy and patient who has given
consent to participate in the study were included in
the study.
Exclusion Criteria: Patient unwilling for chemotherapy and not fulfilling inclusion criterias were excluded from the study.
The patients with lung cancer in inpatient department of AVBRH, SAWANGI who took at least one
cycle of chemotherapy and the patients who were
histologically diagnosed cases of lung cancer and had
been advised chemotherapy by Institutional Tumor
Board Committee (comprising of Oncophysician,
Oncosurgeon, Oncoradiotherapist) were included in
this study.
Patients included in this study were evaluated after
each chemotherapy cycle for improvements in general condition. Routine blood investigations & radiological investigations i.e Xray & CT scans were performed after each cycle to assess the progress after
chemotherapy. FACT-L (4) questionnaire was used
to measure Qol (Quality of life) in patients who
completed the course of chemotherapy.
Exclusion criteria consisted of cooperation problems
and lack of consent. The sample size for this study
included all patients subjected to chemotherapy during the period September 2013 to September 2014.
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RESULTS
Among 42 patients included in the study, 24 were
males (57.2%) and 18 were females (42.8%).
7(16.6%) patients were below the age of 50 years and
35(83.4%) were more than 50 years in age. A total of
16(38%) patients diagnosed with lung carcinoma
were smokers. 32(76.2%) were having non small cell
carcinoma of lung while 10(23.8%) were having
small cell carcinoma of lung.
Out of 32 patients of NSCLC, 16(50%) were males
and 16(50%) were females. 10 patients who were diagnosed with SCLC had 8(80%) of male patients and
2(20%) were female patients.
In NSCLC 5(15.6%) of patients were below the age
of 50 years. 27(84.4%) were above age of 50 years.
Patients with SCLC had 2(20%) below the age of 50
years and 8 (80%0 patients above the age of 50 years
NSCLC group had 9 patients (28.1%) who were
smokers and the rest 23(71.9%) were non smokers.
Patients with SCLC included 7(70%) patients who
were smokers and 3(30%) who were non smokers.
ECOG performance score: In patients with
NSCLC, majority of patients i.e 26(81.2%) had an
ECOG Performance score between 0-2, and
6(18.8%) patients scored between 3 to 5. 9(90%) patients of SCLC had an ECOG performance score
between 0-2, only 1(10%) had performance score between 3-5. A total of 13(30.95%) patients completed
full course of chemotherapy while rest of 29
(69.05.%) were defaulters and dropped out of chemotherapy before completion.
Among those who completed chemotherapy,
8(61.53%) patients were of NSCLC, and 5(39.47%)
were of SCLC. In NSCLC group 3(37.5%) were
males and 5(62.5%) were females, while in SCLC
group 3(60%) males and 2(40%) females completed
the treatment.
Reasons for default: Out of 29 patients who defaulted chemotherapy, 24(82.8%) were cases of
NSCLC and 5(17.2%) were cases of SCLC. The main
reasons for default in NSCLC patients were financial
problems in 13(54.2%), switching to alternate medicine in 5(20.8%) & non tolerance of side effects in
6(25%). Among the SCLC patients, the reasons for
default were switching to alternate medicine in
2(40%), intolerable side effects in 2(40%) and financial problem was seen in 1(20%) patient.
Quality of life: As observed by changes in FACT-L
score before and after chemotherapy, NSCLC patients showed an average improvement of 22.6%,
with males showing 23% and females showing 22.2%
improvement in QOL. Among SCLC patients
showed an average improvement of 27.59%, with
males showing 26.48% and females showing 28.71%
improvement in QOL.
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Table 1: Demographic features of the study participants
Demographic Feature
Sex
Age
Smoking
ECOG
Male
Female
<50
>50
Smoker
Non smoker
ECOG0
ECOG 1
ECOG 2
ECOG 3
ECOG 4
ECOG 5
NSCLC (%)
N=32
16(50.0)
16(50.0)
5(15.6)
27(84.4)
9(28.1)
23(71.9)
8(25.0)
7(21.9)
11(34.3)
6(18.8)
0(0)
0(0)
SCLC (%)
N=10
8(80.0)
2(20.0)
2(20.0)
8(80.0)
7(70.0)
3(30.0)
2(20.0)
4(40.0)
3(30.0)
1(10.0)
0(0)
0(0)
Table 2: Distribution of patients completing
chemotherapy
Gender
Male
Female
NSCLC (%) N=8
3(37.5)
5(62.5)
SCLC (%) N=5
3(60.0)
2(40.0)
Table 3: Distribution of patients according to
reasons for default
Reasons For Default
NSCLC
(n=24)(%)
Financial Problem
13(54.2)
Switching To Alternate Medicine 5(20.8)
Non Tolerance Of Side Effects
6(25.0)
SCLC
(n=5)(%)
1(20.0)
2(40.0)
2(40.0)
Table 4: Fact-L score, before & after chemotherapy
Characteristics Mean Fact-L Score
Before
After
Chemo
Chemo
NSCLC*
Male
56
88
Female
59.28
89.36
SCLC*
Male
57
93
Female
55
94
% Improvement In Qol
23.0
22.2
26.48
28.71
Only 13(30.95%) patients completed the course of
chemotherapy. An increase in Qol score was seen in
these patients. 29 patients (69.05%) dropped out of
chemotherapy during the treatment.
DISCUSSION
In the treatment of lung cancer, chemotherapy has
become a generally accepted and widely applied therapeutic modality. Since the majority of patients with
this disease are not cured by surgery or radiotherapy
and many cases present with advanced stages of disease, chemotherapy is regarded as the most promisPage 15
NATIONAL JOURNAL OF MEDICAL RESEARCH
ing approach to the ultimate control of lung cancer.
In small cell tumors, significant advances in therapy
have produced striking results.6,7 The non-small cell
tumors, however, have remained relatively refractory.
treatment.8,9
In this study 42 cases diagnosed as lung cancer and
treated with chemotherapy over the year were analyzed. Majority of patients belonged to age group
above 50 years as was also reported in previous Indian studies.10 NSCLC was found to be more common than SCLC in nonsmokers, while SCLC was
more common among smokers. 70% of patients with
small cell carcinoma were smokers. This association
has been proved in recent studies.11
Only 30.95% of patients completed the full course of
chemotherapy and thus were assessed for improvements in quality of life following chemotherapy
treatment. FACT-L questionnaire has been developed as a part of FACIT measurement system. On
measuring the scores on FACT-L before and after
the course of chemotherapy, it was found that SCLC
patients showed more improvement in scores than
NSCLC patients. NSCLC patients showed an average improvement of 22.6% while SCLC patients
showed an average improvement of 28% showing
that chemotherapy is more beneficial in small cell
carcinoma patients 29 (69.05%) of the total patients,
left chemotherapy in between. The main reason for
this was found to be financial problems. Majority of
patients in India who are diagnosed with lung carcinoma usually belong to lower socioeconomic group
and are thus unable to afford chemotherapy. With a
per capita income of Rs 50,000, many Indians cannot
afford high prices of chemotherapeutic agents.
Another reason for default was switching to alternate
forms of medicine. This may be partially attributed
to high cost of chemotherapy and the associated side
effects. Partly this can be due to high rates of illiteracy and lack of awareness among patients. About 25%
of patients left chemotherapy because of nontolerance of side effects. This can be avoided by educating the patient about the side effects that may occur and preparing the patient for treatment.
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pivotal role in a patient’s outcome. To minimize or
prevent toxicity, chemotherapy should only be administered if there is adequate baseline blood picture,
renal and liver functions, no contraindication with
regard to underlying medical conditions, and for certain chemotherapeutic agents, further chemotherapy
is discontinued if cumulative doses have reached tolerance levels.12
CONCLUSION
Lack of funds to procure chemotherapy was the major factor responsible for default among patients. In
patients completing the chemotherapy, significant
improvements were seen in QoL. In past few years,
little progress has been made in treatment of lung
cancer patients in form of increased survival. As a
result, the effect of chemotherapy on QoL becomes
important while discussing the benefits of treatment
with patients.
REFERENCES
1.
Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D.
Estimates of worldwide burden of cancer in 2008. Int J Cancer. 2010 Dec 15;127 (12):2893­917.
2.
Michael B Cook, Katherine A McGlynn, Susan S Devesa,
Neal D Freedman, William F Anderson. Sex Disparities in
Cancer Mortality and Survival. Cancer Epidemiol Biomarkers
Prev. 2011 Aug; 20(8): 1629–1637.
3.
Behera D, Balamugesh T. Lung cancer in India. Indian J
Chest Dis Allied Sci. 2004 Oct­Dec;46(4):269­81.
4.
Wintner L M, Giesinger J M, Zabernigg A, Sztankay M, Meraner V, Pall G , Hilbe W, Holzner B. Quality of life during
chemotherapy in lung cancer patients: results across different
treatment lines. Br J Cancer. 2013 Oct 29; 109(9): 2301–
2308.
5.
Chemotherapy for non-small cell lung cancer. Available from
http://www.cancer.org/acs/groups/cid/documents/webco
ntent/003115-pdf.pdf
6.
Hoffman PC, Golomb HM, Bitran JD, et al. Small cell carcinoma of the lung: A five year experience with combined
modality therapy. Cancer 1980, 46. 2550-2556.
7.
Greco FA, Einhorn LH, Richardson RL, Oldham RK. Small
cell lung cancer: progress and perspectives. Semin Oncol.
1978 Sep;5(3):323–335.
Side effects of chemotherapy range from mild, like 8. Selawry OS. The role of chemotherapy in the treatment of
non‐specific tiredness to life‐threatening as in neulung cancer. Semin Oncol. 1974 Sep;1(3):259–272.
tropenic fever. They can be classified into haemato- 9. Vogl SE, Mehta CR, Cohen MH. MACC chemotherapy for
logical, gastrointestinal, dermatological, renal, puladenocarcinoma and epidermoid carcinoma of the lung: low
response rate in a Cooperative Group Study. Eastern Coopmonary, cardiac, neurological, hepatic and gonadal
erative Oncology Group. Cancer. 1979 Sep;44(3):864–868.
toxicities. It is important that doctors and nurses are
10.
Thippanna G, Venu K, Gopalkrishna V, Reddy PNS, Sai
knowledgeable regarding the drugs’ adverse effects
cheiran BG. A profile of lung cancer patients in hydrabad. J
and expected time of occurrence, and know how to
Indian Med Asso. 1999 (97): 357-359
prevent, minimize and manage them. Patients and
families’ education is also important, as many side 11. Vineis P, Alavanja M, Buffler P, et al. Tobacco and cancer:
recent epidemiological evidence. J Natl Cancer Inst, 2004
effects will occur when the patient is at home. In
(96): 99-106.
managing side effects, assessment for patient’s toler- 12. Carol Kwok.. Management of Side Effects from Chemotheance to the prior dose and early intervention play a
rapy. Available from http://www.hkacs.org.hk/content/JTT
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ORIGINAL ARTICLE
CLINICAL EXAMINATION AND FOOT PRESSURE ANALYSIS
OF DIABETIC FOOT: PROSPECTIVE ANALYTICAL STUDY IN
INDIAN DIABETIC PATIENTS
Harshanand J Popalwar1, Anil Kumar Gaur2, Badrinath D Athani3, Jayasree Ramesh4
Author’s Affiliations: 1Senior Resident, Department of PMR, AIIMS Bhopal, Bhopal; 2Head of the Department; 4Assistant Professor, Department of PMR, AIIPMR, Mumbai; 3Special Director General Health Services, Ministry
of Health and Family welfare, Government of India, Delhi
Correspondence: Dr Harshanand J Popalwar Email: [email protected]
ABSTRACT
Aim: Clinical examination of diabetic foot to find out its pathological Complications and analysis of plantar
foot pressure of diabetic foot patients in Indian population.
Method: This was prospective analytical study in Indian diabetic patients. 102 patients were evaluated
through clinical, vascular, neurological and plantar foot pressure assessment.
Results: 35% patients developed diabetic neuropathy. ABI- 62% patients had vascular complication. On foot
examination 51% patients had nail changes, 32% had foot lesion and 52% had foot deformity. 7.8% had
Charcot joint arthropathy, 5.8% had interdigital infection, 38.2 % had restricted joint mobility of first MTP
joint. 20% had past history of foot ulceration; out of which 71% had high peak pressure point areas at healed
ulcer area. High pressure values were seen in healed ulcer group patients. Average value of peak foot pressure
in dynamic mode is- left foot 156.41Kpa (min 105 Kpa- max 346 Kpa) and right foot is 153.05 Kpa (min
100Kpa-max 245Kpa). Maximum values of peak pressure were seen at abnormal pressure point areas such as
4-5th metatarsal heads, lateral aspect of foot and middle of arch.
Conclusion: Meticulous clinical examination can easily identify diabetic neuropathy and related pathological
complications of diabetic foot. This shall help for early diagnosis and prevention of diabetic foot complications. Foot pressure analysis can be useful tool to screen patients of diabetic foot for abnormal high pressure
point areas and can predict future risk of ulceration due to high foot pressure. This study states findings in
Indian diabetic patients.
Key words: clinical examination of foot, diabetic neuropathy, foot pressure analysis.
INTRODUCTION
Diabetes Mellitus (DM) is one of the most common
chronic diseases in nearly all countries and is fast becoming the epidemic of 21st century.1 People with
DM in developing countries are of working age, between 40 and 60 years, and over 60 years in developed countries. This could have a long-lasting adverse effect on a nation’s health and economy, especially for developing countries.2 India leads the world
with largest number of diabetic subjects earning the
dubious distinction of being termed as the “Diabetes
capital of the world”. It is estimated that the total
number of people with diabetes in 2010 to be around
50.8 million in India, rising to 87.0 million by
2030.3 The long-term sequel of the diabetic foot includes motor neuropathy that leads to the clawing of
toes and prominent metatarsal heads. Motor neuropathy is perhaps the most important etiopathogenic
factor in the production of high foot pressure. Motor
neuropathy causes intrinsic muscle atrophy that
promotes foot deformity and decreased joint mobiliNJMR│Volume 6│Issue 1│Jan – Mar 2016
ty. The final result of these changes is the development of high foot pressures under the metatarsal
heads and loss of toe function, especially of the great
toe.4-6
Furthermore, autonomic neuropathy accompanies
the development of chronic sensorimotor neuropathy and at the foot level is responsible for denervation and subsequent anhydrosis of the foot. This
leads to atrophic skin, fissures, and callous formation. Additionally, increased blood stagnation and
swelling in the foot predisposes the foot to ulceration.7-9 Because of sensory neuropathy, high foot
pressures may lead to tissue breakdown and the development of ulceration. The combination of peripheral vascular disease and neuropathy makes the
diabetic patient particularly susceptible to foot ulceration and infection.10 Diabetic foot amputations are
one of the most frequent of diabetic complications.
Patients with foot complications spend higher percentage of their income (32.3%) for treatment when
compared with those without foot infections.11
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Eighty five percent (85%) of diabetes related lower
extremity amputations are preceded by ulceration.
Increased dynamic foot pressures are among the
identified risk factors in the formation of diabetic
foot ulcer.12 Jeremy Rich 13 tried to find out correlation of Forefoot and Rear foot Plantar Pressures in
Diabetic Patients to Foot Ulceration. He conclude
that the peak foot pressures of the forefoot, but not
the rear foot, correlate with neuropathy measurements and can also predict foot ulceration over a
36month period. Measurements of the forefoot peak
pressures, rather than the whole foot, may therefore
be more useful in identifying the at risk patient for
developing foot ulceration.
Limited literature is available to predict data on complications of diabetic foot and foot pressure analysis
in Indian population. This study aims to find out
prevalence of pathological complications of diabetic
foot and analysis of plantar foot pressure in Indian
population.
Objective
The objective of this study were to find out prevalence of pathological complications and risk factors
of diabetic foot in a study population and correlate
between different clinical parameters; and to find out
peak high foot pressure areas for early identification
and prevention of risk of future foot ulceration due
to high foot pressure.
METHODOLOGY
After confirming suitability for the study, the patients
and care takers were explained the nature and duration of examination involved in the study. A written
informed consent was obtained from participating
subjects prior to participation in the study. Institutional ethics committee approved the study.
This was a prospective analytical study conducted in
diabetic foot care clinic at All India Institute of Physical Medicine and Rehabilitation, Mumbai, India. All
patients coimg to the clinic between May 2011 to
Dec 2013 were included in the study after assessing
for inclusion and exlusion criterias New as well as
referred patients for diabetic foot care clinic were included in the study.
Sample size (n): One hundred and two (102) diabetic patients.
Inclusion Criteria: Patients with age between 35 to
85 years of both sexes; who are able to walk independently and having old healed foot ulcers were included in the study.
Exclusion criteria: Patinet having non healing
chronic ulcers; acute ulcers; amputation on one or
both limb; systemic complications of diabetes mellitus; spine deformity; and abnormal gait were exNJMR│Volume 6│Issue 1│Jan – Mar 2016
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cluded from the study..
After assessment of inclusion and exclusion criteria,
patients were first assessed for clinical examination.The parameters assessed include:
1. Demographic parameters including age, sex,
and total duration of diabetes mellitus from date
of diagnosis.
2. Neuropathy diagnosis has been done by use of
neuropathy symptoms score and neuropathy disability score. Young et al14 criteria for clinical diagnosis of DPN (NSS + NDS Score > 10) used
as bed side tool. NSS (Neuropathy Symptoms
Score) is burning, numbness or tingling, fatigue,
cramping, aching, or nocturnal exacerbation.
Score of 1 is given for each symptom and 2 are
given for night exacerbation. Neuropathy Disability Score (NDS): This was used to quantify the
severity of diabetic neuropathy obtained from
physical examination and was based on the examination of tendon reflexes and sensory modalities as previously described. The patellar and
Achilles tendon reflexes were examined. NSS and
NDS score used as bedside tool for diagnosis of
diabetic neuropathy.15
3. Vascular examination of lower limb has been
done by ankle brachial index. Ankle brachial index has been done by measuring blood pressure
at brachial and ankle region using hand held
Doppler ultrasound machine. Ankle brachial index calculated by using formula ankle blood pressure/brachial blood pressure
4. Integumentary examination includes autonomic changes of peripheral neuropathy. This includes
skin examination, loss of hair over dorsum of
foot, tibia and nail changes, and interdigital infection.
5. Musculoskeletal examination for deformity of
toes. Examination includes: hammer toe, clawing
of toes, bunion, hallux rigidus, high arch, flat foot,
amputation of toes, dislocation,hallux valgus,rocker bottom deformity, etc. Other findings
include corn, callosity and fissure. Patient examined for past healed ulcer site.
6. The total range of motion at the first metatarsophalangeal joint (MTPJ) was measured by
Goniometer. For the first MTPJ, the range of
motion from the maximal passive plantar flexion
to maximal passive dorsiflexion was measured.
Normal passive range of motion of the first metatarsal joint is 70° of extension and 45° of flexion.
7. Radiological examination done to find out prevalence of Charcot joint neuro-arthroparthy in
study population.
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8. Foot Pressure Mapping: Multiple foot pressure
mapping systems are available for measurement
of plantar foot pressure. In shoe and platform
methods are used widely for measuring plantar
foot pressure. In this study, the machine used is a
mat platform with basic EDMD system. It captures 100 images per second. The mat was calibrated for each patient by using the patient’s
weight and foot size before each testing session.
The mat system was employed to measure the
static and dynamic plantar foot pressures. Subjects were instructed to stand bare foot on the
mat. Static analysis of the subject’s foot pressure
was done and area of contact and peak pressure
was recorded.
Dynamic analysis was done by asking patient to walk
without footwear over the mat. Value of maximum
peak plantar pressures for the entire foot was obtained. Several practice runs were made to familiarize
the patient with the system and to ensure the recording of natural gait. The environmental conditions of
temperature were maintained. The mean reading of
three mid-gait footsteps was entered for final data
analysis. Machine software is calibrated with color
codes. A peak pressure area with red color shows
maximum pressure and blue color shows least pressure.
Calibration: the pressure is force per unit area.
P=F/A. The pressure color codes calibration is automatic through software and is standardized to patient’s value according to his foot contact area and
body weight. (Red = maximum pressure area, Blue=
minimum)
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Figure 2: Foot Pressure analysis Report. (Dynamic phase) Red color showing maximum
peak pressure point area
Statistical analysis: Microsoft excel 2007 and IBM
SPSS statistics 20.
RESULTS
Total number of patients included in study n= 102.
Average age of all patients was 61.52 years. (Minimum age: 39, Maximum age: 83 years SD 10.05) Sex
distribution- 88 were male and 34 were females. Average duration of diabetes mellitus was 11.49 years.
(Minimum 1 to maximum 35 years SD 7.53)
Table 1: Ankle Brachial Index Values
Ankle brachial
index Range
Above 1.2
1.0 To 1.99
0.9 To 0.99
0.8 To 0.89
0.5 To 0.79
Less Than 0.5
Cases
0
2
37
34
29
0
Severity Of Ankle brachial
index
Normal Or Acceptable
Mild Arterial Disease
Moderate Arterial Disease
Severe Arterial Disease
Table 1 show that 62% have impaired ABI. Out of
that, 33% have mild arterial disease and 29 % moderate arterial disease.
Diabetic neuropathy: Total number of patients
who developed diabetic neuropathy was 36. In diagnosed diabetic neuropathy patients, average duration
of years to develop diabetic neuropathy was 12.9
years. In non neuropathy diabetic patients, average
duration of diabetes is 10.6 years. Statistically no significant correlation has been found between duration
of diabetes mellitus and diabetic neuropathy.(p=0.18)
Figure 1: Foot Pressure analysis Report. (Static
phase) Red color showing maximum peak pressure point area
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Statistical correlation applied between various clinical
parameters. No association found between duration
of diabetes mellitus versus diabetic neuropathy and
its complications. Positive association has been seen
between neuropathy and joint mobility, neuropathy
and history of past ulcer group patients.
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Table: 2 various complications of diabetic foot
Diabetic foot complication
Nail changes
Normal
Atrophy of Nail Of Great Toe
Atrophy of Nail Of All Toes
Onychodystrophy
Lesions of foot
Normal
Callosity
Fissure
Corn
Foot deformities
Normal
Hammer Toe Deformity
Clawing Of Toes
Hallux Valgus
Plano Valgoid Foot
Rocker Bottom Foot
High Arched Foot
Amputation Of Toes
Dislocation Of Toe
Other foot examination findings
Charcot Joint Arthropathy
Interdigital Infection
Loss Of Hair Over Tibial Shin
Skin Changes
First MTP Joint Mobility Restriction
No.(%)
50 (49.0)
19 (18.5)
24 (23.5)
5 (4.9)
70 (68.0)
17 (17.0)
12 (12.0)
3 (3.0)
60 (58.0)
10 (10.0)
4 (4.0)
3 (3.0)
8 (8.0)
2 (2.0)
9 (9,0)
5 (5.0)
1 (1.0)
8 (7.8)
6 (5.8)
51 (50.0)
49 (48.0)
39 (38.2)
Pressure in Past healed ulcer patients: 21 patients
had past history of foot ulceration with most common on base of great toe.
Table 3: Showing peak Pressure Points areas in
Patients with Old Healed Ulcer and Non Ulcer
Patients
Variable
Base of great toe
Other toe
MT Head
Mid foot
Lateral aspect of foot
Heel
Total
Past Healed
ulcer
11
1
4
4
1
0
21
Dynamic peak
pressure point
8
1
4
1
1
0
15
Table 4: showing average peak pressure value in
left and right foot (Dynamic mode) in Patients
with Old Healed Ulcer and Non Ulcer Patients
Right Foot
Left Foot
Pressure in non
ulcer patients
153.31Kpa
155.05 Kpa
Pressure in Healed
Ulcer patients
155.79 Kpa
161.64 Kpa
Table 5: Pressure Values In Static and Dynamic Mode (Abberivations- kpa: Kilo Pascal)
Pressure Dynamic- Left
Pressure Dynamic- Right
Pressure Static- Left
Pressure Static –Right
n
102
102
102
102
Minimum
105kpa
100kpa
44kpa
44kpa
Maximum
346kpa
245kpa
118kpa
118kpa
Mean
156.41kpa
153.07kpa
68.69kpa
67.72kpa
Std. Deviation
34.731
30.801
14.872
13.282
Table 6: maximum peak pressure point areas of foot
Pressure point
no pressure point
base of great toe
first and second metatarsal
third to fifth metatarsal
lateral aspect of foot
middle of arch
heel
Left foot (static)
44
1
13
4
1
3
0
Right foot (static)
45
1
9
10
0
3
0
Patients who had past ulcer history, 71% (15) had
maximum peak pressure point areas at healed ulcer
area. This signifies that 71% patient had risk of recurrent ulceration due to high pressure at same old
healed ulcer site.
Maximum pressure values were seen in dynamic
mode as compared to static mode.
Abnormal peak pressure point areas are - 3rd,4th and
5th metatarsal heads, middle of foot, and lateral aspect of foot. In dynamic mode abnormal peak pressure point areas are high.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Left foot (dynamic)
13
28
35
15
3
6
2
Right foot (dynamic)
19
27
32
13
4
5
2
Table 7: Maximum Pressure point areas in different parts of foot
Overall Pressure Points (area wise):
Dynamic mode
fore foot
mid foot
hind foot
No (%)
88 (86.0)
11 (10.0)
3 (3.0)
Above table shows that forefoot has more peak pressure point areas than mid foot and hind foot.
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DISCUSSION
Very few Indian studies have been done on diabetic
foot complication and foot pressure analysis. Vicente
I et al,16 Studied prevalence and risk factors of Anklebrachial index in patients with diabetes mellitus.
They found that Prevalence of a low ABI in subjects
with or without diabetes was 11.3% and 4.3% and
prevalence of a pathological ABI was 18.8% and 7%,
respectively. Factor associated with a low or pathological ABI were gender, age, duration of diabetes,
the type of anti-diabetic treatment and the presence
of vascular disease in another vascular bed. After
multivariate adjustment, only age and duration of
diabetes continue being significant.
In this study no significant correlation has been
found between ABI and other variates. According to
Ramachandran, C. et al,17 Indians are susceptible to
the major complications related to diabetes like
coronary artery disease, neuropathy, nephropathy
and retinopathy. In this study overall prevalence of
diabetic neuropathy was 35%. Average duration of
years to develop neuropathy was 12.9 years. M J
Young et al 17 done a cross-sectional multicentre
study of randomly selected diabetic patients to establish the prevalence of peripheral neuropathy. The
overall prevalence of neuropathy was 28.5%. The
prevalence of diabetic peripheral neuropathy increased with age. Neuropathy was associated with
duration of diabetes. They concluded that Diabetic
neuropathy increases with both age and duration of
diabetes, until it is present in more than 50% of Type
2 diabetic patients aged over 60 years.
In this study 38.2% patients had restricted joint mobility of first MTP joint. Positive correlation has been
seen between neuropathy and joint mobility. C. H.
M. van Schie18 studied biomechanics of diabetic foot
and shown the importance of range of motion of
first MTP joint. The main motion of the first MTPJ
and the lesser MTPJs is in the sagittal plane (dorsiflexion and plantar flexion). During propulsion the
body weight is moving forward over the hallux creating relative dorsiflexion of the first MTPJ.
Maximum loading of the first MTH and hallux is
practically at the same time during stance in normal
gait, highlighting the importance of the load bearing
function of both the hallux and first MTH. Michael J
Mueller et al 19 studied Plantar Stresses on the Neuropathic Foot during Barefoot Walking. In their
study they proposed mechanism for occurrence of
high metatarsal head peak pressure. They says that,
the Soft tissue clearly plays an important role in
stress distribution, and the thicker tissue under the
rear foot compared with the forefoot may help to
distribute stresses evenly to the underlying bony
structures.
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People with diabetes mellitus and peripheral neuropathy have a high incidence of hammer-toe deformity (hyperextension of the metatarsophalangeal joint)
that is associated with high plantar pressures and skin
breakdown. Although the precise reason for the
hammertoe deformity is not known, weakness and
atrophy in the intrinsic muscles of the foot from peripheral neuropathy are thought to contribute for
further discussion of the muscle and bone changes
secondary to peripheral neuropathy. People with intrinsic muscle weakness develop hammer toe deformity. Early identification of restriction of First MTP
joint mobility and hammer toe deformity can help to
reduce skin break down subsequent ulcer formation.
Tatiana Almeida Bacarin, et al20 studied Plantar pressure distribution patterns during gait in diabetic neuropathy patients with a history of foot ulcers. Results
were-Neuropathic subjects from both the diabetic
neuropathy and Diabetic without neuropathy groups
showed higher plantar pressure than control subjects.
At midfoot, the peak pressure was significantly different among all groups: control group (139.4±76.4
kPa), diabetic neuropathy (205.3±118.6 kPa) and
DNU (290.7±151.5 kPa) (p=0.008). They concluded
that A history of foot ulcers in the clinical history of
diabetic neuropathy subjects influenced plantar pressure distribution, resulting in an increased load under
the midfoot and rearfoot and an increase in the variability of plantar pressure during barefoot gait. The
progression of diabetic neuropathy was not found to
influence plantar pressure distribution. The findings
of above study and pressure values coincide with this
study.
Andrew J M Boulton, et al 21 studied Dynamic Foot
Pressure and Other Studies as Diagnostic and Management Aids in Diabetic Neuropathy. They used
microprocessor-controlled optical system. Fifty-one
percent of neuropathic feet had abnormally high
pressures underneath the metatarsal heads compared
with 17% of the diabetic controls and 7% of non diabetic subjects. All those feet with previous ulceration had abnormally high pressures at the ulcer sites.
They conclude that simple bedside investigations,
such as measurement of the VPT alone, may be useful in identifying those patients at risk of foot ulceration. Foot pressure studies may then be used in such
patients as a predictive and management aid by determining specific areas under the foot that are prone
to ulceration.
Dynamic foot pressure is important for prediction of
ulcer due to high foot pressure. In our study High
pressure values with abnormal peak pressure point
areas are seen at metatarsal heads and mid foot area.
Richard M Stess et al22 in their study “The Role of
Dynamic Plantar Pressures in Diabetic Foot Ulcers”
studied dynamic pressure variables, such as normalized peak pressure of maximum pressure picture
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NATIONAL JOURNAL OF MEDICAL RESEARCH
(MPP), pressure-time integral (PTI), and force-time
integral (FTI), were measured Using the EMED-SF
plantar pressure analyzer, in each foot. They concluded that Neuropathic patients have an increase in
dynamic plantar foot pressures placing them at risk
for plantar ulceration. Instruments such as the
EMED-SF system can be helpful in detecting possible sites of plantar ulcerations by locating the areas
of maximum pressure.
Dynamic plantar foot pressure assessment is important for Identification of high pressure areas of foot
and can help to prevent future ulcer.
CONCLUSION
Meticulous clinical examination can easily identify
diabetic neuropathy and related complications of diabetic foot. This will help for early diagnosis and
prevention of diabetic foot complications. Foot pressure analysis can be useful tool to screen patients of
diabetic foot for high pressure point areas and can
predict future risk of ulceration due to high foot
pressure. This study gives findings and data of complications of diabetic foot and foot pressure analysis
in Indian diabetic patients as limited studies are available.
REFERENCES
1. Shaw J, Sicree R, Zimmet Z. Global estimates of the prevalence of diabetes for 2010 and 2030. Journal of Diabetes
Research and Clinical Practice. 2010; 87:4 –1 4.
2.
Ramachandran A, Das AK, Joshi SR, Yajnik CS, Shah S,
Prasanna KM. Current Status of Diabetes in India and
Need for Novel Therapeutic Agents. Journal of Association
of Physicians;2010; 58: 7-9.
3.
Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med
Res. 2007; 125(March):217-230..
5.
Stess RM, Jensoen SR, Mirmiran R. The role of dynamic
plantar pressures in diabetic foot ulcers. Diabetes Care
1997;20:855
6.
Young MJ, Veves A, Boulton AJM. The diabetic foot: Aetiopathogenesis and management. Diabetes Metab Rev
1993;2:10927.
7.
Veves A, Fernando DJS, Walewski P, Boulton AJM. A
study of plantar pressures in a diabetic clinic population.
Foot 1991;1:8992.
8.
VM, Veves A. Foot pressure measurement. Orthop Phys
Ther Clin N Am 1997;6:1–16
9.
Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L,
Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care 1998;21:17149.
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10. Pham HT, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify persons at
high risk for diabetic foot ulceration: A prospective multicenter trial. Diabetes Care 2000;23:60611
11. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of neuropathic foot ulceration using vibration perception thresholds, a prospective study. Diabetes Care
1994;17:5576.
12. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot
ulcers and amputations in diabetes. In: Harris MI, Cowie C,
Stern MP (eds.). Diabetes in America, Second Edition. NIH
Publications No. 951468, 1995.
13. Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P,
Showstack JA: Lower extremity amputation in people with
diabetes:epidemiology and prevention. Diabetes Care 12:2431, 1989
14. Jeremy Rich, DPM; Aristidis Veves, MD, DSc Forefoot and
Rearfoot Plantar Pressures in Diabetic Patients: Correlation
to Foot Ulceration Wounds. 2000;12(4)
15. Matthew j. young, john l. breddy, aristidis veves, andrew j.
m. boulton, The Prediction of Diabetic Neuropathic Foot
Ulceration Using Vibration Perception Thresholds: A prospective study, diabetes care, volume 17, number 6, June
1994
16. A Chawla, G Bhasin, R Chawla. Validation Of Neuropathy
Symptoms Score (NSS) And Neuropathy Disability Score
(NDS ) In The Clinical Diagnosis Of Peripheral Neuropathy In Middle Aged People With Diabetes . The Internet
Journal of Family Practice. 2013 Volume 12 Number 1.
17. Vicente I, Lahoz C, Taboada M, Laguna F, García-Iglesias
F, Mostaza Prieto JM Rev Clin Esp. Ankle-brachial index in
patients with diabetes mellitus: prevalence and risk factors
2006 May;206(5):225-9.
18. Ramachandran A, Snehalatha C, Viswanathan V. Burden of
type 2 diabetes and its complications – The Indian scenario.
Current Science. 2002; 83:1471–1476
19. C. H. M. van Schie MSC, PhD, A. J. M. Boulton MD,
FRCP Biomechanics of the Diabetic Foot, The Diabetic
Foot Contemporary Diabetes 2006, pages 185-200.
20. Michael J Mueller, Dequan Zou, Kathryn L Bohnert, Lori J
Tuttle and David R Sinacore; Plantar Stresses on the Neuropathic Foot During Barefoot Walking; PHYS THER.
2008; 88:1375-1384.
21. Tatiana Almeida Bacarin,I Isabel C. N. Sacco,I Ewald M.
HennigII; Plantar pressure distribution patterns during gait
in diabetic neuropathy patients with a history of foot ulcers;
CLINICS 2009;64(2):113-20
22. Andrew J M Boulton, Colin A Hardisty, Roderic P
Betts,Christopher I Franks, Richard C Worth, John D Ward
and Thomas Duckworth; Dynamic Foot Pressure and Other Studies as Diagnostic and Management Aids in Diabetic
Neuropathy; Diabetes care 6: 26-33, January -February
1983.
23. Richard M Stess, DPM, Shayne R Jensen, BS and Roya
Mirmiran, BS;The Role of Dynamic Plantar Pressures in
Diabetic Foot Ulcers; Diabetes care, volume 20, number 5,
may 1997.
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ORIGINAL ARTICLE
PREVALENCE OF VITAMIN-A DEFICIENCY & REFRACTIVE
ERRORS IN PRIMARY SCHOOL-GOING CHILDREN
Rupali D Maheshgauri1, Radhika R Paaranjpe2, Abha Gahlot3, Ami Gohil4, Sonali Pote5,
Deepaswi Bhavsar5
Author’s Affiliations: 1Associate professor; 2Assistant Professor; 3Professor; 4UG student; 5PG student, Dept. of ophthalmology, Dr.D.Y.Patil Medical College, Pimpri, Pune
Correspondence: Dr Rupali D Maheshgauri Email: [email protected]
ABSTRACT
Purpose: The objectives of the study were to assess refractive errors in primary school-going children; to
critically analyze the need for supplementation of Vitamin A; and to children of low socioeconomic strata.
Methods: Students were examined from 2 primary schools. Visual acuity was tested using Snellen’s chart, Pictogram & Landolt C chart. Detailed anterior and posterior segment examination was done using Binocular
loop, Ophthalmoscope and Streak retinoscope.
Results: Total no of 560 children of age 3 to 13yr were screened from 2 primary schools.Statistically significant difference was found in the age of the study subject & presence of refractive errors. Percentage of students having Refractive error: myopia (29.64%) is the major cause of refractive error, followed by astigmatism
(4.28%) hypermetropia (3.25%) and amblyopia (1.25%). Conclusion: It was observed that many children had
high refractive error and were undiagnosed. The possible reason could be ignorance on the part of teachers
and parents, even when the children have vision related complains. Also the children in the younger agegroup lack the acumen to judge whether they can see clearly or not. Prevalence of Vitamin A deficiency appears reduced in urban areas.
Key words: Vitamin A deficiency, refractive error, primary school going children,
INTRODUCTION
According to the World Health Organization
(WHO) “Approximately 250,000-500,000 children in
developing countries become blind each year owing
to Vitamin A deficiency, with the highest prevalence
in Southeast Asia and Africa.” 1 Vitamin A is needed
by the retina in the form of a specific metabolite, the
light-absorbing molecule, Retinal, that is absolutely
necessary for both low-light (scotopic) and colour
vision. “Vitamin A” covers both a pre-formed vitamin, retinol, and a pro-vitamin, beta carotene, some
of which is converted to retinol in the intestinal mucosa.2 Vitamin A also functions in a very different
role, as an irreversibly oxidized form of retinol
known as Retinoic acid, which is an important hormone-like growth factor for epithelial and other cells.
It is the role of vitamin A in the visual cycle that we
are concerned with in this study. 3
Vitamin A deficiency can be of two categories:
Primary and Secondary. Primary deficiency
of the vitamin is due to its inadequate intake in the
diet. In certain cases (especially in the developing
countries) early weaning of a child can later lead to
primary deficiency. Secondary vitamin A deficiency is
the result of malabsorption disorders or a defect in
NJMR│Volume 6│Issue 1│Jan – Mar 2016
its metabolism. Poor eyesight is one of the first
manifestations of Vitamin A deficiency. A severe deficiency leads to night-blindness, Bitot’s spots, corneal xerosis and keratomalacia which is a major cause
of blindness in India. There is a decline in clinical Vitamin A deficiency in under-five children in the
country. This could perhaps be due to increase in access to health care, consequent reduction in severity
and duration of common childhood morbidity due to
infections. Data from NNMB surveys show that
there has been substantial decline in prevalence of
Bitot’s’s spots. The NNMB micronutrient survey indicates that currently prevalence of Bitot’s spots in
preschool children is only 0.7% 4 prevalence of night
blindness is less than 0.5 %.
Data from NNMB and ICMR surveys indicate that
prevalence of Bitot’s’s spots is less than 1%. Data
from NNMB survey showed that prevalence of Bitot’s spots is higher in children of illiterate mothers;
prevalence of Bitot’s spots is lowest in children from
small families.5 There are large inter-state variations
in the prevalence of VAD among children. In the
1950s, prevalence of night blindness and Bitot’s
spots in pre-school children ranged between 5 per
cent and 10 per cent in most states. The number of
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NATIONAL JOURNAL OF MEDICAL RESEARCH
children with vision problems has fallen below 10
per 1,000 children in states such as Gujarat and Punjab.6 Secondly, Refractive errors are the most commonly encountered ocular problems worldwide. In
many a case, they go unnoticed, especially among
children: owing to the fact that they are too young to
even realise, let alone tell, that they are having difficulty in seeing clearly. What adds to the iceberg phenomenon of the disease was the fact that India is a
developing nation, with a large population living below the poverty line. This results in a vast number of
children who don’t even know how to read. It were
these children that formed the core interest- in our
study.
The purpose of this study was to find out the efficacy vitamin A supplementation programme and to
sensitize awareness of balanced diet in people of
lower socioeconomic strata. And also to find out the
refractive error in primary school going children and
spread awareness of eye examination in them and
parents to avoid childhood refractive amblyopia.
METHODOLOGY
Ethics: Study was conducted after a ethical clearance
from ethical committee of our Institute (Dr.
D.Y.Patil vidyapeeth)which follows Helsinki Declaration of 1975, as revised in 2000. Permission from
school headmistress was obtained to conduct a
study.
In this prospective study, a total number of 652 students from two primary schools in suburban area,
including both the sexes, between 1 to 13 age group
students were examined in mid-June-August 2015.
All students were examined for both, Vitamin A deficiency and Refractive errors. Vitamin A deficiency
was assessed by looking for specific signs and symptoms along with extra-ocular manifestations, as per
proforma. Visual acuity was tested with Snellen’s
chart, Pictogram and Landolt C chart (for distant vision) Jaeger’s chart (for near vision), anterior segment examination done with help of corneal loop
and torch. Procedure for corneal examination with
the help of Binocular loop and torch: Indistinct or
blurred edges of the corneal light reflex (reflection of
light from the cornea when illuminated) suggest that
the corneal surface is not intact or is roughened, as
occurs with a corneal abrasion or corneal xerosis.
Posterior segment examination was done with Beta
Heinz Direct Ophthalmoscope. Ametopic children
underwent cycloplegic refraction with streak retinoscope and were prescribed glasses after postmydriatic test.
All data was documented and analysed with ‘Statistical Package for Social Science’ version 15(IBM). All
data was analysed for quantitative measures.
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RESULTS
A total of 560 children of age 3 years to 13 years
were screened from two primary schools. Among
560 students, 215 students had refractive error and
345 students revealed emmetropia. Laterality of visual acuity is shown in Table 1
Table 1: Visual Acuity of Each Eye (n=560
Visual Acuity
Right Eye
No. (%)
372 (66.4)
84 (15.0)
51 (9.1)
27 (4.8)
14 (2.5)
7 (1.3)
5 (0.8)
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Left Eye
No. (%)
351 (62.6)
93 (17.0)
62 (11.0)
30 (5.4)
12 (2.1)
6 (1.0)
6 (1.0)
Table 2: Association between Age of the Study
Subject and Refractive Error
Age in
years
5
6
7
8
a
10
11
12
Refractive Error
Yes (%)
No (%)
27 (27.55)
71 (72.45)
32 (32.32)
57(64.04)
9 (17.31)
43 (82.69)
36 (52.94)
32 (47.06)
36 (46.15)
42 (53.85)
14 (40.00)
21 (60.00)
40 (40.82%) 58 (59.18%)
21 (50.00%) 21 (50.00%)
Total (%)
98 (100)
89 (100)
52 (100)
68 (100)
78 (100)
35 (100)
98 (100%)
42 (100%)
X 2 = 27.006; df=7; p value = 0.0001, Highly significant
Statistically significant difference was found in the
age of the study subject and presence of refractive
error. Percentage of refractive error is increased with
the increase in age group. (Table 2 )
Table 3: Association between Gender of the
Study Subject and Refractive Error
Gender
Male
Female
Total
Refractive Error
Yes (%)
No (%)
117 (33.33)
189 (33.75)
98 (32.56)
156 (28.00)
215 (32.97)
345 (61.60)
X2 = 0.016; df=1; p value = 0.899
Total
306 (100)
254 (100)
560 (100)
Table 4: Distribution of Refractive Error
Refractive Error
Myopia
Hypermetropia
Astigmatism
Amblyopia
No. (%)
166 (29.64)
18 (3.25)
24 (4.28)
7 (1.25)
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No statistically significant difference was found in
the gender of the study subject and presence of refractive error. As shown in Table 3 X 2 = 0.016 with
1 df: p value = 0.899
As per shown in table no 4 myopia was the most
common refractive error followed by astigmatism
and hypermetropia
DISCUSSION
A total of 560 children were screened for vitamin A
deficiency and refractive errors in two primary
schools.
A complete ophthalmic examination of 560 children
was then performed. Among them a significantly
high percentage (33.42%) was suffering from refractive errors. The visual acuity testing was done with
the help of Snellen’s chart, Landolt C chart (for distant vision) and Jaeger’s chart (for near vision). All
the children diagnosed with any refractive error or
ocular pathology was further referred for a detailed
examination to the hospital. Those diagnosed with a
refractive error were given a spectacle correction after cycloplegic refraction with appropriate correction.
From Table 4 it was observed that a high percentage
(215) out of 560 students, were diagnosed with refractive errors. Out of which 166 students were diagnosed with myopia. Factors that contributed to a
high percentage of myopia within the study group
includes- Poor socio-economic status, Undiagnosed
case and Ignorance by parents/ teachers when the
child complains of difficulty in seeing.
A study on refractive errors among school children
in Kolkata by Das A, Dutta H, Bhaduri G, De Sarkar
A, Sarkar K, Bannerjee M. their study shows close
resemblance with our study There is an increase of
prevalence of refractive errors with increase of age,
but it is not statistically significant (p > 0.05). which
in our study we found it stastially significant
(p<0.001)considering increase in axial length with
increased age may be the reason for the myopic patients .7 with increasing age patient may have better
perception of surrounding and reports well. There is
also no significant difference of refractive errors between boys and girls. This is comparable to our study
as per which of myopia (29.64%) is the major cause
of refractive error, followed by astigmatism (4.28%)
hypermetropia (3.25%) and amblyopia (1.25%). 7 By
Kawuma M, Mayeku R. 8 They found that astigmatism is commonest followed by hyperopia and least
common, Myopia, as refractive error. Our findings
were the polar opposite of the above mentioned project- myopia being the most common condition. This
reveals that there may be difference in types of refractive errors, but meticulous examination to find
them has to be done in primary school-going children.
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In the study, B.M. El-Bayoumy, A. Saad and A.H.
Choudhury; Landolt broken ring chart and pin-hole
were employed as the primary tools. We too utilized
the same instruments- Landolt broken ring chart and
Snellen’s chart. The principal reason for this was that
majority of children were too young to read. Others
were poor in language skills and incapable of reading
Hindi, Marathi and English Snellen’s charts. We too
concluded that myopia is the most commonly occurring refractive error among children; the majority being cases of school myopia. 9 Gupta et al showed that
overall prevalence of ocular morbidity in government
and private schools did not show any statistical significant difference.10 In our study we too examined
children from two schools- a private institution and a
municipal school. Our observations were similar to
the one stated formerly- there was no significant difference between the findings in the two kinds of
educational set-ups. More importantly, in consistence
with the study in Kolkata by Das et al 7my observations and calculations revealed that gender does not
play a causal role in the development of refractive
errors.
As per study of Murthhy et al. 11 there was an agerelated shift in refractive error from hyperopia in
young children (15.6% in 5-year-olds) toward myopia
in older children (10.8% in 15-year-olds) as compared with our study. Through careful statistical
analysis of the data collected, we deduced that the
risk of developing myopia increases with age. Myopia
existed in the same proportion as the aforementioned studies. Therefore, it would not be erroneous
to say that a similar trend persists through the rest of
the country Nazia Uzma et al 12 stated that the prevalence of refractive error was higher in the urban than
the rural group. Increased literacy rate, duration of
study hours and older age of the child were found to
have contributed more to prevalence of myopia in
the urban group. In the study 54% presented with
refractive errors in the urban group and 3.2% students showed night-blindness as a sign of vitamin A
deficiency.
Comparison with our study showed findings that
were consistent to those of the aforementioned
study. The percentage of children suffering from refractive errors was comparable. But there was no
case of vitamin A deficiency in our study. The study
was also conducted in suburban area as like our area.
The area has been well covered by health-care centres and other medical facilities. Also due to urbanization and mass-coverage of the Vitamin A prophylaxis programme, there seems to be a significant decrease in vitamin A deficiency. We concluded that
viatamin A deficiency varies from place to place.
Study by Chaturvedi S, Aggarwal OP. 13 . Trachoma
(18%) was the most common ocular morbidity followed by vitamin A deficiency (10.6%), it revealed
Page 25
NATIONAL JOURNAL OF MEDICAL RESEARCH
that there are certain parts of India that are still tackling preventable diseases like Trachoma and Vitamin
A deficiency. Vitamin A deficiency is one of the major deficiencies among the lower economic strata of
India. In the fifties and sixties many of the states reported that blindness due to Vitamin A deficiency
was one of the major causes of blindness in children
below five years. A five-year long field trial conducted by NIN showed that if massive dose Vitamin
A (200,000 units) was administered once in six
months to children between one and three years of
age, the incidence of corneal xerophthalmia is reduced by about 80 per cent 14 In view of the serious
nature of the problem of blindness due to Vitamin A
deficiency, it was felt that urgent remedial measures
in the form of massive dose Vitamin A supplementation covering the entire population of susceptible
children should be undertaken. In 1970, the National
Prophylaxis Programme against Nutritional Blindness was initiated as a centrally sponsored scheme.
Under this scheme, all children between ages of one
and three years were to be administered 200,000 IU
of Vitamin A orally once in six months. 15
This programme had been implemented in all the
states and union territories during the last thirty-five
years. The major bottleneck during the 1970s was
lack of infrastructure at the peripheral level to ensure
timely administration of the dose.16 In the 1980s
there was considerable improvement in the infrastructure. The lack of adequate supply of Vitamin A,
which came in the way of improved coverage, was
also corrected. In an attempt to improve the coverage, especially of the first two doses, it was decided
to link Vitamin A administration with the on-going
immunization programme during the Eighth Plan
period. Under the revised regimen a dose of 100,000
IU of Vitamin A was administered to all infants at
nine months along with measles vaccine and a second dose of 200,000 IU was administered at 18
months of age along with booster dose of DPT and
OPV. Subsequently, the children were to receive
three 281 doses of 200,000 IU of Vitamin A every
six months until 36 months of age. 17 The reported
coverage figures under the modified regimen indicate
that there was some improvement in coverage with
the first dose (50 –75 per cent). However, the coverage for subsequent doses was low. In an attempt to
further widen the coverage, some states like Odisha
linked administration of Vitamin A with the pulse
polio immunization campaign. It is reported that the
state took precautions to prevent overdosing by
stopping Vitamin A administration in the preceding
six months. The state reported improved coverage 18.
Following this report several states embarked on a
similar exercise. Planning Commission, the Department of Family Welfare and the Indian Academy of
Pediatrics stated that this strategy is inappropriate. 19
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During the campaign mode administration of Vitamin A, along with pulse polio, in Assam 20 (21) (22) in
November 2001, deaths among children who were
administered massive dose Vitamin A was reported.
Some of these deaths could be coincidental where
Vitamin A had been administered to ill children, but
the possibility that some of the deaths could have
been due to Vitamin A toxicity (either due to administration of higher dose or a massive dose Vitamin A
administration earlier) cannot be ruled out. 23 The
Tenth Five Year plan recommended that the second
and subsequent doses of massive dose vitamin A
may be administered biannually in the pre summer
(April-May) and pre winter (Sept-Oct) period. This
strategy was successfully put into operation in states
like U.P with UNICEF 24 assistance and resulted in
improved coverage for all the doses. In 2006-07, a
policy decision has been taken to cover all children in
the 9 month to 6 yr age group under the massive
dose vitamin A programme. Clinical Vitamin A deficiency often coexists with other micronutrient deficiencies and hence, there is a need for broad-based
dietary diversification programmes aimed at improving the overall micronutrient nutritional status of
children. 25
WHO’s goal 26 is the worldwide elimination of vitamin A deficiency and its tragic consequences, including blindness, disease and premature death. To successfully combat VAD, short-term interventions and
proper infant feeding must be backed up by longterm sustainable solutions. The arsenal of nutritional
“well-being weapons” includes a combination of
breastfeeding
and
vitamin
A
tion 27coupled with enduring solutions, such as promotion of vitamin A-rich diets and food fortification
.28 The basis for lifelong health begins in childhood.
Vitamin A is a crucial component. Since breast milk
is a natural source of vitamin A, promoting breastfeeding is the best way to protect babies from
VAD.29
CONCLUSION
The study was conducted in a municipal school and a
private school. Myopia contributed to 29.64% refractive error being the commonest of the refractive errors. We observed that many children had high refractive error and were undiagnosed. The possible
reason could be ignorance on the part of teachers
and parents when the child complained about difficulty in seeing clearly. Also a child in the younger
age-group lacks the acumen to judge whether he/she
can see properly or not. Lack of proper nutrients and
undernourishment culminate in refractive errors. All
the children with the aforesaid complaints were sent
for detailed ophthalmic examination, and correct
power spectacles were prescribed. During screening
of the children there were new cases of refractive erPage 26
NATIONAL JOURNAL OF MEDICAL RESEARCH
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urban population in New Delhi.” Invest Ophthalmol Vis Sci.
rors of which few had a very high refractive error
2002 Mar; 43(3):623-31. Source - Dr. Rajendra Prasad Centre
and needed immediate correction and a few who had
for Ophthalmic Sciences, All India Institute for Medical Scijust developed myopia-school/simple myopia. The
ences, New Delhi, India.
children with amblyopia were also detected and beNazia Uzma PhD et al- “A comparative clinical survey of the
fore it could progress into other ocular conditions it 12. prevalence
of refractive errors and eye diseases in urban and
was corrected.
rural children.”
If we speculate the present scenario of our country, 13. Chaturvedi S, Aggarwal OP. - “Pattern and distribution of
ocular morbidity in primary school children of rural Delhi.”
we will come to see that India has taken a giant leap
Asia
Pac J Public Health. 1999; 11(1):30-3.Sourceforward in an attempt to improve the general health
Department of PSM, University College of Medical Sciences,
and well-being of the population. Through the decDelhi, India.
ades, more and more emphasis has been laid on reducing the prevalence and incidence of the slow, si- 14. NNMB National Nutrition Monitoring Bureau. 2002.
NNMB Micronutrient Survey. National Institute of Nutrilent killers- the deficiency disorders. The National
tion, Hyderabad.
Programme for Prevention of Nutritional BlindnessNational Nutrition Monitoring Bureau (NNMB). 1979-2006.
launched in 1970- bears testimony to the progress 15. NNMB
Reports. National Institute of Nutrition, Hyderabad.
made by the health-care sector of India.
16. WHO (1973). WHO Chr. 27 (1) 28
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K. Park.: Park’s textbook of Preventive and Social Medicine.
567-569. (21st edition) Published February 2011 by Banarsidas Bhanot Publishers ISBN 8190607995 (ISBN13:
9788190607995
2.
Lancet 2: 325 Editorial (1984)
3.
Carolyn Berdanier : Advanced Nutrition Micronutrients. Pg
22-39.1997
4.
Report of District Nutrition Project. Indian Council of
Medical Research. 1999.< R>
5.
India’s Undernourished Children: A Call For Reform and
Action, World Bank Report:http://siteresources.worldbank.org/HEALTHNUTRIT
IONANDPOPULATION/Resources/28162710956981401
67/IndiaUndernourishedChildrenFinal.pdf; last accessed on
24/09/07
6.
Chakravarty, I., Ghosh, K. Micronutrient Malnutrition - Present Status and Future Remedies. J. Ind. Med. Assoc.; 98:
539.2000
7.
Das A, Dutta H, Bhaduri G, De Sarkar A, Sarkar K, Bannerjee M.- “A study on refractive errors among school children
in Kolkata. J Indian Med Assoc. 2007 Apr; 105(4):169-72.
Source - Regional Institute of Ophthalmology, Medical College, Kolkata 700073.WHO (1982). Techn. Rep. Ser., No.
672
8.
9.
Kawuma M, Mayeku R. – “A survey of the prevalence of
refractive errors among children in lower primary schools in
Kampala district.” Afr Health Sci. 2002 Aug; 2(2):69-72.
Source-Department of Ophthalmology, Makerere University,
Kampala, Uganda.
B.M. El-Bayoumy, A. Saad and A.H. Choudhury- “Prevalence of refractive error and low vision among schoolchildren in Cairo”
10. Gupta M, Gupta BP, Chauhan A, Bhardwaj A – “Ocular
morbidity prevalence among school children in Shimla, Himachal, North India.”
17. Report of the Workshop to Review Programs for Control of
Vitamin A Deficiency in India, 1997.
18. IAP Policy on linking vitamin A to pulse polio programme.
Indian Pediatr 2000; 37:727.
19. National Family Health Survey (NFHS-2) 1998
20. India Times News. 13 November, 2001.
21. Sommer A. Vitamin A Deficiency and its consequences: A
field guide to detection and control. World Health Organisation, Geneva 1996.
22. Bauernfeind JC. 1980. The safe use of vitamin A. A report of
the International vitamin A Consultative Group. Washington, DC.
23. Kapil U. Administration of massive dose of vitamin A and
related deaths in India. BMJ 2001; 323:1206.
24. Vitamin A Global Initiative; a strategy for acceleration of
progress in combating vitamin A deficiency. 1998.
UNICEF/MI/WHO/CIDA/USAID.
25. Gopalan C. Prevention of micronutrient malnutrition. NFI
Bulletin. October 2001; vol 22, No.4.
26. WHO/CHD Immunisation-linked vitamin A supplementation study Group. Randomised trial to assess benefits and
safety of vitamin A supplementation linked to immunisation
in early infancy. Lancet 1998; 352:1257-63.
27. Beaton GH, Martorell R, Aronson KJ et al. “Effectiveness of
vitamin A supplementation in the control of young child
morbidity and mortality in developing countries.” ACC/SCN
State of the Art Series. Nutrition policy discussion paper
No.13. 1993. WHO, Geneva.
28. Viajayaraghavan K, Nayak U, Bamji MS, Ramana GNV,
Reddy V. Home gardening for combating vitamin A deficiency in rural India. Food and Nutrition Bulletin.1997;
18:33729. A Report on National Consultation on Benefits and Safety of
Vitamin A Administration to Pre-school Children and Pregnant and Lactating Women. 2000. Conclusions and Recommendations. Ministry of Health & Family Welfare, New
11. Murthy GV, Gupta SK, Ellwein LB, Muñoz SR, Pokharel
GP, Sanga L, Bachani D. – “Refractive error in children in an
NJMR│Volume 6│Issue 1│Jan – Mar 2016
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NATIONAL JOURNAL OF MEDICAL RESEARCH
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ORIGINAL ARTICLE
EFFECTS OF TADALAFIL ON CARDIOPULMONARY
HAEMODYNAMICS IN PATIENTS OF CHRONIC PULMONARY
DISEASES WITH PULMONARY HYPERTENSION: A PILOT STUDY
Indrajeet Sharma1, Purshottam K. Kaundal2, Malay Sarkar3, Tulika Jha4, Prakash C. Negi5,
Ashok K. Sahai6, Sanjeev Asotra7
Author’s Affiliations: 1Assistant Professor; 2Professor; 4PG Student; 6Professor & Head, Dept. of
ogy; 3Professor & Head, Dept. of Pulmonary Medicine; 5Professor & Head; 7Associate Professor, Dept. of Cardiology,
IGMC, Shimla
Correspondence: Dr Indrajeet Sharma E-mail: [email protected]
ABSTRACT
Background and Objectives: Effect of tadalafil on cardiopulmonary haemodynamics in patients of chronic
pulmonary diseases residing at an altitude has not been studied adequately. The present study reports the effect of tadalafil on cardiopulmonary haemodynamics in patients of chronic pulmonary diseases with PH residing at an altitude ranging between 1000 meters to 2500 meters above mean sea level.
Methods: Seventy six patients of chronic pulmonary diseases with PH diagnosed by echocardiography were
randomized to receive tadalafil 40 mg once a day or to the control group. The effect of tadalafil on cardiopulmonary haemodynamics was assessed after 3 months of tadalafil exposure. The echo Doppler derived indices of cardiopulmonary haemodymics recorded were; TR gradient, pulmonary flow acceleration time, pulmonary vascular resistance, myocardial performance index, RV eccentricity index, tricuspid annular plane systolic excursion and cardiac output. The arterial oxygen saturation was measured by Pulse oxymeter.
Results and Interpretation: Tadalafil significantly improved the indices of RV performance; pulmonary flow
velocity time integral (14.54 ± 3.17cm versus 12.25 ± 2.25cm, p <0.0002), tricuspid annular plane systolic excursion (18.53±4.0mm versus 17.11±3.94mm, p<0.002), RVFS 30.6% vs. 24.8% p<0.003. There was no significant change in the TR gradient although PFAT increased significantly with tadalafil; (89.8±11.7 vs.
76.2±8.2 msec. p<0.001). There was a trend of lower PVR with tadalafil buts not statistically significant
3.6±0.9 vs. 3.1±1.0. Tadalafil also improved the arterial oxygen saturation, SPO 2 (90.91±1.76% versus
88.40±1.79%, p<0.0001) significantly.
Conclusions: Tadalafil improved RV function significantly but its effect on PVR was modest.
Key words: Cardiopulmonary haemodynamics, Phosphodiesterase-5 inhibitors, Pulmonary hypertension, Tadalafil.
Trial registration: CTRI/2015/01/005413.
INTRODUCTION
Pulmonary hypertension (PH), a condition of elevated pressure in the pulmonary vasculature, is a
common co-morbidity observed in the setting of
parenchymal lung disease and in patients who experience chronic hypoxemia.1 Amongst chronic lung
diseases, PH occurs frequently in patients with
chronic obstructive lung disease (COPD) as well as
in patients with interstitial lung disease
(ILD).2 COPD is a leading cause of morbidity and
mortality with WHO’s Global Burden of Disease and
Risk Factors project[3] showing that in 2001, COPD
was the fifth leading cause of death in high-income
countries, accounting for 3.8% of total deaths, and it
NJMR│Volume 6│Issue 1│Jan – Mar 2016
was the sixth leading cause of death in nations of low
and middle income, accounting for 4.9% of total
deaths.3 Interstitial lung diseases (ILDs), also known
as diffuse parenchymal lung diseases (DPLDs) refers
to a group of lung diseases affecting the interstitium
(the tissue and space around the air sacs of the
lungs). It concerns alveolar epithelium, pulmonary
capillary endothelium, basement membrane, perivascular and perilymphatic tissues. As the inflammation
causes thickening and scarring of the interstitium, gas
exchange at the alveolo-capillary membrane gets impaired and patient gradually becomes dyspneic even
at rest.4
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NATIONAL JOURNAL OF MEDICAL RESEARCH
Echocardiography is a non-invasive method for estimation of the presence and severity of PH. TR velocity derived gradient is the most reliable noninvasive method for estimation of the presence and
severity of PH. A TR gradient of more than 46 mm
Hg5 and/or Pulmonary flow acceleration time <90
msec6-7 has been taken as an evidence of the presence of PAH. The sensitivity and specificity for the
detection of PAH depends on the cut-off value of
pulmonary flow acceleration time.
Tadalafil, a selective inhibitor of cGMP-specific
PDE-5, increases the levels of cGMP and thereby
enhances nitric oxide-mediated vasodilatation.8 Alveolar oxygen tension is an important stimulus for
the generation of cGMP by smooth muscles of the
pulmonary vascular resistance vessels. Tadalafil augments the vasodilatory effect of cGMP by inhibiting
its degradation. The longer elimination half-life of
tadalafil makes it suitable for the treatment of PH as
it can be used as once daily dose.9 The response of
PDE-5 inhibitors in the setting of low atmospheric
tension among natives of medium altitude has not
been reported. The present study reports the effect
of tadalafil on the cardiopulmonary haemodynamics
in patients of chronic pulmonary diseases with PH
residing at an altitude of 1000 meters to 2500 meters
above mean sea level.
METHODOLOGY
Study population and selection process: The patient population screened for recruitment to the
study were all consecutive patients of chronic pulmonary diseases; chronic obstructive pulmonary diseases, interstitial lung diseases and post-tubercular
pulmonary fibrosis attending the outpatient service
of pulmonary medicine. Diagnosis of PH was based
on the following criteria; TR gradient of ≥46 mmHg
and/or pulmonary flow acceleration time of ≤90
msec.[5-7] Patients of stable chronic pulmonary disease with PH, aged between 20 to 80 years and willing to participate in the study after informed consent
were enrolled. Patients were excluded if they had a
history or clinical evidence of chronic pulmonary
diseases with acute exacerbation and or without PH,
coronary artery disease, chronic kidney disease, liver
disease, left ventricular failure, myopathy/muscular
dystrophy, peripheral vascular disease/osteoarthritis
of knees, pregnancy, drug history of anorexigens intake, HIV, and those already on tadalafil therapy.
Study design: It was a tertiary care centre hospital
based Randomized controlled trial. Patients were recruited from July 2013 to July 2014 and follow up
ended by Oct. 2014. The study protocol was approved by IGMC ethical committee.
Baseline data collection: Data pertaining to sociodemographic characteristics, exposure to self reNJMR│Volume 6│Issue 1│Jan – Mar 2016
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ported tobacco smoking and biomass fuel smoke was
recorded using structured questionnaires. The status
of effort tolerance using NYHA functional class was
recorded. The medications prescribed for chronic
lung disease by treating physician was also recorded.
Examination included recording of blood pressure,
heart rate, and arterial oxygen saturation with pulse
oxymeter model: DR-50D. Severity of pulmonary
function compromise was assessed by measuring the
lung volumes and flow rates using spirometer model
Vitalgraph-Compact-Buckingham, England.
Echocardiography examination was done in all patients using an echocardiography machine, Model
1E-33 of Philips Medical System using a broad band
phased array adult probe in supine left lateral decubitus position with real time ECG signals to record following indices of cardiopulmonary hemodynamic
parameters:
• Indices of RV systolic Function;
Myocardial performance index (MPI): The MPI is
defined as the ratio of isovolumic time divided by
ET; [(IVRT + IVCT)/ET]. IVRT (Isovolumic relaxation time), IVCT (Isovolumic contraction
time) is the time from tricuspid valve closure to
tricuspid valve opening. Right ventricular ET
(Ejection time) time interval from beginning of
pulse Doppler derived spectral envelop across
RVOT to end of the spectral envelop.
• Pulmonary flow acceleration time (PFAT); Time
interval from beginning of the pulse Doppler signal to the peak of spectral envelop at RVOT.
• Tricuspid Regurgitation (TR) Gradient; Patients
with TR in colour flow imaging TR velocity was
recorded to Quantify the RV-RA instantaneous
peak systolic gradient to estimate PH. TR gradient
of ≥46 mmHg was taken as the evidence of raised
PAP.
• PVR was estimated by recording velocity time integral (VTI) of pulse Doppler spectral recorded in
RVOT and maximum TR velocity (TRV
max)measured by using colour flow mapping
guided Continuous wave TR Doppler signal and
using the formula (TR Vmax/RVOT VTI)×10 +
0.16.
• TAPSE as an index of axial shortening of RV was
recorded with M Mode tracing recorded at lateral
TV annulus in modified four chamber view.
• RVFS % was measured by measuring RV dimensions at end diastole and at end systole recorded
at the tip of TV leaflet in modified four chamber
view using formula RVED-RVES/RVED*100.
• RV. It is calculated from the parasternal short axis
projections as the ratio of the minor axis of the
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dae, divided to minor-axis perpendicular to and
bisecting the septum at the same section.
After baseline evaluation patients were randomized
to tadalafil or control group using stratified randomization method. Patients were stratified based on
gender and age groups of 10 years age interval.
Randomization procedure: The envelope was
opened after patient’s eligibility was confirmed and
informed consent was obtained. Under each strata,
envelope containing equal number of opaque sealed
envelopes bearing treatment codes were numbered
sequentially so that order of treatment allocation
codes was random. The treatment allocation was
concealed and investigator assigning was not participating in patient evaluation and outcome measurement. Treatment group was assigned by picking up
first number in the sequentially numbered sealed
opaque envelop from the respective strata the patient
belonged to.
Intervention; Patients randomized to tadalafil group
received tadalafil 40 mg once a day apart from usual
care prescribed by the treating physician. In the control group patients received usual therapy as per patient’s underlying chronic lung disease.
Follow up Period: All the patients were examined
on scheduled monthly follow up visits for three
months. The dose of usual care medication was adjusted as per discretion of the treating physician. The
medications prescribed by the treating physician were
recorded.
Outcomes measured: At the end of three months
all patients underwent repeat echo Doppler evaluation for recording of indices of cardiopulmonary
haemodynamics as at baseline. Investigator measuring the outcome was blinded to the treatment assigned.
Statistical analysis: The data was reported as percentages and mean±SD for categorical and continuous variables respectively. The differences in the distribution of categorical variables between study
groups were compared by χ2 test and unpaired students t-test for continuous variable. 2 tailed significance at value <0.05 was taken as statistically significant. Data was analysed using Epi Info version 3.4.3.
Trial registration: Central trial registry of India:
CTRI/2015/01/005413.
224 patients screened
-COPD-118
-ILDS- 69 [SLE-17, IPF-24, PSS-25 &
MCTD-3]
-OSA-7
-Post-TB Fibrosis-30
148 Patients did not meet inclusion criteria’s:128 patients had either PFAT>90msec and or TR gradient <46mmHg
9 patients had poor echogenic window
7 patients had H/O CAD and,
4 patients had H/O PTE
76 patients recruited
Control group 36 patients
3 patients lost to follow-up
due to death
Intervention group 40 patients
5 patients lost to follow-up
4 patients died and 1 patient discontinued due
to drug intolerance during follow-up
33 patients included in the analysis
35 patients included in the analysis
Fig 1: Flow chart of patients screened, enrolled, randomized and followed up.
RESULTS
Baseline clinical characteristics of the study
groups: Table 1 describes the distribution of clinical
characteristics of the study population under intervention and control arm; in brief. Both the study
groups were well matched for socio demographical
and geographical characteristics, exposure to tobacco
smoke and biomass fuel smoke, NYHA functional
class, resting SPO 2 , and SPO 2 at peak of 6-MWT.
The baseline distribution of indicators of pulmonary
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hemodynamic status; TR gradient, PFAT, RVOT
VTI, PVR, and indices of RV functions; MPI,
TAPSE, RVFS% and RV eccentricity index was also
well matched. The indices of pulmonary functions
were also similar between the groups. The mean Hb
levels and renal functions were also well matched.
The medications used and use of domiciliary oxygen
therapy was also similarly distributed in both the
groups.
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Table 1: Clinical characteristics of the study groups
Characteristics
Age (Mean ± SD) (years)
Gender (Male) %
Education status (literate) %
Occupation
Employed
Self Employed
Farming
House Keeper
Retired
Residence
Urban
Rural
Smoking Status
Never smoked (yes)
Ex-smoker (yes)
Current smoker (yes)
Smoking Index (Mean ± SD)
Smoke
Biomass fuel smoke exposure (yes)
Frequency of exposure
Occasionally
Frequently
Daily
Duration of Biomass fuel smoke exposure (years)
Group-A (%) (n=35)
62.2 ± 10.9
20 (57.1)
23 (65.7)
Group-B (%) (n=33)
61.7 ± 10.1
17 (51.5)
16 (48.5)
P values
0.86
0.65
0.16
10 (28.6)
5 (14.3)
11 (31.4)
8 (22.9)
1 (2.9)
10 (30.3)
4 (12.1)
2 (6.1)
13 (39.4)
4 (12.1)
0.05
6 (17.1)
29 (82.9)
10 (30.3)
23 (69.7)
0.21
9 (25.7)
23 (65.7)
3 (8.6)
422.45 ± 578.21
26 (74.3)
33 (94.3)
10 (30.3)
17 (51.5)
6 (18.2)
394.88 ± 481.27
23 (69.7)
33 (100)
0.40
13 (37.1)
18 (51.4)
4 (11.4)
35 (44.89 ± 16.65)
14 (42.4)
15 (45.5)
4 (12.1)
33 (49.70 ± 9.76)
0.89
0.83
0.68
0.17
0.15
Table 2: Baseline cardiopulmonary haemodynamic parameters, pulmonary function test variables,
biochemical investigations and medications
Characteristics
NYHA Class (Mean ± SD)
SPO 2 at rest
SPO 2 after 6MWT
TR grad. (mmHg)
PFAT (msec)
PFVTI (cm)
PVR (woods unit)
MPI
TAPSE (mm)
RVFS (%)
RV Eccentricity Index (Systole)
RV Eccentricity Index (Diastole)
SVC(%predicted)
FVC(%predicted)
FEV 1 (%predicted)
FEF 25-75% (%predicted)
FEV 1 /FVC(%predicted)
Hb (gm/dl)
BUN (mg/dl)
Creatinine (mg/dl)
Medications:
Methylxanthines group OD
LABA+ Corticosteroids OD
Anticholinergics OD
Anticholinergics+ LABA OD
Domiciliary O 2 therapy
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Group-A (%) (n=35)
2.33 ± 0.48
88.76 ± 1.7
80.64 ± 2.8
11 (53.05 ± 10.55)
77.75 ± 5.25
11.92 ± 2.41
11(3.76 ±1.49)
0.32 ± 0.19
15.76 ± 2.15
24.21 ± 7.09
1.06 ± 0.02
1.06 ± 0.01
52.27 ± 10.31
45.12 ± 12.07
42.05 ± 15.17
18.78 ± 14.48
73.07 ± 13.11
14.89 ± 1.41
40.17 ± 12.25
1.09 ± 0.15
Group-B (%) (n=33)
2.43 ± 0.61
88.37 ± 1.8
79.14 ± 5.0
14 (60.24 ± 19.17)
73.71 ± 9.29
12.78 ± 2.91
11(3.78 ± 1.66)
0.35 ± 0.22
17.11 ± 3.94
30.17 ± 8.32
1.06 ± 0.01
1.06 ± 0.01
52.73 ± 13.05
46.79 ± 14.27
42.63 ± 16.73
17.78 ± 7.30
71.81 ± 10.85
14.93 ± 1.81
38.82 ± 12.19
1.08 ± 0.17
P values
0.48
0.37
0.14
0.28
0.11
0.19
0.98
0.54
0.09
0.003
0.77
0.37
0.87
0.60
0.88
0.72
0.67
0.92
0.65
0.67
16(48.5)
22(66.7)
24(72.7)
5(15.2)
6(18.2)
25(71.4)
27(77.1)
28(80.0)
7(20.0)
12(34.3)
0.05
0.34
0.48
0.60
0.13
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Table 3: Effects of tadalafil on the cardiopulmonary haemodynamic status
Characteristics
NYHA Class
SPO 2 at rest
SPO 2 after 6MWT
TR grad. (mmHg)
PFAT (msec)
PFVTI (cm)
PVR (woods unit)
MPI
TAPSE (mm)
RVFS (%)
RV Eccentricity Index (Systole)
RV Eccentricity Index (Diastole)
SVC(%predicted)
FVC(%predicted)
FEV 1 (%predicted)
FEF 25-75% (%predicted)
FEV 1 /FVC(%predicted)
Hb(gm/dl)
BUN(mg/dl)
Creatinine(mg/dl)
Medications:
Methylxanthines group OD
LABA+ Corticosteroids OD
Anticholinergics OD
Anticholinergics+ Corticosteroids OD
Domiciliary O2 therapy
Group-A (n=35)
2.31 ± 0.58
90.94 ± 1.75
83.89 ± 4.56
14 (56.70 ± 13.27)
89.87 ± 11.70
14.54 ± 3.17
14 (3.16 ± 1.08)
0.33 ± 0.20
18.53 ± 4.0
30.60 ± 8.21
1.05 ± 0.01
1.05 ± 0.01
63.49 ± 12.05
58.06 ± 14.39
56.47 ± 15.47
24.31 ± 8.98
77.45 ± 9.38
14.98 ± 1.76
33.33 ± 6.98
1.02 ± 0.11
Group-B (n=33)
2.45 ± 0.51
87.91 ± 2.17
78.55 ± 4.92
11 (55.22 ± 10.14)
76.29 ± 8.21
12.25 ± 2.25
11 (3.64 ± 0.93)
0.33 ± 0.18
15.96 ± 2.90
24.82 ± 7.48
1.06 ± 0.01
1.06 ± 0.01
53.84 ± 9.78
45.13 ± 10.56
41.21 ± 12.70
18.55 ± 13.85
73.65 ± 14.02
14.87 ± 1.36
44.02 ± 15.57
1.12 ± 0.16
Mean difference(95% CI)
0.14(-0.12 to 0.40)
-3.03(-3.99 to -2.08)
-5.34(-7.63 to -3.05)
-1.48(-11.17 to 8.21)
-13.58(-18.50 to -8.65)
-2.29 (-3.62 to -0.95)
0.49(-0.35 to 1.32)
-0.01(-0.10 to 0.09)
-2.57(-4.27 to -0.87)
-5.78(-9.59 to -1.97)
0.01(0.00 to 0.01)
0.01(0.00 to 0.02)
-9.66(-14.99 to -4.32)
-12.94(-19.08 to -6.80)
-15.26(-22.14 to -8.38)
-5.76(-11.38 to -0.14)
-3.80(-9.63 to 2.04)
-0.12(-0.87 to 0.64)
10.69(4.91 to 16.74)
0.10(0.04 to 0.17)
P value
0.29
0.0000
0.0000
0.76
0.0000
0.0002
0.24
0.89
0.002
0.003
0.007
0.001
0.0003
0.0001
0.0001
0.0001
0.19
0.76
0.0006
0.001
23(65.7%)
28(80.0%)
27(77.1%)
6(17.1%)
14(40%)
18(54.5%)
26(78.8%)
25(75.8%)
6(18.2%)
8(24.2%)
-0.11(-0.35 to 0.12)
-0.01(-0.21 to 0.18)
-0.01(-0.22 to 0.19)
-0.17(-0.21 to 0.19)
-0.15(-0.38 to 0.06)
0.35
0.90
0.89
0.91
0.17
Effect of Tadalafil on Cardiopulmonary Hemodynamics:
Indices of RV Function; Tadalafil improved indices of RV systolic Function significantly; increased
pulmonary flow velocity time integral (PFVTI)
(14.54 ± 3.17 cm versus 12.25 ± 2.25 cm, p
<0.0002), increased tricuspid annular plane systolic
excursion
(TAPSE)(18.53±4.0
mm
versus
17.11±3.94 mm, p<0.002), Improved RVFS
30.6±8.2% vs. 24.8±7.4% p<0.002 ,improved right
ventricular eccentricity index in systole (1.05±0.01
versus 1.06±0.01, p<0.007) and in diastole
(1.05±0.01 versus 1.06±0.01, p<0.001), significantly.
Pulmonary Hemodynamics; Tadalafil did not result in significant change in TR gradient (56.7±3.2
vs. 55.2±10.1) However Pulmonary flow acceleration
time (PFAT increased significantly (89.8±11.7 vs.
76.2±8.2 p<0.001. There was a trend of decrease in
PVR but was statistically not significant (3.1±1.0 vs.
3.6±0.9)
Pulmonary Functions; (Table 2) It was intriguing
that the all the indices of pulmonary functions; FVC,
FEV 1 and ratio of FEV 1 /FVC were significantly
improved in the tadalafil group.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Effort Tolerance; NYHA Class; There was no significant change in the functional class with tadalafil
(2.3±.5 vs. 2.4±0.5). Resting SPO2; Tadalafil increased resting SPO2 and post 6-Minute walk test
significantly.
Renal functions; Blood urea and serum Creatinine
levels were significantly reduced by tadalafil.
DISCUSSION
The effect of tadalafil on cardiopulmonary haemodynamics was assessed in patients of chronic pulmonary disease with PH residing at altitude of 1000 to
2500 meter from sea level. Tadalafil improved the
RV systolic function significantly as demonstrated by
significant increase in TAPSE, RVFS%, RVOT VTI,
and improvement in renal function. This improvement in RV systolic function is possibly mediated by
decrease in PVR. Although tadalafil decreased the
PVR (mean difference of 0.48 woods with 95% C.I.
of -0.35 to 1.32) woods unit but was statistically not
significant. Wide confidence interval of the mean
change in PVR indicates the limited power of the
study to detect the true change in PVR with tadalafil
due to small sample size. There was no significant
decrease in TR gradient as the indicator of change in
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NATIONAL JOURNAL OF MEDICAL RESEARCH
PA systolic pressure (PASP). The failure to decrease
in PASP with tadalafil may be related to proportionate increase in RV output. The usual treatment prescribed to the intervention and control group was as
per the discretion of the treating physicians. There
were no significant differences in the medications
prescribed between the groups. Tadalafil may produce relaxation of the airway smooth muscle also
leading to airway dilatation and improving the ventilator function. The significant increase in SPO 2 by
tadalafil observed may be due to improvement in
pulmonary function and RV output.9-11
The improvement of glomerular filtration with tadalafil apart from improved cardiopulmonary
haemodynamic effects could also be due to the vasodilatory effect of tadalafil on the renal vascular bed.
Tadalafil, as other PDE5 inhibitors, prevents the
breakdown of NO derived cGMP, primarily in vascular smooth muscle cells, thus inducing vasodilator
effects. It was observed in a study done on rats that
at the renal level, PDE5 is localized to the vasculature, glomeruli, mesangial cells, cortical tubules, and
inner medullary collecting duct cells of rat kidney,
where its inhibition positively affects renal haemodynamic and excretory function.12 The vasodilatory action of tadalafil is of a special importance in light of
the intrarenal activation of vasoconstrictory systems
that contribute to reduction in GFR, together with
vascular congestion in the outer medulla and activation of tubule-glomerular feedback.13 The improvement in arterial saturation may also be mediated by
an improvement in the ventilation-perfusion matching caused by tadalafil through vasodilatation of
pulmonary arterioles perfusing better ventilated alveoli.14
Tadalafil has been reported to have vascular smooth
muscle relaxation effect on bronchial smooth muscles isoenzyme-selective PDE inhibitors that have
been known to cause bronchodilation are usually related to PDE type-3 and PDE type-4 types, but recently PDE type-5 inhibitions also has been implicated in reversing bronchoconstriction. Therefore, it
is possible that oral tadalafil therapy may improve
airway functions by causing airway smooth muscle
relaxation. Tadalafil is a selective inhibitorof cyclicGMP specific PDE-5, which is the predominant enzyme that metabolizes cyclic-GMP. Thus by inhibiting its metabolism, cyclic-GMP levels are raised.1521 Another mechanism of improvement in indices of
pulmonary function test is decrease in airway hyperreactivity and decrease in airway inflammation and
mucus production. It is possible that oral tadalafil
therapy may improve airway functions by causing
airway smooth muscle relaxation. These results were
supported by some studies.21-22 However, The significant improvements in pulmonary function tests
cannot be due to the tadalafil alone as patients were
also advised to take inhaled bronchodilators also
NJMR│Volume 6│Issue 1│Jan – Mar 2016
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both long term and short term on regular basis depending on patients condition. Thus the improvement in cardiopulmonary haemodynamic status with
tadalafil in patients of chronic pulmonary disease can
be attributed to diverse mechanisms.
LIMITATIONS
It was a Pilot study. Study subjects were not truly inhabitants of high altitudes thus the efficacy of tadalafil in patients of chronic pulmonary disease residing
at high altitude with hypobaric hypoxia cannot be
ascertained from the present study. It was not a placebo controlled double blind study thus the element
of measurement bias and placebo effect cannot be
ruled out.
CONCLUSION
In the present study, tadalafil 40mg once daily
showed significant improvement in the cardiopulmonary hemodynamic status in patients with chronic
pulmonary diseases with PH.
REFERENCES
1. Simonneau G, Robbins IM, Beghetti M, Channick RN, Delcroix M, Denton CP, et al. Updated clinical classification of
pulmonary hypertension. J Am Coll Cardiol. 2009 Jun
30;54(1Suppl):S43-S54.
2. Todd MK, Paul MH. Right ventricular dysfunction in
chronic lung diseases. Cardiolclin. 2012;30:243-56.
3. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray
CJL. Global burden of disease and risk factors. Washington:
The World Bank. 2006.
4. Interstitial
Lung
Disease
and
Asbestos.
http://www.interstitial lung disease.com/html. (Cited on
March 21st, 2013).
5. Negi PC, Marwaha R, Asotra S, Kandoria A, Ganju N,
Sharma R, et al. Prevalence of High Altitude Pulmonary Hypertension Among the Natives of Spiti Valley—A High Altitude Region in Himachal Pradesh, India. High Alt Med Biol.
2014 Dec;15(4):504-10.
6. Kumar U, Ramteke R, Yadav R, Ramam M, Handa R,
Kumar A. Prevalence and Predictors of Pulmonary Artery
Hypertension in Systemic Sclerosis. JAPI. 2008 June; 56:41317.
7. Lanzarini L, Fontana A, Campana C, Klersy C. Two simple
echo-Doppler measurements can accurately identify pulmonary hypertension in the large majority of patients with
chronic heart failure. J Heart Lung Transplant. 2005; 24:745–
54.
8. Global Initiative for Chronic Obstructive Lung Disease.
Global strategy for the diagnosis, management, and prevention of COPD. 2014. Global Initiative for Chronic Obstructive Lung Disease. http://www.goldcopd.org/ Guidelines/guidelines-resources.html. (cited on 9 June 2014).
9. Thabut G, Dauriat G, Stern JB, Logeart D, Lévy A, MarrashChahla R, et al. Pulmonary haemodynamics in advanced
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COPD candidates for lung volume reduction surgery or lung
transplantation. Chest. 2005;127(5):1531-36.
of lung fibrosis and pulmonary hypertension: a randomised
controlled trial. Lancet. 2002;360:895-00.
10. Bharani A, Patel A, Saraf J, Jain A, Mehrotra S, Lunia B. Efficacy and safety of PDE-5 inhibitor tadalafil in pulmonary
arterial hypertension. Indian Heart J.2007;59: 323–328.
17. Tessler RB, Zadinello M, Fiori H, Colvero M, Belik J Fiori
RM. Tadalafil improves oxygenation in a model of newborn
pulmonary hypertension. PediatrCrit Care Med. 2008;9:33032.
11. Galiè N, Brundage B, Ghofrani H, Oudiz R, Simonneau G,
Safdar Z, et al. Tadalafil therapy for pulmonary arterial hypertension. Circulation. 2009;119: 2894–2903.
12. Bishara B, Abu-Saleh N, Awad H, Ghrayeb N, GoltsmanI,
Aronson D, et al. Phosphodiesterase-5 inhibition protects
against increased intra-abdominal pressure-induced renal dysfunction in experimental congestive heart failure. Eur J of
Heart Failure. 2012;14:1104-11.
13. Guzeloglu M, Yalcinkaya F, Atmaca S, Bagriyanik A, Oktar
S, Yuksel O, et al. Beneficial effects of tadalafil on renal
ischemia-reperfusion injury in rats. Urol Int. 2011;86:197-03.
14. Kucuk A, Yucel M, Erkasap N, Tosum M, Koken T Ozkurt
M, et al. The effects of PDE-5 inhibitory drugs on renal
ischemia/reperfusion injury in rats. MolBiol Rep. 2012;
39:9775-82.
15. Santos RC, De Faria AP, Barbaro NR, Modolo R, FerreiraMelo SE, Matos-Souza JR, et al. Tadalafil-induced improvement in left ventricular diastolic function in resistant hypertension. Eur J Clin Pharmacol. 2014; 70:147-54.
16. Ghofrani HA, Wiedemann R, Rose F, Schermuly RT,
Olschewski H, Weissmann N, et al. Sildenafil for treatment
NJMR│Volume 6│Issue 1│Jan – Mar 2016
18. Charan NB. Does sildenafil also improve breathing?
CHEST. Jul 2001;120(1):305-06
19. Zahmatkesh MM, Faramarzi S, Shahmiri SS, Sharif MR,
Taghiyan M, Naemy V, et al. Evaluation of the Sildenafil Effects on Forced Expiratory Volume in One Second (FEV 1 )
in Patients with Chronic Obstructive Pulmonary Disease
(COPD). Indian J of applied research. Nov 2013;3(11).36466.
20. Stanopoulos I, Manolakoglou N, Pitsiou G,Boutou AK, Argyropoulou. Sildenafil may facilitate weaning in mechanically
ventilated COPD patients: a report of three cases. Anaesth
Intensive Care. Aug 2007;35(4):610-3.
21. Toward TJ and Broadley KJ. Airway reactivity, inflammatory
cell influx and nitric oxide in guinea-pig airways after
lipopolysaccharide inhalation. Br J of Pharmacol.
2000;131:271-81.
22. Wang T, Liu Y, Chen L, Wang X, Hu XR, Feng YL, et al.
Effect of sildenafil on acrolein-induced airway inflammation
and mucus production in rats. EurRespir J. 2009; 33:1122-32.
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NATIONAL JOURNAL OF MEDICAL RESEARCH
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ORIGINAL ARTICLE
A STUDY ON AWARENESS OF TOBACCO USE AND CANCER
RISK AMONG MEDICAL STUDENTS
(Col) Prakash G Chitalkar1, Rakesh Taran2, Deepak Singla3, Prashant Kumbhaj3
Author’s Affiliations: 1Professor; 2Associate Professor; 3Senior Resident, Department of Medical Oncology, Sri Aurobindo Institute of Medical Sciences,Indore, Madhya Pradesh
Correspondence: Dr Prashant Kumbhaj Email: [email protected]
ABSTRACT
Introduction: Tobacco use is a major health and social problem worldwide.Among the Ill effects of tobacco
use, the proportion of cancer in Male and female is 56.4% and 44.9%.Youth in general and adolescents in particular fall prey to this deadly habit with severe physical, psychological, and economic implications.Among the
youth, students are particularly involved due to increasing academic pressures and life related stress
Objective: The objective of the study was to Estimate the Awareness on Use of Tobacco and cancer risk
among medical students.
Material and methods: it was a Cross sectional study and was done in Sri Aurobindo Medical College. Prior
permission was obtained from college authorities.Ethical Approval is obtained from the ethical committee of
Sri Aurobindo institute of medical sciences.The study period was of 3 months duration i.e. from may 2015 July 2015. 300 Under graduate medical students were selected for the study.
Results: Awareness about ill effect of tobacco was high.About 90% students were aware of role of smoking
in causing oral and lung cancer, whereas only 60 % were aware of other cancers caused by smoking other than
lung and oral.80% students were aware of role of passive smoking in causing cancer.Reason for starting
smoking was Influence of friends, parents and movies were 22%, 20%, 27% respectively. Surprisingly 31%
students gave reason for exam and life related stress for their smoking. 97% tobacco users were male and 3 %
were female.In females all were using smoking tobacco.
Conclusion: The awareness among medical students regarding harmful effects of tobacco use and its cancer
risk was very high.
Key words: Tobacco use, smoking, medical students
INTRODUCTION
Tobacco use is a major health and social problem
worldwide. Tobacco use kills nearly 6 million people
each year and causes loss of hundreds of billions of
dollars worldwide. Most of these deaths occur in
low- and middle-income countries1.In India, around
10.9% use tobacco in one or the other
form 2.Among the Ill effects of tobacco use, the proportion of cancer in Male and female is 56.4% and
44.9% respectively.3 Youth in general and adolescents in particular fall prey to this deadly habit with
severe physical, psychological, and economic implications.4 Among the youth, students are particularly
involved due to increasing academic pressures and
life related stress.5 Easy availability of tobacco in different forms, Encouragement from peer group and
the lure of popularity make a teenager an easy prey.5
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Objective: The objective of the study was to Estimate the Awareness on Use of Tobacco and cancer
risk among medical students.
METHODOLOGY
It was a Cross sectional study and was done in Sri
Aurobindo Medical College. Prior permission was
obtained from college authorities. Ethical Approval
is obtained from the ethical committee of Sri Aurobindo institute of medical sciences. The study period
was of 3 months duration i.e. from may 2015 - July
2015. 300 Under graduate medical students were selected for the study. Students who were present on
the day of interview were included in the study. The
purpose of the study was explained to the students,
confidentiality was ensured. The data were collected
regarding age, sex, socioeconomic class, influencing
factor for tobacco use, form of product used, their
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NATIONAL JOURNAL OF MEDICAL RESEARCH
knowledge about passive smoking and association of
tobacco use and cancer.
Tobacco users were defined as having used tobacco
at any stage in their life. On user was Those who had
not used tobacco products in any form even once in
their lifetime. The data collected were compiled and
analyzed.
RESULTS
In Table 1, age, sex and socioeconomic status wise
distribution of the study population was shown: Majority (35%) of the study population was in the age
group 19-20 years followed by 18-19 years (26%). In
the study population, 53% were males and 47 %
were females. Socio economic status: Based on Kuppuswamy’s Classification, majority of the study
population belonged to Middle class (60%).
Table 1: Demographic details of the study population
Variables
Age in Years
Sex
Socio economic status
Factor
17-18
18-19
19-20
>20
Male
Female
Upper
Middle
Lower
Numbers (%)
60(20.0 )
78(26.0)
105(35.0)
57 (19.0)
159(53.0)
141(47.0)
60(20.0)
180(60.0)
60(20.0)
Table 2: Percentage of knowledge, Use and Reason for tobacco use
Variables
Numbers (%)
Knowledge on Ill effects of tobacco use
Oral cancer
270 (90.0)
Lung cancer
255(85.0)
Other cancers
180(60.0)
Passive smoking
240(80.0)
Use of tobacco in any form
60(20.0)
Smoking
51(85.0)
Chewing Tobacco
9(15.0)
Combined use
3(5.0)
Reason for tobacco use
Friends
13(22.0)
Parents’ smoking
12(20.0)
Movies
16(27.0)
Academic Stress
19(31.0)
Table 2 shows percentage wise distribution about
knowledge, ill effects and influence of smoking. In
the study population 20% students were using tobacco,85% were using as smoking tobacco,15% using as
chewing tobacco and 5% populations using both
smokeless and smoking tobacco. Awareness about ill
effect of tobacco was high. About 90% students
NJMR│Volume 6│Issue 1│Jan – Mar 2016
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were aware of role of smoking in causing oral and
lung cancer, whereas only 60 % were aware of other
cancers caused by smoking other than lung and
oral.80% students were aware of role of passive
smoking in causing cancer. Reason for starting smoking was Influence of friends, parents and movies
were 22%, 20%, 27% respectively. Surprisingly 31%
students gave reason for exam and life related stress
for their smoking. 97% tobacco users were male and
3 % were female. In females all were using smoking
tobacco.
DISCUSSION
The prevalence of tobacco use in this study was
20%.The studies conducted among undergraduate
medical students in different parts of India reported
the prevalence of tobacco consumption ranging from
8.7% to 50.7%.6-17The cultural & geographical factors may be the reason for such a wide variation. The
cigarette smoking was most common form of tobacco use in the present study, this is also shown by
study done by Selokar et al.17 In this study, cause for
initiating tobacco use was mainly academic stress
(31%),followed by movies (27%)which is also shown
by Sargent JD et al19 in their study, while in studies
done by Ganesh et al 8,Aggarwal et al 10, Kumari et
al 11,Basu et al 12,Sharma et al 13 and Selokar et al 17
the peer pressure was observed to be the main cause
for initiation.
Among tobacco users about 20 % medical student’s
tobacco consumption habit was affacted by parental
tobacco use. Studies done by Ramakrishna et
al 7,Ganesh et al 8,Kumari et al 11 and Basu et al 12
shows the similar findings.The tobacco consumption
among female students was lower to that of male in
our study.This was statistically significant and the
similar findings have been shown by Ramakrishna et
al 6, Chatterjee et al 7,Basu et al 12and Thankappan et
al 16. In the present study high level of awareness
(90% ) about the adverse effect of tobacco consumption is comparable to the studies done by Khan et
al 9 in Bareilly (89.53%)and Sharma et al 13 in Dehradun (91.8%).
The study of Sreeramareddy et al 18 among the medical students of five Asian countries including India,reported that prevalence of smoking among
males was higher than females in all countries which
were statistically significant. About 80 percent of individuals who start smoking during adolescence will
continue to smoke in adulthood, and one third of
these individuals will die prematurely due to smoking
related disease20. So we should make a stretagy to
limit youth access to tobacco products by making
Smoke free air laws and state,by enforcing age restrictions for sales,increasing Taxes and cost of tobacco products,Restrictions on flavored tobacco
products.
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NATIONAL JOURNAL OF MEDICAL RESEARCH
LIMITATIONS
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9.
Khan S, Mahmood S E, Sharma A K, Khan F. Tobacco Use
Among Medical Students: Are They Role Models Of The
Society? Journal of Clinical and Diagnostic Research. 2012; 6:
605-7.
There might be possibility that some tobacco users
did not disclose about tobacco use despite of being
ensuring about their confidentiality,so the prevalence 10. Aggarwal S, Sharma V, Randhawa H, Singh H.Knowledge,
attitude and prevalence of use of tobacco among male mediof tobacco users observed in our study may not give
cal students in India: A single centre cross-sectional study.
the correct picture.
Ann Trop Med Public Health. 2012;5:327-9.
CONCLUSION
11. Kumari R, Nath B. Study on the use of tobacco among male
medical students in lucknow, India*. Indian J Community
Med. 2008 Apr; 33 (2): 100-3.
The awareness among medical students regarding 12. Basu M, Das P, Mitra S, Ghosh S, Pal R, Bagchi S. Role of
harmful effects of tobacco use was very high. Most
family and peers in the initiation and continuation of smokcommon reason behind tobacco use among medical
ing behavior of future physicians. J Pharm Bioallied Sci. 2011
Jul;3(3):407-11.
students is academic pressure followed by influence
of movies.
13. Sharma M, Aggarwal P, Kandpal S D. Awareness about Tobacco Use Among Medical Students Of Uttarakhand. Indian
J Community Health. 2011; 22:23-5.
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Ramakrishna GS, Sankara Sarma P, Thankappan KR. Tobacco use among medical students in Orissa. Natl Med J India. 18. Sreeramareddy C T, Suri S, Menezes R G, Kumar H H N,
Rahman M, Islam M R et al. Self-reported tobacco smoking
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wards training about tobacco smoking in medical curricula: A
SK. A study on habits of tobacco use among medical and
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19. Sargent JD, Tickle JJ, Beach ML, et al. Brand appearances in
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contemporary cinema films and contribution to global marS. Prevalence and factor associated with current smoking
keting of cigarettes. Lancet 2001; 357:29 2012 US Surgeon
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al.gov/library/reports/preventingyouthtobacco
use/(Accessed on August 22,2012)
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ORIGINAL ARTICLE
A STUDY TO EVALUATE AND COMPARE THE EFFICACY AND
SAFETY OF TOPICAL CYCLOSPORINE-A 0.5% WITH TOPICAL
PLACEBO (ARTIFICIAL TEARS) IN ALLEVIATING THE CLINICAL
FEATURES ASSOCIATED WITH VERNAL KERATOCONJUNCTIVITIS
Abha Gahlot1, Rupali Maheshgauri2, Bhargav Kotadia3, Kanisha Jethwa3, Gira Raninga3
Author’s Affiliations: 1Professor; 2Associate Professor; 3Junior Resident, Dr. D. Y Patil Medical College, Pune
Correspondence: Dr Abha Gahlot E-mail: [email protected]
ABSTRACT
Introduction: Vernal keratoconjunctivitis is a severe, typically seasonal recurrent ocular inflammatory disorder. Topical cyclosporine-A is inhibitory to many T-cell dependent inflammatory mechanisms which are likely
to play role in treatment of vernal keratoconjunctivitis.
Methodology: The study was conducted on 100 patients of vernal keratoconjunctivits selected from Ophthalmology out patients Department of Dr. D.Y Patil Hospital, Pune. Patients were divided in two groups of
50 each, group I and group II. It was double masked comparison study to assess and compare the efficacy of
0.5% topical Cyclosporine-A and topical placebo in the treatment of vernal keratoconjunctivits.
Results: Comparing therapeutic response of symptoms in two groups at day 28 of the study shows topical
cyclosporine was better and favored over placebo. Patients showed improvement in following symptoms accordingly. Itching: 49 in group I, 33 in group II. Discharge: 33 in group I, 4 in group II. Photophobia: 32 in
group I, 1 in group II. Foreign body sensation: 35 group I, 11 in group II. Patients showed improvement in
following signs accordingly: Conjunctival inflammation: 40 in group I, 11 in group II. Papillary hypertrophy:
15 in group I, none in group II. Limbal changes: 7 in group I, none in group II.
Conclusion: The use of topical cyclosporine for treatment of vernal keratoconjunctivitis should be encouraged to prevent complications associated with the natural course of the disease and prolonged topical use of
corticosteroids.
Keywords: Vernal keratoconjunctivitis, Cyclosporine-A, Papillary hypertrophy, Limbal changes, Itching
INTRODUCTION
Vernal keratoconjunctivitis(VKC) is defined as “recurrent, bilateral, interstitial, inflammation of the
conjunctiva of periodic seasonal incidence, self limiting in character and (as yet) of unknown aetiology,
characterized by flat topped papillae usually on the
tarsal conjunctiva resembling cobblestones in appearance, a gelatinous hypertrophy of the limbal conjunctiva, either discrete or confluent and a distinctive
type of keratitis associated with itching, redness of
the eyes, lacrimation and a mucinous or lardaceous
discharge usually containing eosinophils.VKC has a
seasonal predilection for spring time, with peak incidence between April and August, for some individuals, the disease can manifest itself year round.1
Pathologically, there is hypertrophy of adenoid layer
of conjunctiva with infiltration of eosinophils. There
is marked eosinophilia of inflammatory exudates as
well as raised tear and serum IgE. IgE mediated reactions involve mast cell degranulation and release of
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prostaglandins, chemical mediators as histamine,
slow reacting substances of anaphylaxis and serotonin. These vasoactive amines cause increased capillary permeability, cellular infiltration, increased serum
neutrophil chemotactic activity and exudation.2
Recent studies have shown prevalence of local helper
T-cell type 2 response in vernal keratoconjunctivitis,
with the presence of helper T-cell type 2 like cells in
tears and conjunctival biopsy specimens. Interleukin
(IL) – 3, IL-5, IL-6 and granulocyte – macrophage
colony-stimulating factor are particularly expressed in
conjunctival eosinophils of vernal keratoconjunctivitis patients. High levels of tear IL-5 and eosinophil
cationic protein (ECP) have also been found in patients with vernal keratoconjunctivitis.So, T-cell mediated inflammation appears to play central role in
pathogenesis of vernal keratoconjunctivitis.3
Topical cyclosporine-A is inhibitory to many T-cell
dependent inflammatory mechanisms. It has unique
ability to selectively suppress the synthesis and proPage 38
NATIONAL JOURNAL OF MEDICAL RESEARCH
duction of interleukins. Cyclosporine-A also has direct and indirect inhibitory effects on mast cell activation and mediator release, which are likely to play
role in treatment of allergic inflammation. It is antiapoptotic,
immunomodulatory
and
antiinflammatory.4
Topical cyclosporine-A has been successfully used in
vernal keratoconjunctivitis, with an improvement in
symptoms and clinical signs. The aim of our study is
to compare efficacy of topical cyclosporine A drops
with placebo in steroid resistant cases of vernal keratoconjunctivitis.5,6
METHODOLOGY
Selection of Cases:
- Hundred patients having bilateral signs and symptoms of vernal keratoconjunctivitis were selected of
any age, sex and habitat attending out patients department of Ophthalmology, Dr. D.Y Patil Hospital,
Pune. Patients were studied to evaluate and compare
the efficacy of topical cyclosporine A 0.5% with topical placebo (artificial tears CMC 0.5%) in treating
vernal keratoconjunctivitis. All these patients were in
contact with clinician prior to the study, so that they
were using topical steroids for atleast 2 weeks and
remained refractory, with persistent or progressive
inflammation.
- Patients with other active ocular disease or infection, a history of ocular surgery, serious medical illness and concurrenttreatment for other allergic conditions like rhinitis were excluded from the study.
Ethical committee permission was taken prior to the
study and written informed consent was taken from
each patient.
Diagnosis of Vernal Keratoconjunctivitis: This
was done on the basis of history and examination.
Prior to initiation of therapy, relevant history and
clinical details were recorded according to proforma.
A detailed history was recorded with special reference to history of swollen eye, burning/stinging sensation, discharge/tearing, foreign body sensation,
photophobia, itching and any past ocular history.
History of allergic symptoms elsewhere in body and
family history of allergy was taken. Detailed examination of both the eyes under diffuse illumination and
slit lamp examination was done to confirm the conjunctival, limbal and corneal signs such as lid edema,
conjunctival chemosis, conjunctival inflammation,
conjunctival discharge, papillary hypertrophy, limbal
changes and also to rule out any other ocular pathology. Visual acuity of the patients was also recorded.
Grading of Patients: Allergic ocular symptoms i.e.
itching, swollen eyes, burning/ stinging, discharge/tearing, foreign body sensation, photophobia
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and allergic signs i.e. lid edema, conjunctival chemosis, conjunctival inflammation/injection, papillary
hypertrophy and limbal changes were rated using a
scale from 0-3 i.e. allergic symptoms were rated as 0
for none, I for mild, II for moderate and III for
marked, while signs were rated as 0 for none, I for
mild, II for moderate and III for severe.
Grouping of Patients: Hundred patients of vernal
keratoconjunctivitis were included in the study. They
were randomly divided into two groups of fifty each,
50 receiving cyclosporine A and other 50 receiving
placebo drops.
Treatment Regime: In this masked paired study,
patients were randomly assigned either to have topical cyclosporine A 0.5% or topical placebo (artificial
tears CMC 0.5%) 2 times daily for 4 weeks. Both the
eye drops were dispensed to the patients in identical
sterile vials coded I for cyclosporine-A & II for placebo,by masked health personnel unassociated with
the study. Thus, the nature of the drug in each vial
was masked.
Follow up: After the initial baseline assessment,
treatment was started and every patient was subsequently examined after 7 days, 14 days, 21 days and
28 days of initiation of therapy. At each visit, the
signs and symptoms were graded as already explained. Response to therapywas measured for each
sign and symptom in relation to vernal keratoconjunctivitis and rated +2 for much improved, +1 for
improved, 0 for no change, 1 for worse and –2 for
much worse.
RESULT
Itching
Gradewise distribution of group I and group II
treated eyes for itching at day 0: In group I, 45
(90%) patients and in group II, 47(94%) patients
presented with severe, grade 3 itching. 5(10%)
patients and 3 (6%) patients in group I & II respectively had mean baseline score of 2 on day
0.
Therapeutic response at day 28 of group I and II
for itching: At the end of study, 49 patients in
group I had much improved symptoms while in
group II, 30 patients reported with much improved symptoms and 17 had +1 (improved) response. Ocular itching improved almost 100% in
group I patients as compared to group II patients.
Discharge
Gradewise distribution of group I and group II
treated eyes for discharge/tearing at day 0: 28
patients (56%) in group I had severe discharge/tearing while 11 had moderate and 1 had
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mild discharge. In group II, 26 patients presented
with severe discharge, 13 with moderate and 1 with
mild discharge/watering.
Therapeutic response at day 28 of group I and II for
discharge/tearing: Evaluation for therapeutic response at the end of study showed that 33 patients in group I were much improved, with 7
patients having improved symptoms. In group
II, only 4 patients had improvement of ocular
discharge while 46 had no change in discharge
or tearing.
Photophobia
Gradewise distribution of group I and II treated
eyes for photophobia at day 0: Most of the patients 32( 64%) in group I and 28(56%) in group
II presented with moderate photophobia. 3(6%)
patients in group I and 5(10%) in group II had
marked photophobia at baseline evaluation. Mild
photophobia was seen in 5(10%) patients in
group I and 6 (12%) in group II.
Therapeutic response at day 28 of group I and II
for photophobia: At the end of study, 32 patients had much improved photophobia with 8
patients improved and 10 patients had no
change in group I. In comparison, 47 patients in
group II had no change .
Foreign body sensation
Gradewise distribution of group I and II treated
eyes for foreign body sensation: At the day 0 in
group I,27 patients(54%) and 26 patients( 52%)
in group II had marked foreign body sensation.
8 (16%) in group I and 9(18%) in group II presented with moderate foreign body sensation.
Mild foreign body sensation was reported in 6
(12%) in group I and 7(14%) in group II vernal
keratoconjunctivits patients.
Therapeutic response at day 28 of group I and II
for foreign body sensation: At the end of the
study in group I, 35 patients had much improved
symptoms with 6 improved and 9 had no change
while in group II, 27 patients reported improvement in foreign body sensation, 11 cases
had much improved and no improvement in 12
cases.
Conjunctival Inflammation
Gradewise distribution of group I and II treated
eyes for conjunctival inflammation at day 0: In
group I, 12(24%) patients & in group II, 11
(22%) patients had severe conjunctival inflammation at day 0, while 19(38%) in group I and
22(44%) in group II patients presented with
moderate conjunctival inflammation. Mild conjunctival inflammation was seen in 19(38%) patients in group I and 17(34%) in group II.
Therapeutic response at day 28 of group I and II
for conjuntival inflammation: Evaluation for
therapeutic response at the end of study showed
that 40 patients had much improved cojunctival
inflammation and 9 improved in cyclosporine
treated eyes. 11 patients had improvement in
their condition while 39 patients had no change
in placebo treated eyes.
Table 1: Comparision of symptoms and it’s severity in group 1 and Group 2.
Symptoms
Itching
Discharge
Photophobia
Foreign body sensation
Conjunctival inflammation
Papillary hypertrophy
Limbal changes
Mild
1
5
6
12
2
18
Group 1
Moderate
5
11
3
8
19
18
8
Papillary Hypertrophy
Gradewise distribution of group I and II treated
eyes for Papillary hypertrophy at day 0: Baseline
evaluation showed that 9(18%) patients in group
I and 10(20%) patients in group II presented
with grade 3 papillae. Moderate papillary hypertrophy was present in 18(36%) patients in group
I and 19(38%) patients in group II. Mild papillary reaction was present in 2 patients (4%) in
group I and 1patient (2%) in group II, while no
papillae were present in 21(42%) in group I and
20 (40%) in group II patients.
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Severe
45
28
32
27
19
9
3
Mild
1
6
7
11
1
17
Group 2
Moderate
3
13
5
9
22
19
9
Severe
47
26
28
26
17
10
2
Therapeutic response at day 28 of group I and II
for papillary hypertrophy: At the end of study,
papillary hypertrophy was much improved in 15
patients and improved in 14 , while 21 patients
had no change in papillary reaction group I. In
placebo treated eyesiegroupII, 16 patients had
improved papillae while 34 patients had no
change in papillary reaction.
Limbal Change
Gradewise distribution of group I and II treated
eyes for Limbal changes at day 0: 62% of patients in both groups presented with limbal
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NATIONAL JOURNAL OF MEDICAL RESEARCH
changes on baseline evaluation, 5% patients in
both cyclosporine treated and placebo treated
eyes had severe limbal changes (grade 3), while
8(16%) in group I and 9(18%) in group II presented with (grade 2) moderate limbal changes
18(36%) in group I and 17 (34%) in group II
had mild limbal changes. No limbal changes
were seen in 19 (38%) patients of both groups.
Therapeutic response at day 28 of group I and II
of limbal changes: 7 patients showed much improvement and 21 patients had improvement in
limbal changes with topical cyclosporine treated
while 22 presented with no improvement at the
end ofstudy. 13 patients showed improvement
and 37 patients had no improvement in placebo
treated eyes.
DISCUSSION
The present study was conducted on hundred
patients to compare the effects of topical cyclosporine and topical placebo (artificial tears
CMC 0.5%) in vernal keratoconjunctivitis in the
department of Ophthalmology, Dr.D.YPatil
Medical College, Pune. Topical cyclosporine
0.5% and topical placebo (CMC 0.5%) were
used, one drop 2 times a day for 4 weeks. Most
of the patients in the study were males i.e. 39
males in group I and 37 in group II with 11
(22%) females in group I and 13 (26%) in group
II 66% in group I and 78% in group II were
from rural areas. The maximum number of patients, 18 in group I and 25 (50%) in group II
were of 10-12 years age group. The disease was
seen to have a chronic, recurrent form with a
majority of patients 28 (56%) in group I and 20
(40%) in group II having history of 1 to 3 years.
Most of these patients had exacerbation in
summer. The mixed form of disease was most
common, found in 50% in group I and 46% in
group II patients.
In the present study, topical cyclosporine 0.5%
have been found to be safe and effective in alleviating prominent ocular symptoms of itching,
discharge, photophobia and foreign body sensation on day 7, 14 21 and 28 of the study. Among
the signs, conjunctival inflammation was reduced significantly with topical cyclosporine in
comparison to topical placebo but papillary
hypertrophy and limbal changes remained largely
unaffected probably due to shorter duration of
time.
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Comparing therapeutic response of symptoms in
two groups at day 28 of the study shows topical
cyclosporine was better and favoured over placebo.
Total 49 patients showed improvement in itching in group I and 33 in group II. 33 patients
showed improvement in discharge in group I
and only 4 in group II. 32 patient showed improvement in photophobia in group I and 1 in
group II. 35 patient showed improvement in
foreign body sensation in group I and 11 in
group II. Greater numbers of patients, at the
end of study, were improved for signs of vernal
keratoconjunctivitis with topical cyclosporine
than topical placebo. 40 patients showed improvement in conjunctival inflammation in
group I and 11 in group II. 15 patients showed
improvement in papillary hypertrophy in group I
and none in group II. 7 patients showed improvement in limbal changes in group I and
none in group II.
CONCLUSION
The study suggests that topical cyclosporine -A
is safe and effective in treatment of severe vernal keratoconjunctivitis. Most of its effects on
signs and symptoms were achieved after 2 weeks
of treatment. The only side effect was mild
burning sensation and tearing soon after the instillation of the eye drops.
REFERENCES
1. Barradah. Bull OphthalmolSoc Egypt, 1956;49:115.
Quoted from duke Elder's system of Ophthalmology.
1965;VIII (part I) 491. Henry Kimpton London.
2. BenEzra D, Matanoros N, Cohan E. Treatment of severe vernal keratoconjunctivitis with-cyclosporine a
eye drops. Transplant Proc 1988;20(2 suppl 2):644-9.
3. Leonardi A. Vernal keratoconjunctivitis, pathogenesis
and treatment. Progress in Retina and Eye Research
2002;21:319-39.
4. BenEzra D, Pe’er J, Brodsky M, Cohen E. Cyclosporine eye-drops for the treatment of severe vernal keratoconjunctiviitis. Am J Ophthalmol 1986;101:278-82.
5. El-Asrar AM, Tabbara KF, Geboes K et al. An immunohistochemical study of topical cyclosporine in vernal
keratoconjunctivitis. Am J Ophthalmol 1996;121:15661.
6. Gupta V, Sahu PK. Topical cyclosporine A in the
management of vernal keratoconjunctivitis. Eye
2001;15:39-41.
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ORIGINAL ARTICLE
PREVALENCE AND RISK FACTORS OF NON FATAL ROAD
TRAFFIC ACCIDENTS IN A COMMUNITY SETTING OF
DISTRICT DEHRADUN
Shubham M. Sharma1,Ruchi Juyal2, Shaili Vyas3, Jayanti Semwal4
Author’s Affiliations: 1Demonstrator; 2Professor; 3Assistant Professor; 4Professor and Head, Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun
Correspondence: Dr Ruchi Juyal Email: [email protected]
ABSTRACT
Objectives: To study the prevalence and various environmental risk factors related to Road Traffic Accidental injuries in district Dehradun.
Material and Methods: A cross-sectional descriptive study was conducted in rural and urban areas of district
Dehradun. Multistage stratified random sampling method was used to reach the desired sample size. Overall
4000 individuals were interviewed using a structured pretested questionnaire. The data was entered in computer and analyzed by using SPSS software version 20.
Results and conclusion: Maximum numbers of Road Traffic Accident (RTA) victims were in the age group
of 20 – 29 years (33.6%). Males (79.5%) were involved significantly more as compared to females (20.5%).
Most of the RTAs (61.9%) occurred during evening hours (4 – 10pm) and on crowded municipality roads
(43.9%). Rural area had significantly more accidents (69.6%) as compared to urban area (30.8%). Maximum
RTAs (78.7%) happened to occur on good roads.
Key words: Prevalence, Community, Environmental Risk Factors, Road Traffic Accident.
INTRODUCTION
Accidental injuries are a neglected epidemic in developing countries, causing more than five million
deaths every year. Unfortunately, accidents occur due
to carelessness, recklessness and over confidence and
not often due to ignorance. These injuries account
for high economic and social costs for communities
around the globe. The costs involved are greater in
low- and middle-income countries, where many public health systems have yet to prioritize injuries as a
major health concern, despite the cost-effective methods available to prevent them.1 Indirect estimates
by the World Health Organization (WHO) suggest
that unintentional injuries account for 3.9 million
deaths worldwide, of which about 90% occur in low
and middle income countries. The majorities of these
deaths are attributable to Road Traffic injuries, falls,
drowning, poisoning and burns. In 2004, WHO estimated about 0.8 million deaths in India were due to
unintentional injuries.2
Road Traffic Accidents (RTAs) can be studied in
terms of agent (Vehicle), host (human) and environmental factors, which play an important role before,
during and after a trauma event. In India, not many
systematic and scientific studies are available to highlight specific human, vehicle and environmental factors responsible for several types of injuries. Hence,
NJMR│Volume 6│Issue 1│Jan – Mar 2016
the present epidemiological study was planned to address this research gap by focusing mainly on the
prevalence and role of various risk factors including
environmental factors in Road Traffic Accidents in a
community setting. These findings are a part of a
larger study carried out to know about the magnitude
and pattern of injury in our area.
METHODOLOGY
This community based cross sectional study was
conducted in the rural and urban areas of district
Dehradun. Ethical clearance from the ethical committee of the institute was taken prior to conduction
of survey. A sample of 3992 was worked out taking a
prevalence of 30.6% 3 as a reference. It was rounded
off to 4000 and for comparison point of view, equal
number of subjects (2000) were covered in both
groups (urban and rural). All individuals who have
sustained an accidental injury in the last one year that
needed medical attention or stay in bed at least for
one day; or required to stop regular work or activity
for at least one day after injury were included in the
study. Individuals with mental illness, physical or developmental disabilities were excluded from the
study.
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A pre-designed, semi structured (modified version of
WHO questionnaire) was used to carry out the survey.4 This included socio demographic details of the
family, details pertaining to the Road Traffic Accident and other injuries and factors related to RTA.
Data was collected by house to house survey in the
chosen areas. Multistage stratified random sampling
was used to select the household. After taking written consent from the head of the family, interview of
the eligible subject was taken. For children, proxy
interview of the mother/ guardian/ caretaker was
undertaken. Collected Data was compiled and analyzed by using SPSS software version 20. Percentages
and proportion were calculated for all the variables,
while Chi square test was applied for association between two variables.
RESULTS
The study population comprised of all individuals
who had sustained a traffic accidental injury in the
last twelve months preceding the survey that needed
medical attention or stay in bed for at least one day;
or to stop regular work or activity for at least one day
after the injury.
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Table 2: Sex wise distribution of RTA victims
Variable
Male
Female
P value
Urban (%)
(n=74)
68 (91.8)
6 (8.2)
< 0.001
Rural (%)
(n=170)
126 (74.3)
44 (25.7)
< 0.001
Total (%)
(n=244)
194 (79.5)
50 (20.5)
< 0.001
Table 3: Environmental factors in RTAs
Variable
Urban (%)
(n=74)
Light conditions
Good
45 (60.8)
Dim light
13 (17.6)
Dark
16 (21.6)
P value
< 0.001
Weather conditions
Clean/Clear 60 (81.0)
Rainy
11 (14.9)
Foggy
3 (4.1)
P value
< 0.001
Rural (%)
(n=170)
Total (%)
(n=244)
93 (54.7)
46 (27.1)
31 (18.2)
< 0.001
138 (56.5)
59 (24.2)
47 (19.3)
< 0.001
161 (94.7)
9 (5.3)
0 (0.0)
< 0.001
221 (90.6)
20 (8.2)
3 (1.2)
< 0.001
Out of all injuries occurring in the surveyed population in last twelve months, fall accounted for 49.1%,
RTA for 29.3%, assault 6.5% and others 15.1% of
the cases. Maximum number of RTA victims (Table
- 1) were in the age group of 20 – 29 years (33.6%)
followed by 30 – 39 years age group (23.8%).
Similar trends were seen in both the areas. It was
observed that overall males (79.5%) were involved
significantly more in RTAs as compared to females
(20.5%) (Table– 2). Trends were similar in both urban and rural areas.
Most of the RTAs (61.9%) occurred during evening
hours (4 – 10pm) followed by day time i.e 10am –
4pm (21.7%). Similar trends were seen in both the
areas (Figure – 1). Most of the RTA cases occurred
when day light was adequate (56.5%) and weather
was Good (90.6%) (Table-3).
Table 1: Age wise distribution of RTA victims
Variable
< 10 yrs.
10 – 19 yrs.
20 – 29 yrs.
30 – 39 yrs.
40 – 49 yrs.
50 – 59 yrs.
≥ 60 yrs.
P value
Urban (%)
(n=74)
4 (5.5)
9 (12.3)
29 (39.7)
22 (30.1)
4 (5.5)
4 (4.1)
2 (2.7)
< 0.0001
Rural (%)
(n=170)
29 (17.0)
21 (12.3)
53 (31.0)
36 (21.1)
17 (9.9)
10 (6.4)
4 (2.3)
< 0.0001
For chi square age groups are
≤ 19, 20
years
Total (%)
(n=244)
33 (13.5)
30 (12.3)
82 (33.6)
58 (23.8)
21 (8.6)
14 (5.7)
6 (2.5)
< 0.0001
-39, 40-59 and ≥ 60
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Figure 1: Time distribution of Road Traffic Accidents
Table 4: Road related factors in RTAs
Variable
Type of road
Highway
Rural/Brick road
Municipality road
P value
Road conditions
Good
Bad
Average
P value
Urban (%) Rural (%) Total (%)
(n=74)
(n=170)
(n=244)
26 (35.1)
6 (8.1)
42 (56.8)
> 0.05
58 (34.1)
47 (27.7)
65 (38.2)
< 0.001
84 (34.4)
42 (21.7)
107 (43.9)
> 0.05
62 (83.8)
3 (4.0)
9 (12.2)
<0.001
130 (76.5)
6 (3.5)
34 (20.0)
<0.001
192 (78.7)
9 (3.7)
43 (17.6)
<0.001
It was also observed (Table – 4) that maximum
RTAs occurred on municipality roads (43.9%), followed by highways (34.4%). In urban area, RTA on
the municipality roads was significantly higher
(56.8%) as compared to rural area (38.2%). Maximum RTAs (78.7%) happened to occur on good
roads, while only 3.7% occurred on bad roads. SimiPage 43
NATIONAL JOURNAL OF MEDICAL RESEARCH
lar findings were observed in RTAs in both rural and
urban areas.
DISCUSSION
In our study, maximum number of RTA victims
were in the age group of 20 – 29 years (33.6%) followed by 30 – 39 years age group (23.8%). Similar
results were also observed by Mahajan N and Jha
N5,6.In contrast, Dixit et al from Srinagar Garhwal,
Uttarakhand reported that 50% of drivers involved
in RTAs were less than 40 years of age and 15.8% of
drivers were less than 20 years of age.7 There was
male preponderance in our study as males (79.5%)
were significantly more involved in RTAs as compared to females (20.5%). Similar results were also
observed by Patil S and Jha N.6,8
RTAs maximally (61.9%) occurred during evening
hours (4 – 10pm) followed by 10am – 4pm (21.7%).
Similar results were also observed by Dixit S and
Verma P.7,9 In contrast, Kandpal et al in their study
from Dehradun Uttarakhand, observed that majority
of accidents (76.8%) occurred during day time i.e.
from morning to evening with a peak (31.1%) in afternoon.10Day light was reported to be adequate in
most of the RTA cases (56.5%) and weather was
good (90.6%). It might be due to the fact that this
part of Uttarakhand, fog usually occurs in winter
evenings and clears by late morning and people avoid
travelling during night and early morning hours. The
days in winters are usually sunny unlike plain areas.
In rural area no RTA was reported under foggy conditions, while in urban area 4.1% of cases were seen.
Similar results were also observed by Joshi et
al.11 Maximum RTAs (78.7%) were reported to occur
on good roads, while only 3.7% occurred on bad
roads. This shows that despite of good road conditions, RTAs are bound to happen because of human
factors such as not following the traffic rules properly, rash driving, overloading and other such conditions. Similar results were also observed by Dixit S.7
CONCLUSIONS & RECOMMENDATIONS
From the above study it can be concluded that the
prevalence of RTA injuries are fairly high in rural as
well as urban areas of district Dehradun. Its increasing prevalence in rural community and in the younger age group is a pointer to the fact that the burden
of RTAs is going to rise in near future.
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Greater attention should be paid towards the prevention of RTA in India. Computerized Trauma Registry, health insurance coverage of population for efficient and timely management of injured persons,
devising better road and traffic management networks as well as educating the public in general for
road safety measures including use of personal safety
gears as well as following traffic rules etc. are some
of the few recommendations advised for prevention
and better management of RTA injuries.
REFERENCES
1. Injuries: the neglected burden in developing countries. Richard A Gosselin, David A Spiegel, Richard Coughlin &
Lewis G Zirkle. Bulletin of the World Health Organization,
2009; 87:246-246. doi:10.2471/BLT.08.052290.
2. World Health Organization: The Global Burden of Disease:
2004 update. Geneva: World Health Organization; 2008.
3. Kalaiselvana G, Dongre AR, Mahalakshmy T. Epidemiology
of injury in rural Pondicherry, India. Journal of injury and
violence research. 2011;3(2):62.
4. Shankar G, Naik VA, Powar R. Epidemiolgical Study of
Burn Injuries Admitted in Two Hospitals of North Karnataka. Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine.
2010; 35(4):509-512. doi:10.4103/0970-0218.74363.
5. Mahajan, N., Aggarwal, M., Raina, S., Verma, L. R., Mazta, S.
R., & Gupta, B. P. (2013). Pattern of non-fatal injuries in
road traffic crashes in a hilly area: A study from Shimla,
North India. International journal of critical illness and injury
science, 3(3), 190.
6. Jha, N., Srinivasa, D. K., Roy, G., &Jagdish, S. (2003). Injury
pattern among road traffic accident cases: A study from
South India. Indian J Community Med, 28(2), 84-90.
7. Dixit, S., Tyagi, P. K., Singh, A. K., Gupta, S. K., & Malik,
N. Clinico – epidemiological profile of Road Traffic incidents admitted at a Tertiary care Hospital in Garhwal - Uttarakhand.
8. Patil, S. S., Kakade, R. V., Durgawale, P. M., &Kakade, S. V.
(2008). Pattern of road traffic injuries: A study from western
Maharashtra. Indian journal of community medicine: official
publication of Indian Association of Preventive & Social
Medicine, 33(1), 56.
9. Verma, P. K., &Tiwari, K. N. (2004). Epidemiology of Road
Traffic injuries in Delhi: Result of a survey. In Regional
Health Forum (Vol. 8, No. 1, pp. 6-14).
10. Kandpal SD, Vyas S, Deepshikha, Semwal J. Epidemiological
profile of Road Traffic Accidents reporting at a Tertiary Care
Hospital in Garhwal Region of Uttarakhand. Indian J Comm
Health.2015; 27, 2: 235-240.
11. Joshi, A. K., Joshi, C., Singh, M., & Singh, V. (2014). Road
traffic accidents in hilly regions of northern India: What has
to be done? World journal of emergency medicine, 5(2), 112.
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ORIGINAL ARTICLE
STUDY ON CLINICOEPIDEMIOLOGICAL PATTERN OF
FOREIGN BODIES IN OTORHINOLARYNGOLOGY AND
ASSOCIATED MORBIDITIES
Richa Gupta1, Manish Mittal 2
Author’s Affiliations: 1Assistant Professor. Dept. of ENT, S.S. Medical College, Rewa (MP), 2 Assistant Professor,
Dept. of PSM, Pacific Medical College, Udaipur (Rajasthan)
Correspondence: Dr Manish Mittal E-mail: [email protected]
ABSTRACT
Background: Foreign bodies in ENT are common occurrence. The present research was conducted to study
clinicoepidemiological pattern of 117 cases of foreign bodies in ear, nose & throat presented to the S.S. Medical college & G.M. Hospital, Rewa.
Materials & methods: The present study was a case series of 117 patients of foreign bodies in ear, nose &
throat who presented to the S.S. Medical college & G.M. Hospital, Rewa from January 2014 to August 2014.
Results: Among 117 patients 58.12 % were males with age ranging from 14 months to 75 years. Most patients 82 (70.09 %) belong to <10 year age group. Commonest site of lodgement of foreign body was ear
(58.97 %) followed by nose (18.80 %). Commonest type of foreign body was insect (24.79 %).
Conclusion: Foreign bodies in ENT are commonly encountered. They should be diagnosed timely and managed with utmost care to prevent complications.
Keywords: Ear, Foreign body, Insect, Nose
INTRODUCTION
Otorhinolaryngeal foreign bodies are continuing
medical problem and their referral to the otorhinolaryngologist for removal is a common occurrence. 1-3
The incidence of foreign body is seen throughout the
year with a surge in cases during rainy season when
flying insects are more common. The FB removal
success depends on the patient’s cooperation, the
doctor’s ability, the type of FB, the previous manipulation, the visibility and depth of the FB and the
available equipment.4
Foreign body in ear nose & throat can pose a complication if not treated timely by skilled otorhinolaryngologist. The negligence of patient and their
attendants can lead to delayed diagnosis and difficulty in managing the case. The cooperation by patient in eliciting history and while local examination
of foreign body by otorhinolaryngologist plays a vital
role. Foreign body in ear can be managed with the
help of removal by instruments like jobson horn
probe, alligator forceps, packing forceps or syringing
depending on the type of foreign body and duration
between time of insertion and presentation. FB can
be removed either under local or general anaesthesia
depending upon age of patient.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
METHODOLOGY
The present study was a case series of 117 patients of
foreign bodies in ear, nose & throat who presented
to the S.S. Medical College & G.M. Hospital, Rewa
from January 2014 to August 2014. The relevant data
were collected with regard to age and sex distribution, site of lodgement, type of foreign body, laterality, associated complaints, duration between incident
& presentation, clinical presentation, complication &
management as per the predetermined questionnaire.
All the patients were examined thoroughly with appropriate investigations like X-ray neck, chest and
abdomen as per requirement. Various instruments
played a vital role in management such as Jobson
Horne probe, crocodile forcep, endoscope, laryngoscope and oesophagoscope with forceps.
RESULTS
The male predominance i.e. 58.12 % was observed in
present study. Most patients (70.09 %) belonged to <
10year age group followed by 11.11 % in 11-20 year
age group (Table no. 1).
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Table 1: Age-wise distribution of cases (N=117)
Age
<10
11-20
21-30
31-40
41-50
>50
Cases (%)
82 (70.09)
13 (11.11)
11 (9.40)
6 (5.13)
3 (2.56)
2 (1.71)
Table 2: Distribution of cases according to site
of lodgement of foreign body (N=117)
Site
Ear
Nose
Oesophagus
Hypopharynx
Nasopharynx
Oropharynx
Larynx
Bronchus
Cases (%)
69 (58.97)
22 (18.80)
19 (16.24)
3 (2.56)
1 (0.85)
1 (0.85)
1 (0.85)
1 (0.85)
Table 3: Type of foreign body as per its location
(N=117)
Location
Ear
Nose
Oesophagus
Hypopharynx
Nasopharynx
Oropharynx
Larynx
Bronchus
Type
Insect
Wheat
Pencil tip
Cotton ball
Star sequence
Others
Beans
Groundnut
Tamarind seed
Insect
Button
Coin
Denture
Fishbone
Glass
Groundnut
Fishbone
Fishbone
Nosepin
Cases (%)
29 (24.79)
20 (17.09)
4 (3.42)
3 (2.56)
1 (0.85)
12 (10.26)
10 (8.58)
7 (5.98)
3 (2.56)
1 (0.85)
1 (0.85)
17 (14.53)
2 (1.71)
2 (1.71)
1 (0.85)
1 (0.85)
1 (0.85)
1 (0.85)
1 (0.85)
The youngest patient was 14 months while oldest patient was 75 years old. The most common site of
lodgement of foreign body is ear (58.97 %) followed
by nose (18.8 %) cases. Least common site of
lodgement was nasopharynx , larynx , bronchus and
oropharynx with 0.85 % cases each (Table no. 2).
The time of incidence and presentation varied from
within an hour to 1 month. About 52.13 % patients
presented within an hour of foreign body insertion
while 25.64 % percentage patients presented within
24 hours. Rest of the cases presented i.e. 8.54 % arrived between 1-10 days and 13.67 % cases came between 11 days to 1 month.
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The most common type of foreign body in ear was
insect (24.79 %) followed by wheat in 17.09 % cases.
Beans were the commonest foreign body in nose
(8.58 %) cases. Coin was the most common foreign
body in oesophagus followed by denture. Fishbone
came out to be the commonest foreign body in hypopharynx, oropharynx and larynx (Table no. 3).
About 44.92 % cases among foreign body ear presented without symptoms. While the common symptoms noted were blockadge sensation in 29.98 %,
hypoacusis in 14.49 %, otalgia in 11.59 %. Among
foreign body nose the symptoms were blockadge
sensation (45.45 %) & unilateral rhinnohrea (31.81
%). No symptoms were seen in 22.7 % cases.
Odynophagia was seen in 31.57 % cases and vomiting in 15.78 % of foreign body oesophagus. No
symptoms were observed in 52.63 % foreign body
oesophagus cases. In foreign body oropharynx & larynx foreign body sensation was the symptom. The
foreign body nasopharynx and bronchus presented
with no symptom and respiratory distress respectively. The complications such as laceration of external ear i.e. 14.49 % and tympanic membrane perforation i.e. 1.45 % were seen in cases handled previously
before arrival in hospital. Among foreign body nose
patients 4.54 % patient had perforation of nasal
symptom. Foreign body in 29.06 % cases were removed under general anaesthesia or sedation. The
foreign body ear was removed with the help of jobson horn probe, syringing (in cases of intact tympanic membrane), nasal packing forceps or hook. In
oesophageal foreign bodies, oesophagoscopy and
forceps were used for removal. For bronchial foreign
bodies bronchoscope was used.
DISCUSSION
Foreign bodies in ear nose & throat account for majority of emergencies in otorhinolaryngology. Foreign
body refers to any object that is placed in nose or
mouth that is not meant to be there and could cause
harm without any medical attention.5 To reach a final
diagnosis thorough history should be elicited along
with detailed examination and appropriate investigations. In majority of the cases children reported the
history of foreign body insertion to their parents or
caregivers. This helped the ENT surgeon in adequate
and timely removal of foreign body. In most of the
cases, by how easy it is to identify such foreign bodies and for the patient to report the issue to his/her
caregiver.6
In our study we found male predominance which
was in accordance with studies of other authors. 4
Ear, nose, and throat (ENT) foreign bodies are more
common among children, although adult age groups
are involved.7 In present study we found that most
of the patients belong to less than 10 year age group
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with incidence of foreign bodies decreasing as age
advances. This might be because of inquisitive and
exploratory behavior of children.
In our study we found ear to be the commonest site
of lodgement of foreign body followed by nose, oesophagus and pharynx. This is in accordance with
previous studies7 with ear being the most common
site and nose second most common. Our study differs in oesophagus being third common site which
might be due to small size of ingested foreign bodies
which passed pharynx. Mostly foreign body cases
presented within 24 hours with a vast majority of patient arriving within an hour of foreign body insertion. This is in accordance with previous studies.4
The time of presentation of patients immediately after insertion indicates their awareness towards their
health and knowledge of various ailments. A few patients arrived after a delay of 24 hours. This might be
due to the lack of ENT surgeon in their locality or
their inaccess to medical facilities. A few patients
were already handled by general practitioners and
presented with complication such as laceration of
external ear canal and tympanic membrane perforation. In foreign body ear cases the most common
foreign body was insect followed by wheat. Wheat is
a common foreign body in this region might be because children play with wheat during harvesting season and insert it while playing. Multiple foreign bodies in both ears were found in such cases. Hence
otorhinolaryngologist must always be careful while
dealing with these foreign bodies to ensure complete
removal.
In the foreign body ear patients the symptoms may
start with hypoacusis,otalgia, otorrhoea or tinnitus.
In the oropharynx, the main symptom is odynophagia.4,8 In our study blockadge sensation, hypoacusis
or otalgia were the main symptoms. In foreign body
nose cases blockadge sensation and unilateral rhinnohrea was the common symptom. In oeophageal
foreign bodies odynophagia and vomiting were the
most common symptoms. Foreign bodies are of
grave concern to the surgeon as their removal not
only demands a great skill but there is unpredictability in the degree of difficulty of the procedure.9 FB
removal is often carried out in an operating room,
with the patient under sedation or general anesthesia.4,10 In present study 29.06 % required general anaesthesia or sedation. In majority of cases requiring
anaesthesia patient was either uncooperative especially children or foreign body was in oesophagus or
bronchus. In a previous study the relationship between the need for general anesthesia for removal of
FB ranged from 8.6 to 30% .11
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CONCLUSION
Foreign body cases should be handled with utmost
priority especially the cases with prior manipulations
and complications. The masses should be educated
about consulting otorhinolaryngologist in case of
foreign body insertion. The caregivers should encourage their child to inform their parents without
hesitation.
A vast majority of cases can be handled easily but
otorhinolaryngologist must be vigilant enough to
categorize the cases as per cooperation, previous
manipulation, dimensions and location of foreign
body in order to ensure best possible procedure and
need for anaesthesia.
REFERENCES
1.
Ijaduola GT, Okeowo PA. Foreign body in the ear and its
importance: The Nigerian experience. J TropPediatr
1986;32:4-6.
2.
Endican S, Garap JP, Dubey SP. Ear, nose and throat foreign bodies in Melanesian children: An analysis of 1037 cases. Int J PediatrOtorhinolaryngol 2006;70:1539-45.
3.
Aracy P, Tanit G, Ossamu B, Marcia A, Fernando V, Claudio M, et al. Ear and nose foreign body removal in children.
Int J Pediatrotorhinolaryngol 1998;46:37-42.
4.
Tiago MPC, Salgado DC, Correa JP, Pio MRB, Lambert
EE. Corpoestranho de orelha, nariz e orofaringe: experiência de um hospital terciário. Rev Bras Otorrinolaringol.
2006, 72:177-81.
5.
Chadha S., Sardana P, Bais AS. Migrating foreign bodies in
bronchus. IJO & HNS Aug 1999. Special no. FB:143-45.
6.
Figueiredo RR, Azevedo AA, Kós AO, Tomita S. Complications of ENT foreign bodies: a retrospective study. Braz J
Otorhinolaryngol. 2008;74(1):7-15. PMID: 18392495
7.
Chiun KC, Tang IP, Tan TY, Jong DE. Review of ear, nose
and throatforeign bodies in Sarawak General Hospital. A
five year experience. Med J Malaysia 2012;67:17-20.
8.
Marques MPC, Sayuri MC, Nogueira MD, Nogueirol
RB,Maestri VC. Tratamento dos corposestranhosotorrinolaringológicos: um estudoprospectivo. Rev Bras Otorrinolaringol. 1998, 64:42-7.
9.
Jane Y Yang. Bronchoesophagology. Ballenger S. Otorhinolaryngology head and neck surgery 16th edition1553.
10. Mukherjee A, Haldar D, Dutta S, Dutta M, Saha J, Sinha R.
Ear, nose and throat foreign bodies in children: a search for
socio-demographic correlates. Int J PediatrOtorhinolaryngol. 2011;75(4):510-2.
11. Thompson SK, Wein RO, Dutcher PO. External auditory
canal foreign body removal: management practices and outcomes. Laryngoscope. 2003, 113:1912-5.
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ORIGINAL ARTICLE
A PROSPECTIVE STUDY OF COMPARISON BETWEEN OPEN
GASTROJEJUNOSTOMY AND LAPAROSCOPIC ASSISTED
GASTROJEJUNOSTOMY IN PATIENTS OF POST CORROSIVE
INGESTION PYLORIC STENOSIS
Samir M.Shah1, Chirag K. Patel2, Smit M. Mehta2, Vikram B. Gohil3
Author’s Affiliations: 1Professor & Head; 2Resident Doctor; 3Associate Professor, Department of General Surgery,
Govt. Medical College, Bhavnagar, Gujarat
Correspondence: Dr Chirag K. Patel Email: [email protected]
ABSTRACT
Background: It is important to understand and study the trends in the incidence of various factors responsible for gastric outlet obstruction in the present scenario and outline the rationale behind treatment of gastric
outlet obstruction by open and laparoscopic method.
Method: This is a prospective study of 70 patients diagnosed as GOO .We observed all case of GOO, but to
minimize the bias in comparison of Open Gastrojejunostomy and Lap Assisted Gastrojejunostomy due to
disease condition, we included those 30 patients of post corrosive ingestion pyloric stenosis for comparison
between two operations. We also observed the nature of corrosive injury to stomach. Intra operative findings
and postoperative complications were noted.
Results: We observed that benign etiology was more common for GOO (58%) compared to malignant cause
(42%) and post corrosive ingestion pyloric stenosis was most common benign cause(42%) of GOO, Pancreatic cancer was most common malignant cause(18.5%) of GOO. Corrosive ingestion was more common in
younger age group (66% in 15 -30yr age) and female gender(63.34%) and mostly as a suicidal attempt(86.66%)
and most common corrosive agent was sanitary cleansing agent(hydrochloric acid) (70%).Post prandial nonbillious vomiting and weight loss were consistent symptom and appeared after 6-8 week of corrosive ingestion
and 50% of patient of post corrosive ingestion pyloric stenosis had concomitant esophageal stricture. In
present study those patient operated with Lap Assisted Gastrojejunostomy had smaller size of incision, reduce
intra operative need of blood transfusion, less post-operative pain and less chance of wound infection, early
drain and suture removal and early discharged from hospital with minimal post-operative morbidity and without significant increase in total duration and cost of operation.
Conclusion: As compared to Open Gastrojejunostomy, Lap Assisted Gastrojejunostomy is better alternative
operative method for pyloric stenosis.
INTRODUCTION
Gastric outlet obstruction (GOO, also known as pyloric obstruction) is not a single entity; it is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment
to gastric emptying. Clinical entities that can result in
GOO generally are categorized into 2 well-defined
groups of causes—benign and malignant. It is important to understand and study the trends in the incidence of various factors responsible for gastric outlet
obstruction in the present scenario and outline the
rationale behind treatment of each patient with different etiology for gastric outlet obstruction by open
and laparoscopic method. Corrosive injuries of the
stomach are not uncommon in developing countries.
The spectrum of gastric injury due to corrosives can
vary from acute partial or total gastric mucosal or
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transmural necrosis to chronic gastric injuries of different types. We report our experience in different
etiology of GOO, and post corrosive ingestion pyloric stenosis, and comparison between open and laparoscopic assisted Gastrojejunostomy.
METHODOLOGY
This is a prospective study of patient admitted with
clinical feature suggestive of pyloric obstruction in
surgery department of Sir T. Hospital Bhavnagar
from April 2013 to April 2015. Data of all the patients with pyloric obstruction were collected. All the
patients underwent upper gastrointestinal tract contrast studies and esophagogastroduodenoscopy to
assess the site and extent of pyloric stenosis, also CT
scan and USG and other hematological investigaPage 48
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tions for diagnosis of other etiological factor of
GOO. We observed all 70 patients of pyloric obstruction, but to minimize the bias in comparison of
Open Gastrojejunostomy and Lap Assisted Gastrojejunostomy due to disease condition, we included only those patients of post corrosive ingestion pyloric
stenosis for comparison. For randomization odd
numbers of patients were operated with Lap Assisted
Gastrojejunostomy and even numbers of patients
were operated with Open Gastrojejunostomy.
Information collected with attention to age, gender,
presenting complaints, cause of pyloric stenosis , interval between time of corrosive ingestion and presentation as pyloric stenosis in hospital, nature of corrosive agent, mode of ingestion, definitive procedure
performed is Gastrojejunostomy ,intraoperative data
( length of incision, need of intraoperative blood
transfusion, duration of operation) and post operative data(post operative pain, wound infection, suture
removal, drain removal, total hospitalized days,
weight gain). Patients were followed up at 2 week
and 3 month.. Definitive surgery (Gastrojejunostomy) was performed in 30 patients of post corrosive
ingestion pyloric stenosis. Feeding jejunostomy were
kept in those patients had concomitant esophageal
stricture and significant weight loss. Operations were
performed in presence of senior surgeons. Permission to carrying out study was taken from ethical
committee of institute and funding was taken from
institute.
Inclusion criteria: Patients admitted to the surgery
wards with a clinical diagnosis of GOO, Endoscopic
and radiological evidence of gastric outlet obstruction, age 18 -80 year, willing for operative intervention.
Procedure: Open Gastrojejunostomy performed as
a conventional anterior loop side by side Gastrojejunostomy. In Lap Assisted Gastrojejunostomy initially
stomach and jejunal loop mobilised by laparoscopy,
then small upper midline vertical incision kept over
epigastrium. Part of stomach and jejunal loop taken
outside of peritoneal cavity under laparoscopic guidance and side to side gastrojejunal anastomosis performed by hand sewn method.
RESULTS AND DISCUSSION
As mentioned in table :1 ,We observed that ,out of
70 patients of gastric outlet obstruction, 41(58%)
having benign etiology (most common post corrosive ingestion pyloric stenosis,42%) and 29 patient(42%) having malignant cause(most common
pancreatic cancer,18.5%). As compared to Vivek sukumar et al study 1 reported, 38.60% having benign
etiology and 61.40% having malignant etiology.
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As mentioned in table 2, out of 30 patients, Corrosive ingestion was more common in younger age
group (66% in 15 -30yr age) and Similar findings
were observed in Sharma et al2 in which mean age
group of post corrosive ingestion was 31 year with
male predominant but in our study we observed that
female gender (63.34%) were more predominant and
mostly as suicidal attempt (86.66%) most probably
due to familial and marital conflicts and more suicidal tendency in female gender3.
Table 1: Etiology of Gastric Outlet Obstruction
Etiology
Benign etiology
Peptic ulcer disease
Corrosive ingestion
Hypertrophic pyloric stenosis
Prepyloric web
Malignant etiology
Gastric cancer
Gastric polyp
Pancreatic cancer
Cholangiocarcinoma
Cases (n=70)(%)
41(58.0)
5(7.0)
30(42.0)
5(7.0)
1(1.0)
29(42)
10(14.28)
1(1.42)
13(18.5)
5(7.14)
Table 2: Natural History of Disease and Clinical
Feature
Factor
Age
Gender
Mode of corrosive ingestion
Corrosive agent of ingestion
Duration of a presentation of patients as a pyloric stenosis
Presenting clinical feature
Nonbillious Vomiting
Weight loss
Dysphasia
Concomitant esophageal stricture
# year,* Hydrochloric acid
Most common
Groups (%)
15-30 yr#(66)
Female (63.34)
Suicidal (86.66)
Sanitary cleansing
agent, HCl* (70.0)
6-8 weeks (63.34)
100
73.34
46.67
14 (46.66)
Other similar findings were observed like most
common corrosive agent was sanitary cleansing agent
(70%) , because of easy availability at home and
working place, post prandial nonbillious vomiting
and weight loss were consistent symptom and appear
after 6-8 week of corrosive ingestion because gradual
narrowing of pyloric part of stomach .But we observed that those patients had concomitant esophageal stricture had initial complain of dysphasia and
pyloric stenosis become evident after esophageal dilatation and oral feeding. In present study 50% of
patients of post corrosive ingestion pyloric stenosis
had concomitant esophageal stricture as study conducted by N.ananthkrishnan was reported two third
of patients had concomitant esophageal stricture
along with gastric corrosive injury.4
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Table 3: Camparision of Open Gastrojejunostomy and Laproscopic Assisted Gastrojejunostomy
Factors
Length of incision(mean)
Need of intraoperative blood transfusion
Total duration of operation (mean)
Post op abdominal pain (no of patients)
Mild
Moderat
Severe
Post op drain removal (mean)
Wound infection
Post op suture removal (mean)
Duration of hospitalization after operation (mean)
Outcome
Cured
Morbidity in form of wound infection
Anastomotic leak
Reflux gastritis
Dumping syndrome
Weight gain after operation within 3 month(mean)
*POD: post operative day
Out of 30 patients, 6 patients required feeding jejunostomy up to definitive surgery for nutritional support. We observed that even after placement of feeding jejunostomy there was no significant increase in
weight gain, so we planned for early definitive procedure (Gastrojejunostomy) within 6-8 weeks of post
corrosive ingestion.
As mentioned in table: 3,We observed that Gastrojejunostomy is definitive operative procedure for pyloric stenosis to relieve obstructive symptom of pyloric stenosis but as mention in table 3, those 15 patients of post corrosive ingestion pyloric stenosis operated by Lap Assisted Gastrojejunostomy had
smaller size of incision because mobilization of stomach and jejunum done by laparoscopic method, it
reduced post-operative pain and chance of wound
infection, it lead to early suture removal. In Laparoscopic Assisted Gastrojejunostomy, there was minimal intra operative dissection so reduced intra operative need of blood transfusion and early drain and
suture removal and early discharge from hospital
with minimal post-operative morbidity and without
significant increase in total duration in Lap Assisted
Gastrojejunostomy in which time was utilized for laparoscopic asses. In Lap Assisted Gastrojejunostomy, we were done hand sewn anastomosis between
stomach and jejunum which reduced the cost of operation compared to total Laparoscopic Gastrojejunostomy in which staper is used for anastomosis between stomach and jejunum.
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Laparoscopic Assisted
Gastrojejunostomy (n=15)
4-5 cm
2 patients
133.33 min
Open Gastrojejunostomy (n=15)
9-10 cm
8 patients
127 min
3
0
0
4.3 day
0 (0 %)
7th POD
4.5 day
4
4
1
5.96 day
4(26.66%)
10.06th POD*
7.65 day
100%
0%
0%
0%
0%
10.3 kg
100%
26.66%
0%
0%
0%
11.2kg
CONCLUSION
Compared to Open Gastrojejunostomy, Lap Assisted Gastrojejunostomy operation is better alternative for pyloric stenosis with advantage of smaller
size of incision, reduce intra operative need of blood
transfusion, less post-operative pain and less chance
of wound infection, early drain and suture removal
and decrease duration of hospitalization and decrease
morbidity without significant increase in total duration and cost of operation.
REFERENCES
1.
N Am J Med Sci. 2015 Sep; 7(9): 403–406,Demographic
and Etiological Patterns of Gastric Outlet Obstruction in
Kerala, South India by Vivek Sukumar, Chirukandath Ravindran, and Ramachandra Venkateshwara Prasad.
2.
CIB tech journal of surgery ISSN, 2015 vol.4, January –
April, p, 1-4/Sharma et al.-Surgical management of gastric
corrosive stricture.
3.
The Scientific World Journal, Volume 2013 (2013), Article
ID 485851, 9 pages. Review Article, Life Cycle and Suicidal
Behavior among women by Pablo Mendez-Bustos, Jorge
Lopez-Castroman, Enrique Baca- García , and Antonio Ceverino.
4.
International scholarly research network, ISRN gastroenterology, volume 2011, acute corrosive injuries of the stomach by. N.anantnkrishnan 2010.
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ORIGINAL ARTICLE
STUDY OF CHANGE IN MACULAR VOLUME WITH
UNCONTROLLED HBA1C LEVELS IN A DIABETIC PATIENT
IN ABSENCE OF DIABETIC MACULAR OEDEMA
Parag Apte1, Priti Kumari2, Debapriya Datta2, Nilesh Jagdale2, Jatin Patel2, Richa Naik2
Author’s Affiliations: 1Assistant Professor; 2PG Resident, Department of Ophthalmology, Dr D. Y Patil Medical College, Pimpri, Pune
Correspondence: Dr Debapriya Datta E-mail: [email protected]
ABSTRACT
Background: This study is aimed to find out the correlation between change in macular volume on optical
coherence tomography (OCT) in patients with uncontrolled HbA1c levels .
Methods: It is a observational study. Patients with diabetes mellitus for over 5 years were included in the
study. Only one eye of each patient was selected for analysis. Eyes with proliferative diabetic retinopathy were
not included in the study. Chronic HBA1c level was defined as mean HbA1c value in last one year duration.
Central Subfield Volume (CSV) , Central Subfield Thickness (CST) and Total Macular Volume (TMV) were
all measured by OCT.
Results: 50 eyes from 50 patients (22 women and 28 men ; mean age 63.5 years ). Mean duration of Diabetes
Mellitus (DM) being 10.5 years. 6 patients had Type 1 DM and 44 patients had Type 2 DM. Of these , 19 eyes
(38 % ) had no diabetic retinopathy (DR) and 31 eyes (62 % ) had non proliferative diabetic retinopathy. In
statistical analysis , CST ( mean 188.82 ± 27.62 µm , p = 0.03 ) , CSV ( mean 0.148 ± 0.022 mm3 , p = 0.03 )
and TMV ( mean 6.495 ± 0.717 mm3 , p = 0.003 ), all positively correlated with chronic HBA1c level (8.95 ±
1.40 % ).
Conclusion: There is a positive correlation between chronic HbA1c and macular volume in patients with
DM > 5 years duration without Macular oedema. Our studies suggest that there are changes in values of subclinical macular volume or thickness before onset of diabetic macular oedema (DMO) becomes clinically significant. Strict glycaemic control ( HbA1c levels below 6 ) is needed in case of diabetic patients to prevent development and further deterioration of macular function prior to development of DMO .
Key words: Macular thickness, macular volume, HbA1c, non proliferative diabetic retinopathy, diabetic macular oedema – optical coherence tomography
INTRODUCTION
Diabetic Macular oedema is defined as retinal thickening within 2 disc diameters of the centre of the
macula , causing leakage of plasma constituents into
the surrounding retina due to microvascular changes
in the blood retinal barrier and ultimately leading to
retinal oedema.1 It is one of the commonest cause of
visual loss in DM. Diabetic macular edema is classified in focal and diffuse types and this is important
because the treatments of the two types are different.
Focal edema is caused by leakage from micro aneurysms and is associated with hard exudates rings.
Diffuse edema is caused by leakage from retinal capillaries and arterioles. Two types of laser treatment
for DMO are focal and grid. Focal laser treatment is
used to treat focal diabetic macular edema; the purpose is to close the leaking micro aneurysms. Grid
NJMR│Volume 6│Issue 1│Jan – Mar 2016
laser is used to treat diffuse macular edema and is
applied in areas of retinal thickening with diffuse leakage.1 The Early Treatment Diabetic Retinopathy
Study (ETDRS) Research group (1985) demonstrated the focal laser photocoagulation reduces moderate
vision loss by 50 % or more in DMO.
The Wisconsin Epidemiology Study of Diabetic Retinopathy (WESDR) in 1995 showed that there is an
increase in diabetic macular edema in patients with
increase HbA1c.2 Two other randomized trials conducted revealed that good control and reduction in
HbA1c levels lead to a decrease in rates and development and progression of Diabetic macular edema
as well as diabetic retinopathy.3,4,5 The drawback of
these earlier studies were that they were unable to
detect mild changes in macular edema. A newer
modality, OCT enables us to study the structures of
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NATIONAL JOURNAL OF MEDICAL RESEARCH
the macula properly and detect even minimal
changes in thickness. Some recent studies have
shown that there is retinal thickness before development of macular edema.6 Another recent study
states that as the probability of macular thickening
increases on OCT examination there is probability of
increase in severity of diabetic retinopathy.
The purpose of this study is to find out the correlation between change in macular volume on optical
coherence tomography (OCT) in patients with uncontrolled HbA1c levels.
METHODOLOGY
It is a observational study conducted in 50 patients
attending the ophthalmology OPD between Jan15July 15. Written informed consent was taken from all
patients. Ethics Committee Clearance was obtained
before starting the study.
Inclusion criteria: Patient who had diabetes since
>5 years without macular edema with or without
NPDR were include in the study.
Exclusion criteria: Patient having eyes with proliferative diabetic retinopathy (PDR); Eyes with cystoids serous maculae edema (CSME); and Other modalities like epiretinal membrane (ERM), age-related
macular edema (ARMD), prior laser IV Bevacizumab, Triamcinolone were excluded from the study.
One eye of each patient was selected. If both eyes
had increase macular thickness the eye with thinner
macula was selected. A complete ocular examination
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was done which included VA using Snellens, intraocular pressure (IOP) measurement with non contact
tonometer; dilated fundus examination with direct
ophthalmoscopy and indirect ophthalmoscopy, OCT
was used to evaluate macular thickness and volume.
RT (Retinal thickness), CST (Central Subfield Thickness), CSV (Central Subfield Volume), TMV (Total
Macular Volume) were recorded for each patient.
CST and CSV are the mean thickness and volume in
a region <0.05 mm from the fovea respectively.
TMV is the total volume within a radius of 3mm
from the fovea. Single sample of HbA1c was taken
to check glycaemic control over last 3 months.
Statistical analysis- Pearson’s correlation coefficient was used to find out the relationships between
age, duration of diabetes, HbA1c level, CST, CSV
and TMV. P value <0.05 was considered statistically
significant. All patients were divided into 2 groups
with no diabetic retinopathy and those with NPDR.
RESULTS
50 eyes from 50 patients (22 women and 28 men;
mean age 63.5 years) were selected. Mean duration of
DM being 10.5 years. 6 patients had type 1 DM and
44 patients had type 2 DM. Of these, 19 eyes (38%)
had no DR and 31 eyes (62%) had NPDR. In statistical analysis, CST (mean 188.82 +/-27.62um,
p=0.03) CSV (mean 0.148 +/- 0.022 mm3,p=0.03)
and TMV (mean 6.495 +/- 0.717mm3, p=0.003) , all
positively correlated with chronic HbA1c level (9.95
+/- 1.40%).
Table 1: Comparisons between patients with and without diabetic retinopathy
Variable
Age(years)
Diabetic duration(years)
HbA1c value
CST
CSV
TMV
No DR
61.5+/-14.7
12.3+/-5.9
9.1
180.4+/-26.2
0.146+/-0.166
6.356+/-0.612
Table 1 shows that patients who had more uncontrolled HbA1c levels showed more macular thickening. However there was no significant difference in
age and DM in 2 groups. P value is calculated by independent sample t-test.
DISCUSSION
OCT is the new and precise method to look for macular thickening which was used in our study.7
The increase in macular thickening in DM can be
explained by 2 mechanisms. Firstly microvascular
damage can cause changes in hemodynamic of macula causing thickening of macula due to breakdown of
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NPDR
61.75+/-12.5
13.7+/-4.2
10.6
192.6+/-26.2
0.156+/-0.100
6.616+/-0.761
P value
0.753
0.335
0.002
0.012
0.030
0.046
inner blood retinal barrier. Studies have shown that
long standing hyperglycemia can cause hydration of
macula due to osmosis and also increase in foveal
thickening.
Endometrial cell dysfunction due to microvascular
damage causes changes in structure of retinal cells
and the microvascular damage is more with uncontrolled HbA1c and our results are similar to that.8,1
In our study TMV has stronger correlation to uncontrolled HbA1c as compared to CST and CSV. This
finding is different from an earlier study which
shows that CST is preferred for OCT measurement
of central macula. This difference could be due to
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NATIONAL JOURNAL OF MEDICAL RESEARCH
DMO which was excluded from the study unlike
previous study which has included it. The hemodynamic changes in pre-macular edema stages are diffused disturbances rather than focal changes in fovea. So in our study there is change in TMV instead
of CMV.9
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3.
The Diabetes Control and Complications Trial Research
Group. The effect of intensive treatment of diabetes on the
development and progression of long-term complications in
insulin-dependent diabetes mellitus. N Engl J Med. 1993;
329:977–986.
4.
UK Prospective Diabetes Study (UKPDS) Group. UK prospective diabetes study VIII. study design, progress and performance. Diabetologia. 1991;34:877–890.
5.
No treatment was given to the patients who participated in our study because patient did not have
CSME.
Higgins GT, Khan J & Pearce IA (2007): Glycaemic control
and control of risk factors in diabetes patients in an ophthalmology clinic: what lessons have we learned from the
UKPDS and DCCT studies? Acta Ophthalmol Scand 85:
772–776.
6.
Browning DJ, Fraser CM & Clark S (2008a): The relationship
of macular thickness to clinically graded diabetic retinopathy
severity in eyes without clinically detected diabetic macular
oedema. Ophthalmology 115: 533–539.
CONCLUSION
7.
Schaudig UH, Glaefke C, Scholz F & Richard G (2000):
Optical coherence tomography for retinal thickness measurement in diabetic patients without clinically significant
macular oedema. Ophthalmic Surg Lasers 31: 182–186.
8.
Ferris FL III & Patz A (1984): Macular oedema. A complication of diabetic retinopathy. Surv Ophthalmol 28: 452–461.
9.
Kayykcyolu O, Ozmen B, Seymenoglu G, Tunali D, Kafesciler SO, Guclu F & Hekimsoy Z (2007): Macular oedema in
unregulated type 2 diabetic patients following glycaemic control. Arch Med Res 38: 398–402.
In our study, there is more significant increase in
TMV, CST, CSV in subgroup with NPDR than sub
group with no DR. this finding is similar to an earlier
study done by Browning.10,11
In our study we concluded that there is a positive
correlation between macular volume and thickness in
patients with uncontrolled HbA1c levels. Hence
these patients require regular follow up since they are
more prone to develop macular edema and hence
regular OCT was advised to these patients for early
detection and treatment of macular oedema.
REFERENCES
1.
Antcliff RJ & Marshall J (1999): The pathogenesis of oedema
in diabetic maculopathy. Semin Ophthalmol 14: 223–232.
2.
Klein R, Moss SE, Klein BE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. XI. The incidence of
macular edema. Ophthalmology. 1989;96:1501–10.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
10. Browning DJ, Fraser CM & Clark S (2008a): The relationship
of macular thickness to clinically graded diabetic retinopathy
severity in eyes without clinically detected diabetic macular
oedema. Ophthalmology 115: 533–539.
11. Browning DJ, Glassman AR, Aiello LP et al. & the Diabetic
Retinopathy Clinical Research Network (2008b): Optical coherence tomography measurements and analysis methods in
optical coherence tomography studies of diabetic macular
oedema.Ophthalmology 115:1366–1371.
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ORIGINAL ARTICLE
EVALUATION OF VISUAL OUTCOME OF CATARACT
SURGERY IN RURAL EYE-CAMPS IN THE STATE OF
MAHARASHTRA
Rupali D Maheshgauri1, Abha Gahlot2, Sonal Kohli3, Radhika R Paaranjpe4, Bhagyashree Kadam5,
Gira Raninga5
Author’s Affiliations: 1Associate professor; 2Professor; 3UG student; 4Assistant professor; 5PG student, Dept. of ophthalmology, Dr.D.Y.Patil Medical College, Pimpri, Pune
Correspondence: Dr Rupali D Maheshgauri Email: [email protected]
ABSTRACT
Aim: The present study was conducted to evaluate patients’ satisfaction and success of cataract surgery.
Methods: This population based retrospective study included 1000 patients .Out of which 500 were operated
in surgical camp and remaining 500 were operated in “Pdm. Dr. D. Y. Patil Medical College Hospital and Research Centre, Pimpri, Pune in institution setup from July to December 2013.The study was conducted at a
number of camps held in peripheral north Maharashtra .Evaluation of visual acuity and patients satisfaction
with scheduled porforma was done. Statistical analysis was performed with the help of cataract monitoring
outcome software developed by International Centre for Eye Health, London School of Hygiene and Tropical
Medicinefor evaluation of genderdifference, visual acuity, complications and patients satisfaction.
Result: In camp, 71.60% female and 28.40% male patients operated. And in base hospital, 58.40% male and
41.60% female were operated..Post operative.Visual acuity of 6/6 in base hospital was 90.4% and in camp was
69.2%. Number of visits in base hospital was 81.6% and in camp was 43% due to lack of post operative follow-ups cause of absence of transportation coupled with socio-economic background..Thepost operativecomplication rate and patients satisfaction in base hospital was 9.6% and 83% respectively and .In camp was
30% and58.6 % respectively.
Conclusion: Camp services should be at same location of base hospital with good transportation that helps
to make doctor- patient bonding and improve visual outcome. Involvement of the local community leaders
may provide an improved alternative.
Key words: Cataract, Visual acuity ,patient satisfaction
INTRODUCTION
WHO defines cataract as “clouding of the crystalline
lens of the eye which prevents clear vision”. Cataract
is the leading cause of unavoidable blindness worldwide .1 Epidemiologic models estimated that more
than 20 million people in the world are blind from
cataract and with increased life expectancy; it is projected that this will increase to 50 million by
2020.2 Eye camps in rural areas provide inexpensive
surgery to poor patients. The results of surgery in
eye camps are often not evaluated and the role of
IOL implantation under camp has been questioned.
Rural eye camps are able to provide a cost- effective
.Several patients did not visit and not taken post operative care which leads to complications after surgery.
The two models of this study were discussed in the
rural Maharashtra especially the backward regions
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such as Vidarbha.9 These models were complimentary and proposed to work in conjunction. Repetitive
eye-camps with the same set of professionals also
provide an emotional integration of the patients with
their doctors, thereby giving better result with cataract related complications of the rural poor. The patients already suffering with systemic diseases and
having a very low pre-operative visual acuity are
proposed to be separated and provided differential
treatment at the base hospital. It will reduce percentage of post-operative complications and would lead
to better acceptability of the camp operated model.
The “Vision 2020: Right to Sight” initiative, calls
upon us to take initiative to achieve the goals of right
to sight for all. With this background in mind, the
present study was undertaken with a hypothesis that
a viable solution for cataract afflicted rural populace
can be provided by improvising and improving the
models of camps being organised for cataract surgerPage 54
NATIONAL JOURNAL OF MEDICAL RESEARCH
ies.
Aims & Objective: To evaluate patients satisfaction
and visual outcome after cataract surgery in rural
surgical camp and institutional level. Objective of
this study is a right to sight and to eliminate avoidable blindness by 2020. The burden of blindness has
an enormous personal, social and economic impact,
limiting the educational potential and quality of life
of otherwise healthy people, and producing a severe
drain on family, community, social and health services. Blindness is also associated with lower life expectancy .13
METHODOLOGY
Study Site and Context: The population-based retrospective study was conducted at camps held in peripheral north area of Maharashtra. The field study
was also extended to the OPD of the base hospital at
Pdm. Dr. D. Y. Patil Medical College Hospital and
Research Centre, Pimpri, Pune. The study included
1000 patients (500 camp-operated and 500 base hospital operated) and were examined in period of July
to December 2013. Patients above 40 years suffering
from age-related cataract who have undergone cataract surgery in past 3 years were included. The success of cataract surgery is assessed by visual acuity 68 weeks post-operatively. The world health organisation recommends that at least 90% of patients have a
good outcome ( i.e., corrected distance visual acuity
[CDVA] > 6/18) after cataract surgery and that a
poor outcome (CDVA < 6/60) be limited to 5% of
cases.14
Inclusion criteria- Patients suffering from age-related
cataract who have undergone cataract surgery in past
3 years Patients from rural areas, who have been selected by government/NGOs through camps for
free surgery.Walk-in patients’ suffering from cataract
attending the tertiary care centre in a private medical
college and eventually operated.
Exclusion criteria: Patients having pre-existing corneal opacity, pseudoexfoliation, uveitis etc.
Ethical committee approval was taken.
Data collection procedures: manually, with the help
of a Performa. Procedure for examination of visual
acuity: Visual acuity in each eye was tested with Snellen’s chart and Landolt C chart (distant vision), Jaeger’s chart (for near vision).15 Procedure for corneal
examination with the help of Binocular loop and
torch examination was done to exclude a corneal
abrasion or corneal xerosis. 15 Fundus examinations
done under pupillary dilatation with use of Beta
Heinz direct ophthalmoscope when light is shown in
one eye, both the pupils constrict. Constriction of
the pupil to which light is shown, is called direct
light reflex; and that of the other pupil, is called conNJMR│Volume 6│Issue 1│Jan – Mar 2016
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sensual or indirect light reflex.16 Collected data has
been evaluated with the help of cataract monitoring
outcome software developed by International Centre
for Eye Health, London School of Hygiene and
Tropical Medicine.17
RESULTS
In camp, 71.60% female and 28.40% male patients
operated. And in base hospital, 58.40% male and
41.60% female were operated as shown in table 1.
Table1: Male-Female percentage Camp operated
and Base operated patients
Gender
Male
Female
Total
Camp operated (%)
142(28.40)
358(71.60)
500 (100)
Base operated (%)
292(58.40)
208 (41.60)
500 (100)
Table 2: Visual Acuity in postoperative patients
Visual Acuity
PLPL+
1/60
3/60
3/60-6/60
6/60
6/36
6/24
6/24-6/18
6/18
6/12
6/9
6/6
Base Hospital
0
0
0
0
3
0
0
0
11
34
0
0
452
Camp Operated
13
0
0
0
22
0
14
0
47
58
0
0
346
Table 3: Post-operative follow-up
Visits
1
2
3
4
Base Hospital (%)
457(91.4)
431(86.2)
411(82.2)
408(81.6)
Camp operated (%)
426(85.2)
402(80.4)
351((70.2)
215 (43.0)
Table 4: Post-Operative Cataract Complications
Post-operative catAract complications
Corneal Haze
Wound Leak
Vitreous Loss
Endophthalmitis
TASS
Base- Hospital
(%)
34 (6.8)
0 (0.0)
3 (0.6)
0 (0.0)
11 (2.2)
Camp- operated
(%)
58 (11.6)
14 (2.8)
22 (4.4)
13 (2.6)
47 (9.4)
Table 5: Satisfaction to Surgery
Satisfaction to
Surgery
Satisfied
Average Satisfaction
Not Satisfied
Base Hospital
(%)
415 (83.00)
57 (11.40)
28 (5.60)
Camp Operated
(%)
293 (58.60)
75 (15.00)
132 (26.40)
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Total
500 (100)
500 (100)
Table 2 shows Post operative Visual acuity of 6/6 in
base hospital was 90.4% and in camp was 69.2%.
As shown in Table 3 Number of visits in base hospital was 81.6% and in camp was 43% it due to lack of
post operative follow-ups cause of absence of transportation coupled with socio-economic background.
Definitely no of visits of patients are more in base
operated patients.
Table no 4 describes the patient satisfaction after
surgery.
Analysis of the satisfaction level of camp- operated
and base-operated patients after a period of 4-6
weeks shows a higher level of satisfaction for the latter. The patients having systemic diseases diagnosed
out of routine screening are transferred to the base
hospital for improved management for avoiding incidence of intra & post-operative complication.
Table no 5 describes postoperative complication incidence of endophthalmitis is high in camp operated
patients.
DISCUSSION
Cataract is the leading cause of blindness in India.
The male patients are taken care of and transported
to improved health care centres such as the base
hospital in our case, whereas the female patients belonging to the same group have to depend largely on
the free health camps organised nearer to their dwellings.
In our study, 71.60% female and 28.40% male were
operated in camp while , 41.60% female and 58.40%
male were operated in base hospital. Similar results
were seen in a study conducted by as of our study
undertaken by Gogate Pet al al at a base hospital and
outreach camps in the rural areas in Maharashtra.10
As per this study, 59.1% female patients were operated at camp and 48% were operated at hospital. The
study undertaken by Kapoor H et al similar with our
study as efficacy of eye camps can be improved by
repeat camp at the same venue, was evaluation of
visual outcome of cataract surgery in an Indian eyecamp.3 In another study of Nowak R et al on outcome of an outreach microsurgical project in Nepal
,compare with our study with application of appropriate surgical techniques and standard protocols at
camp level.4 Another similarity with our study was
conducted by Murthy G V et al the better visual acuity levels achieved in base hospitals as compared to
camp operated cataract patients.5 Our proposed
model acquires significance as it will lead to improved visual acuity, satisfaction and surgical care to
the rural population especially the females near their
community living.
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One study done by Finger RP at al highlightened the
importance of providers building trust by organizing
regular outreach in the same location.6 A study was
done by Pai SG at alin which patient were screened
in camp and transported to base hospital for low rate
of intraoperative complications.7 A study done by
Jagat Ram at al ,found that follow up in camp operated children declined gradually.8 A other study was
done by Reddy A et al found that outcome for the
eyecamp operated patients was almost similar with
patients operated in hospital.9 One study was done
by Gogate P et al l found that postoperative follow
up at base hospital was very poor.10
A study undertaken by R Anand,et al in Chandigarh
on visual outcome following cataract surgery in rural
Punjab had similar outcome to our study.11 One
study done by Rushoo A et al found that large scale
operations were held in rural area due to intensive
volunteer cataract programs.12 In above mentioned
studies result were similar with our study. The results
thrown up by us findings show a wide gap between
the qualitative results achieved between the two sets
(camp and base hospital) of medical services. As
similar set of professionals performed these services,
the results were expected to be similar. This throws
up another challenge to find out ways and means to
improve the qualitative results of the camp operated
cataract patients. Perhaps, the two models proposed
by us may provide a lasting solution.
Model 1: “On site repetitive eye-camps at the same
location, with the same set of medical professionals
(especially the surgeon) using standardised techniques and acceptable level of sterilisation.” The advantage of such a model is to provide a qualitative
and consistent post-operative care by the same set of
medical professionals who operated the patients in
the camp. While comparing the results of the camp
operated patients with those of well-equipped hospitals, a major difference which was observed was that
in a hospital condition normally the post operative
care is carried out by the same medical professionals,
whereas follow-up in a camp may or may not be
done by the same professionals. This was also found
to be one of the major reasons for the patients not
coming forward for post operative care in camp
conditions and also better results with consistency in
operations carried out at hospitals. Repetitive eyecamps with the same set of professionals also provide an emotional integration of the patients with
their doctors, thereby giving better results.
Model 2: “Patients identified after screening at
camps, suffering from systemic diseases, are proposed to be referred to base hospitals for surgery and
follow-up. Transportation from the camp to the base
hospital and back to their respective places postsurgery, with provision of regular transportation for
follow-up minimises post-operative complications.”
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NATIONAL JOURNAL OF MEDICAL RESEARCH
The two models are complimentary and proposed to
work in conjunction, to provide aholistic solution to
the problems associated with cataract related complications of the rural poor. The patients already suffering with systemic diseases and having a very low preoperative visual acuity are proposed to be separated
and provided differential treatment at the base hospital. It will reduce percentage of post-operative complications and would lead to better acceptability of
the camp operated model.
Another interesting aspect , though not related directly to our study is the level of ignorance and superstition that afflicts the rural populace, especially
the poor, the aged and the female, resulting in acceptance of cataract related diseases as a fate and not
making enough attempts to attend the especially organised rural camps for getting proper medical
treatment at the appropriate time. This also results in
post operative complications.
CONCLUSION
During our study we come to the conclusion considering the socio-economic and gender specific importance of the camp operated cataract services. In most
of the studies it has been established beyond doubt
that the management of incidence of cataract in the
Indian subcontinent in general and rural Maharashtra
in particular cannot be carried out without the camps
being organised especially for this purpose. However,
as discussed earlier, the results thrown up by our
findings show a wide gap between the qualitative results achieved between the two sets (camp and base
hospital) of medical services. As similar set of professionals performed these services, the results were
expected to be similar. This throws up another challenge to find out ways and means to improve the
qualitative results of the camp operated cataract patients. To improve the techniques at the camp and
providing repeat services at the same location and
involvement of the local community leaders may
provide an improved alternative.
REFERENCES
1.
ThyleforsB Negrel A-D, Pararajasegaram R, Dadzie KY.
Global data on blindness. Bull World Health Organization.
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1995;73:115121
2.
Thylefors B. ‘A global initiative for the elimination of avoidable blindness’ Amer. Journal of Ophthalmol. 1998;125:9093 also available at Community Eye Health11(25):1-3
3.
Kapoor H., Chatterjee A., Daniel R., Foster R. Evaluation of
visual outcome ofcataract surgery in an Indian eye camp. (Br
J Ophthalmol1999;83:343-346)
4.
Nowak R, Grzybowski A. Outcome of an outreach microsurgical project in rural Nepal. (Saudi Journal of Ophthalmology 2013; 27(1):3–9
5.
Murthy GV, Gupta SK, Talwar D. ‘Assessment of cataract
surgery in rural India.Visualacuity outcome’. (ActaOphthalmologicaScandinavicaVolume 74, Issue 1,pages 60–63, February 1996)
6.
Robert P. Finger, David G. Kupitz, Frank G. Holz, Seetha
Chandrasekhar, BharathBalasubramaniam, Ramanathan V.
Ramani and Clare E. Gilbert. ‘Regular provision ofoutreach
increases acceptance of cataract surgery in South India’.
(Tropical Medicine andInternational Health volume 16 no
10 pp 1268–1275 october 2011)
7.
SGPai, SJ Kamath, V Kedia, K Shruthi, A Pai. ‘Cataract Surgery in Camp patients: astudy on visual outcomes’. (Napalese
Journal of Ophthalmology; Vol 3, No 2, 2011,Pai)
8.
Jagat Ram, JaspreetSukhija and Virendra K Arya. ‘Comparison of Hospital Versus Rural Eye Camp based Pediatric
Cataract Surgery’ (Middle East Afr J Ophthalmol. 2012 JanMar;19(1): 141-146)
9.
Reidy A, Mehra V, Minassian D, Mahashabde S. ‘Outcome
of cataract surgery in centralIndia: a longitudinal follow-up
study’ (Br J Ophthalmol 1991 Feb;75(2):102-5.
10. ParikshitGogate, MS(Ophth) MSc FRSc (Ed) and Anil N
Kulkarni, Ms (Ophth). ‘Comparison of Cataract Surgery in a
Base Hospital and in Peripheral Eye Camps.’ (Community
Eye Health. 2002;15(42):26-27).
11. R Anand, A Gupta, J Ram, U Singh, R Kumar. ‘Visual outcome following cataractsurgery in rural Punjab. Indian Journal of Ophthalmology’ 2000:48(2):153-8
12. Adel A. Rushood‘Outcomes of Cataract Surgeries Over 16
Years in Camps Held by AlBasar International Foundation
in 38 Underdeveloped Countries’.(Middle East Afr
JOphthalmol.2011 Apr-Jun; 18(2): 129-135).
13. RamanjitSihota, RadhikaTandon, ‘Parsons Diseases of the
Eye’(Chapter 34, The causes and prevention of blindnessVision 2020, Page 544).
14. Kathryn Colby ‘Merck manuals: Last full review/revision’
1(April2009)
15. Limburg H, Foster A, Gilbert C, Johnson GJ, Kyndt M.
‘Routine monitoring of visualoutcome of cataract surgery.
Part 1: development of an instrument.’ Br J Ophthalmol.2005;89:45-49.
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ORIGINAL ARTICLE
ASSESSMENT OF THE PROFILE OF PSYCHIATRIC
MANIFESTATIONS IN CANNABIS USERS: A CROSS
SECTIONAL STUDY
Indrajeet Sharma1, Tulika Jha2, Purshottam K. Kaundal3
Author’s Affiliations: 1Assistant Professor, Department of Pharmacology, AIMS, Rajsamnd; 2Post-Graduate student; 3Professor; Department of Pharmacology, Indira Gandhi Medical College, Shimla-1, Himachal Pradesh, India
Correspondence: Dr Indrajeet Sharma E-mail: [email protected]
ABSTRACT
Background: Cannabis is the world’s most commonly used illicit drug, with approximately 200 to 300 million
regular users. It occupies fourth place in worldwide popularity among psychoactive drugs, after caffeine, nicotine and alcohol. Nowadays, cannabis is widely used by young people and, the prevalence of lifetime use of
cannabis by young adults has increased in many developed countries over the past several decades.
Methods: It was a one year cross-sectional observational study. The study included 60 patients, who had
been taking cannabis for at least previous six months with a frequency of minimum 20 days/month. The eligible patients fulfilling inclusion and exclusion criteria and giving written informed consent were enrolled in
the study.
Results: Most common co-morbid psychiatric disorders were bipolar affective disorders, current manic episode with or without psychotic features (25.0%). Second most common co-morbid disorder was cannabis induced psychosis which was present in thirteen patients (21.7%). Seven patients (11.7%) had acute and transient psychosis; six patients (10.0%) were diagnosed as schizophrenia, whereas three patients (5.0%) had Psychosis Not Otherwise Specified (NOS). Anxiety disorder and depressive disorder accounted for 10% and
3.4% of comorbidity, respectively. Two patients (3.3%) were having cannabis dependence syndrome with
withdrawal state and three patients (5.0%) were having cannabis dependence syndrome only without any associated psychiatric comorbidity.
Conclusion: Among the various psychiatric disorders, bipolar affective disorder, current episode mania with
or without psychotic features was the most prevalent disorder.Most of cannabis users seeking treatment suffer
from various psychiatric comorbid disorders particularly psychotic disorders (38.4%).
Key words: Cannabis, Bipolar affective disorder, Psychiatric comorbidity.
INTRODUCTION
Cannabis is associated with a significant psychiatric
comorbidity.1 The effects of cannabis use on the aetiology and course of psychiatric disorders such as
psychotic or mood disorders have been examined by
the researchers. Cannabis users experience euphoria
and changes in thought processes with thoughts being experienced as fragmented or more accurate. In
addition, changes occur in visual and auditory perception and in the perception of time as well as
changes in short term memory and attention. The
use of high doses of cannabis may even result in psychotic symptoms like delusions and hallucinations;
the latter phenomena are sometimes described as
cannabis psychosis.2-6 However, the incidence and
prevalence of such cannabis psychosis is not wellknown because the concept of cannabis psychosis is
NJMR│Volume 6│Issue 1│Jan – Mar 2016
poorly defined and the specificity and existence of
such a nosological entity remains controversial.7-8
Both DSM-IV-TR9 and ICD-1010 have given various
categories of disorders associated with the use of
cannabis, with ICD-10 having a wider approach. The
most important thing which is apparent from the
classification is that cannabis is implicated as the
causative agent for all the categories, but on the contrary, research has shown that it may not act as a
causative agent, but may worsen the pre-existing
mental illness or may unmask the mental illness in
predisposed subjects.9
The association between cannabis use and psychotic
symptoms and/or disorders has also been explained
by the hypothesis that patients use cannabis as a
form of self-medication. Within the framework of
the self-medication hypothesis, several sub hypotheses can be considered.11-13
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Considering the fact that India remains a traditional
cannabis use country, the importance of research
from our country cannot be overestimated. Furthermore, in view of the paucity of literature from our
state, the present study was planned to assess the
profile of psychiatric manifestations in cannabis users.
METHODOLOGY
Set up and study design: The study was conducted
at Indira Gandhi Medical College, Shimla, which is a
tertiary care centre of Himachal Pradesh from July2014 to June-2015, located in North India and caters
to the majority of population of the state. It was a
Cross-sectional observational study. The study protocol was approved by IGMC ethical committee.
Study population and selection process: Patients
attending out-patient department (OPD) and inpatient department (IPD) services of psychiatry department were the patient population screened for
enrolment in the study. The study included 60 patients, who had been taking cannabis for at least previous 6-months with a frequency of minimum 20
days/month. The eligible patients fulfilling following
inclusion and exclusion criteria and giving informed
consent were enrolled in the study. Inclusion criteria
includedpatients within the age group of 18-65 years,
consuming cannabis for the last >6 months with a
frequency of 20 days/month or more, and having
willingness to participate in the study.An exclusion
criterion includedpatients fulfilling the criteria for
abuse/dependence for other substances except nicotine and evidence of an organic mental disorder.
Baseline data collection: Demographic and clinical
data was obtained from the patients or relatives and
recorded using structured formats. Psychiatric symptoms were assessed using Mini-International Neuropsychiatric Interview 6.0 (M.I.N.I.6.0)14. Diagnosis of
psychiatric disorders was made according to ICD1010. If the patient was found to have some psychiatric syndrome, the severity of the same was assessed
using appropriate scales such as: Young Mania Rating Scale, Brief Psychiatric Rating Scale, Hamilton
Depression Rating Scale or Hamilton Anxiety Rating
Scale as per the psychiatric diagnosis. Assessments
were done when the patients were in sober state.
Statistical analysis: In the study various sociodemographic and drug related variables were compared
by using appropriate statistical methods. The categorical and continuous variables were reported as
percentages and mean ± standard deviation respectively.2 tailed value of <0.05 was taken as statistically
significant. Data was analysed using statistical software Epi Info version 3.4.3.
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RESULTS
Baseline clinical characteristics of the study
groups: Table 1 describes the distribution of clinical
characteristics of the study population under observation
Table 1: Socio-Demographic characteristics of
the patients
Characteristics
Age (yrs)(Mean ± SD)
Sex
Rural/Urban:
Rural
Urban
Marital status:
Single
Married
Divorced/Widowed
Type of family:
Nuclear
Joint
Socioeconomic status*:
Upper
Upper middle
Lower middle
Upper lower
Lower
*Modified Kuppuswamy’s scale
Patients (%)
31.63 ±10.86
100% (male)
43 (71.7)
17 (28.3)
30 (50.0)
27 (45.0)
3 (5.0)
44 (73.3)
16 (26.7)
0
11 (18.3)
20 (33.3)
17 (28.3)
12 (20.0)
Age of initiating cannabis use: Most of the patients (38.3%) initiated cannabis consumption before
the age of 20 years. Only four patients (6.7%) had
initiated cannabis consumption after the age of >40
years. The mean age of initiating cannabis use was
23.98 ± 8.30.
Duration of cannabis use: Majority of the patients
(58.3%) were consuming cannabis for 6-10 years.
Only one patient (1.7%) had history of cannabis consumption for more than 20 years. Mean duration of
cannabis use was 8.08 ± 3.83.
Patients with History of past abstinence attempts: Out of sixty patients, 28 patients (46.6%)
had made abstinence attempts in the past. 20 patients
had one abstinence attempt and 8 patients had made
two abstinence attempts. Among the patients who
made one or two abstinence attempts in the past, the
duration of abstinence attempt was less than three
months in majority of cases (20 out of 28 patients).
None of the patients had made >2 abstinence attempts and in none of the cases, the duration of abstinence was more than 9 months.
Total Psychiatric co-morbidities: Vast majority of
the patients (91.7%) had psychiatric co-morbidities.
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Table-2: Psychiatric co-morbid disorder in cannabis dependent patients
Psychiatric co-morbid disorder
Cannabis dependence syndrome with psychiatric co-morbidities
Schizophrenia
Acute and transient psychosis
Psychosis NOS
Cannabis induced psychosis
Manic episode without psychotic features
Manic episode with psychotic features
Bipolar affective disorder, current episode mania without psychotic features
Bipolar affective disorder, current episode mania with psychotic features
Severe depressive disorder without psychotic features
Recurrent depressive disorder
Generalized anxiety disorder
Mixed anxiety and depression
Panic disorder
Cannabis dependence syndrome with withdrawal state
Cannabis dependence syndrome
Types of Psychiatric co-morbidities: Most common co-morbid psychiatric disorder was bipolar affective disorders, current manic episode with or
without psychotic features (25.0%). Additional three
patients (5.0%) were diagnosed having first episode
mania with or without psychotic features. Second
most common co-morbid disorder was cannabis induced psychosis which was present in thirteen patients (21.7%). Seven patients (11.7%) had acute and
transient psychosis; six patients (10.0%) were diagnosed as schizophrenia, whereas three patients
(5.0%) had Psychosis Not Otherwise Specified
(NOS). Anxiety disorder and depressive disorder accounted for 10% and 3.4% of comorbidity, respectively. Out of sixty patients observed, two patients
(3.3%) were having cannabis dependence syndrome
with withdrawal state and three patients (5.0%) were
having cannabis dependence syndrome only without
any associated psychiatric comorbidity.
DISCUSSION
In the present study, mean age of the patients was
31.63 ± 10.86 years and 78.3% of the patients were
more than 20 years old. There was no female patient.
This probably reflects that consumption of cannabis
by females is less prevalent in this region and it may
be culturally unacceptable also.15,16,1738.3% of the patients initiating cannabis consumption were within
the age range of 18-25 years which is comparable to
the study by Arias et al.16 where 42% of the patients
started consuming cannabis between 16-25 years.
Mean age of initiating cannabis consumption was
23.98 ± 8.30 years. In most of the Western studies,
the age of cannabis initiation was lower in comparison to that of the Indian studies suggesting that the
cannabis use begins at younger age in Western population.18,19The mean duration of cannabis use in our
study was 8.08 ± 3.83 years and 50.0% patients were
consuming cannabis for 6-9 years. Only 1.7% paNJMR│Volume 6│Issue 1│Jan – Mar 2016
Cases (%)
6 (10.0)
7 (11.7)
3 (5.0)
13 (21.7)
1 (1.7)
2 (3.3)
7 (11.7)
8 (13.3)
1 (1.7)
1 (1.7)
3 (5.0)
2 (3.3)
1 (1.7)
2 (3.3)
3 (5.0)
tients had history of cannabis consumption for more
than 20 years. In the present study, 46.6% patients
had history of abstinence attempts in the past. Sarkar
et al.20 has found almost similar percentage of patients (45.3%) had attempted abstinence in the past.
A vast majority of our patients had comorbid psychiatric disorders.21 In our study, 25.0% (15) patients
were suffering from bipolar affective disorder, out of
which 13.3% (8) had current manic episode with
psychotic features and 11.7% (7) had current manic
episode without psychotic features. Our findings
were in coherence with some studieswhere 15.4%
(10) patients had current manic episode with psychotic features and 13.4% (9) patients had current
manic episode without psychotic features.16,21 In the
present study, second most common psychiatric comorbid illness found was cannabis induced psychosis
which was present in 21.7% patients. The prevalence
of cannabis induced psychosis was more or less similar to that of the previous studies where it ranged
from 11.5% to 34.5%.16,19,20,21Clinical research has
shown that high proportions of persons with schizophrenia report regular cannabis use and meet criteria
for cannabis use disorders.22,23 In the present study,
11.7% of patients had acute and transient psychosis
and 10.0% of patients qualified for a diagnosis of
schizophrenia. 5.0% patients had Psychosis Not
Otherwise Specified (NOS). Chen et al.19 noted that
13.7% of patients had acute and transient psychosis
and 8.0% of patients had schizophrenia. Arseneault
L et al.24 however have observed a lesser number of
patients (23.4%) with features of schizophrenia.In
our study, 5.0% patients were diagnosed as having
first episode mania, out of which, 3.3% patients were
labelled as manic episode with psychotic features
while another 1.7% as manic episode without psychotic features. Previous studies have reported variable frequency of manic episode in cannabis users.
23,25 Like our observations, Arias et al.16 have also
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found almost similar frequency of first manic episode in their sample.
10. World Health Organisation. ICD-10 Classification of Mental
and Behavioural Disorders: Clinical Description and Diagnostic Guidelines, Geneva: World Health Organisation.
1992.
CONCLUSION
11. Dixon L, Haas HG, Weiden PJ, Sweeney J, Frances AJ.
Drug abuse in schizophrenic patients: Clinical correlates and
reasons for use. American J of Psychiatry. 1991; 148:224–30.
Many patients were suffering from various comorbid
and cannabis induced psychiatric disorders and such
patients were associated with high cannabis use.
Among the psychiatric disorders, bipolar affective
disorder, current episode mania with or without psychotic features was the most prevalent disorder. It
was seen in around 25% of patients. So, in the present study we may conclude that most of cannabis
users seeking treatment suffer from various psychiatric comorbid disorders particularly psychotic disorders (38.4%).
LIMITATIONS
It was a hospital based cross sectional study and
sample size was relatively small. History of cannabis
use was based as reported by patient/family member.
No body fluid test for cannabinoids was done.
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1. Grover S, Basu D. Cannabis and Psychopathology: Update
2004. Indian J of Psychiatry. 2004; 46:299-09.
2. Basu D, Malhotra A, Bhagat A, Varma VK. Cannabis psychosis and acute schizophrenia: a case-control study from
India. European Addiction Research. 1999; 5:71-73.
3. Chaudry HR, Moss HB, Bashir A, Suliman T. Cannabis psychosis following bhang ingestion. British J of Addiction.
1991; 86:1075-81.
4. Imade AGT, Ebie JC. A retrospective study of symptom
patterns of cannabis-induced psychosis. ActaPsychiatricaScandinavica. 1991; 8:134-36.
5. Núñez LA, Gurpegui M. Cannabis -induced psychosis: A
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6. Onyango RS. Cannabis psychosis in young psychiatric inpatients. British J of Addiction. 1986; 81:419–23.
7. Cantwell R, Harrison G. Substance misuse in the severely
mentally ill. Advances in Psychiatric Treatment. 1996; 2:11724.
8. Poole R, Brabbins C. Drug induced psychosis. British J of
Psyciatry. 1996; 168:135-38.
12. Frances RJ. The wrath of grapes versus the self-medication
hypothesis. Harvard Review of Psychiatry. 1997; 4:287–89.
13. Khantzian EJ. The self-medication hypothesis of substance
use disorders: reconsideration and recent applications. Harvard Review of Psychiatry. 1997; 4:231–44.
14. Sheehan D, Janavas J, Harnett-Sheehan K, Sheehan M, Gray
C. Mini International Neuropsychiatric Interview, English
version 6.0.0. January 1, 2010.
15. International Institute for Population Sciences (IIPS) and
Macro International. 2007. National Family Health Survey
(NFHS-3), 2005–06: India: Volume II.
16. Arias F, Szerman N, Vega P, Mesias B, Basurte I, Morant C,
Ochoa E, Poyo F, et al. Abuse or dependence on cannabis
and other psychiatric disorders. Madrid study on dual pathology prevalence. ActasEspPsiquiatr. 2013;41(2):122-9.
17. Basu D, Malhotra A, Varma VK. Cannabis related psychiatric syndromes: A selective review. Indian J of Psychiatry.
1994; 36:121-28.
18. Brook JS, Cohen P, Brook DW. Longitudinal study of Cooccurring Psychiatric disorders and substance use. J of the
American Academy of Child and Adolescent Psychiatry.
1998; 37:322-30.
19. Chen CY, Wagner F, Anthony J. Marijuana use and the risk
of major depression episode: epidemiological evidence from
the United States National Comorbidity Survey. Social Psychiatry and Psychiatric Epidemiology. 2002; 37:199-06.
20. Sarkar J, Murthy P, Singh SP. Psychiatric morbidity of cannabis abuse. Indian J of Psychiatry. 2003; 45:182-88.
21. Macfadden W, Woody GE. Cannabis related disorders. In.
Comprehensive textbook of Psychiatry by Kaplan &Sadock
(7th edition). 2000; 990-98.
22. Thomas H. Psychiatric symptoms in cannabis users. British J
of Psychiatry. 1993; 163:141-49.
23. McGee R, Williams S, Poulton R, Moffitt T. A longitudinal
study of cannabis use and mental health from adolescence to
early adulthood. Addiction. 2000; 95:491–03.
24. Arseneault L, Cannon M, Poulton R, Murray R, Caspi A,
Moffitt TE. Cannabis use in adolescence and risk for adult
psychosis: longitudinal prospective study. British Medical J.
2002; 325: 1212-13.
25. Arseneault L, Cannon M, Witton J, Murray RM. Causal association between cannabis and psychosis: examination of the
evidence. British J of Psychiatry. 2004; 184: 110- 17.
9. American Psychiatric Association. Diagnostic and Statistical
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American Psychiatric Association, Washington, DC. 2000.
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ORIGINAL ARTICLE
EFFECTS OF INTRATHECAL BUPIVACAINE WITH NORMAL
SALINE VERSUS BUPIVACAINE WITH FENTANYL IN
PATIENTS UNDERGOING SURGERY
Jigna R Shah1, Manish Bhatt2
Author’s Affiliations: 1Assistant Professor; 2DNB student, Department of Anesthesia, GMERS Medical College, Sola,
Ahmedabad
Correspondence: Dr Jigna R Shah E-mail: [email protected]
ABSTRACT
Objective:To know the effects of intrathecal 0.5% Bupivacaine 2.5 cc with 0.5 cc normal saline and 0.5%
Bupivacaine 2.5 cc witth 25 μg fentanyl for various lower abdominal surgeries.
Methods: A comparative study were conducted in 60 (ASA grade I / II) patients. The onset and duration of
both sensory and motor blockade was compared using relevant scales i.e. Sensory scale and Bromage Scale. Intra-operative and post-operative hemodynamic monitoring was done. The complications which occurred
were noted and studied. - The duration of analgesia after sensory wear off was compared between the 2
groups using Visual Analogue Scale. - Quality of post-operative analgesia was studied between the groups.
Results: The duration of sensory and motor block as well as duration of effective analgesia was significantly
longer in the bupivacaine–fantanyl group as compared with both bupivacaine–normal saline groups.
Conclusion: Addition of intrathecalfantanyl to bupivacaine was more advantageous than bupivacaine with
normal saline with special regard to its analgesic properties among surgical patients.
Keyword:-bupivacaine, fentanyl, intrathecal
INTRODUCTION
PAIN is defined as an "unpleasant sensory and emotional experience associated with actual or potential
tissue damage or described in terms of such damage". Postoperative analgesia is now getting prime
importance since few years in elective; emergency as
well as day care surgeries. It is becoming popular all
over world due to number of advantages to patient,
hospital and community such as -1) Minimal psychological stress. 2) Decreased post-operative complication. 3) Greater flexibility about timing of surgery
with rapid return to routine activities. 4) It improves
respiration, hemodynamic stability and relieves sympathetic overactivity. 1,2,3
Over the past few years, post-operative analgesia has
evolved from intravenous injections of pain killers to
complex and skillful techniques requiring advanced
knowledge, equipment and drugs. The aim is to have
the technique which is minimally invasive, takes less
time and causes minimal alteration in routine activities. The technique should give prolonged analgesia,
be economically acceptable and have the least number of complications.4-8
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Regional anaesthesia is preferred to general anaesthesia because of less risk of aspiration and other complications associated with tracheal intubation. There
is enhanced ability to communicate with the patient
and greater potential 2 for post-operative analgesia.
There is reduced incidence of post-operative residual
paralysis, nausea, vomiting, lethargy and central respiratory depression. Among regional anaesthesia,
spinal anaesthesia is a simple, reliable technique
which is quick in onset. Short acting local anaesthetic
like lignocaine is now being questioned for various
reports of transient to permanent neurological damage. In contrast, use of Bupivacaine in spinal anaesthesia is rarely followed by neurological symptoms.
For the same reason, we accepted it as our basic drug
for anaesthesia and decided to study the effectiveness
of injection fentanyl with injection. Bupivacaine intrathecally for post-operative analgesia.9-15
The present study was designed to compare effect of
intrathecal 2.5 cc Bupivacaine 0.5% heavy with 0.5 cc
normal saline and 2.5 cc Bupivacaine 0.5% heavy
with fentanyl 25 μg in various urological, gynaecological and general surgeries.
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METHODOLOGY
The present study was conducted in 60 patients. Patients accepted for the study were all ASA I or II
physical status in the age group of 16-60 years posted
for various lower abdominal surgeries, under spinal
anaesthesia. The patients were divided into 2 groups,
group A and group B with each having 30 patients.
Pre-operative evaluation: Detailed pre-anaesthetic
check-up was done when patients were referred in
pre-anaesthetic clinic. Patients having contraindications to spinal anaesthesia like spinal deformity, local
infection, bleeding diathesis, mental retardation or
neurological deficit were excluded from study group.
Routine laboratory tests like Hb%, renal function
tests, serum electrolytes, urine examination, blood
sugar and chest x-ray were done in all cases. Patients
were explained about the procedure in detail and
written consent was obtained. All patients were instructed to fast for minimum 8 hours prior to scheduled time of surgery. No patients received any sedative and narcotic premedication before arrival in operation theatre.
On arrival in the operation theatre, usual monitoring
like ECG, pulse- oximetry, blood pressure cuff were
applied and baseline pulse, BP, Respiratory rate were
noted. I.V. line was secured with 18G intravenous
cannula and preloading with 500 ml of Ringer lactate
was done in all patients. After giving lateral position,
lumbar puncture was done in L3 - L4 space with
no.25G Quincke's spinal needle by median route. After confirming free flow of CSF, drug was injected
over 10 seconds.
Study participants and procedure: They were divided into 2 groups and received following drugs in
spinal anaesthesia. Group A: 2.5cc of 0.5 Bupivacaine heavy + 0.5 cc Normal saline Group B: 2.5 cc
of 0.5% Bupivacaine heavy + 25 μg fentanyl (0.5cc).
Immediately after completion of the block patients
were returned to normal position and following observations were recorded. All the times were recorded from the point of injection of drug in CSF.
The onset and duration of sensory blockade were assessed by using pinprick test, bilaterally in midclavicular line every 2 minutes for first 20 minutes
and then every 5 minutes till level is stabilised. Highest level of sensory block and time to reach highest
level were recorded. Motor blockade was assessed by
using Bromage scale and its onset time is recorded.
This is defined as the time to reach grade of 3 in
Bromage scale. 31,43Grade 0: Full flexion of knees and
feet, Grade 1 Just able to flex the knees, full flexion
of feet, Grade 2 Unable to flex the knees, some flexion of feet, Grade 3 Unable to move legs or feet.
Duration of grade 3 of Bromage scale was noted and
time to recover to grade 0 of Bromage scale was
noted.
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After the establishment of adequate level of analgesia, surgery was started and time of begining of surgery was noted. I.V. fluids were continued intraoperatively at the rate of 2 ml/kg/hour. Intraoperatively pulse, BP and SPO2 were monitored
every 5 min. for first 30 min. and thereafter every 15
min till the end of surgery. Bradycardia was defined
as pulse rate < 60 / min and was treated with inj. Atropine 0.6 mg I.V. Hypotension was fall in BP more
than 30% of baseline value and was treated with I.V.
fluids and injection. Mephentermine sulphate 6 mg if
required. Any other complication like nausea, vomiting, inadequate block were noted and any supplementation in form of sedatives analgesics or anaesthetic agent was recorded.
At the end of surgery, surgical time was recorded and
patients were observed in PACU till the patient
complained of pain as per Visual Analogue Scale.
Rest, foot end elevation and hydration were advised.
The time taken for 2 segment regression (T1) and
total duration of motor blockade was noted. Patients
were allowed to ambulate when (a) sensory block is
regressed to S2 level and time noted (T2. and (b)
complete recovery of motor blockade. All the patients were kept in PACU under observation with
continuous ECG monitoring, SPO2, pulse, BP and
respiratory rate. Duration in minutes after surgery
was noted in those patients who had unbearable pain
and this was considered as 25 as per VAS. This time
was labelled as T4 min and data was used in discussion. The VAS score of ≤ 25 mm is considered analgesic success. Duration of analgesia was observed
from time to S2 segment wear off (T2) i.e. sensory
reversal to time of request of analgesic dose.
Monitoring of complications: Patients were observed carefully for any complications. Retention of
urine was defined as time to urination (from induction) > 6 hours or feeling distress or pain whatever is
less. Accepted measures to get relief are reassurance,
hot water bag and catheterisation. All urosurgical patients had catheterisation post-operatively before
shifting the patient to PACU, so retention of urine
was not observed post-operatively. At the time of
transferring the patient to their respective ward, patients were prescribed oral analgesics or inj. Diclofenac sodium 1 amp. i.m. as and when required.
They were instructed to drink plenty of fluids and
rest for the remainder of day. They were also asked
to report complications like headache, backache, dysaesthesia in buttocks, thigh and lower limb upto 1
week.
Statistical analysis:Data were analysed using Unpaired 't' test and Fischer exact test with P < 0.05
considered statistically significant. Data were presented as mean values, Mean ± SD and numbers
(percent). Hemodynamic parameters were represented graphically as well as in tables.
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RESULTS
Table 1: Demographic characteristics
Highest level of sensory blockade was T6 in both
groups. There was no significant difference in onset
time and the time to reach highest sensory level in
both groups. The time intervals for sensory level to
regress 2 segments (T1) and Sensory regression to S2
dermatome (T2) were prolonged in group B patients
compared to group A (12% and 14% respectively) (P
< 0.001). The judgement of sensory blockade by sensory scale is almost same in both patients. The onset
of motor blockade was similar in both group of patients. The assessment of motor blockade done by
Bromage scale showed that duration of motor blockade was not prolonged by addition of fentanyl. The
onset of spinal block is almost same in both groups.
Variable
Age (Years)
Gender
Male
Female
Height (cms)
ASA
Grade - I
Grade - II
Surgeries
Gynecological
Urological
General
Group A (n=30)
36.8 ± 5.8
Group B (n=30)
37.2 ± 3.4
13
17
158.2 ± 3.84
12
18
154 ± 4.36
24
6
24
6
13
07
10
11
07
12
Group A(n=30)
Group B (n=30)
7 ± 2.4
T6
11 ± 3.4
150 ± 7.4
180 ± 12.4
7.2 ± 3
T6
12 ± 2.2
162 ± 8.2
206 ± 6.4
8.6 ± 4.1
110 ± 30
160 ± 40
8.4 ± 3.2
124 ± 18
168 ± 35
Group A: bupivacaine + normal saline,
Group B: bupivacaine + fentalnyl
Table 2: Characteristics of block
Variable
Characteristics of sensory block
Mean Time of Onset (Mean ± SD) min.
Highest Sensory level
Mean Time from injection to Highest sensory level
Mean Time for 2 segment regression from highest sensory level - T1
Mean Time for sensory regression to S2 from highest sensory level. T2
Characteristics of motor block
Mean Onset to grade III motor block
Mean Duration of Grade III motor block
Mean Time to reach grade 0 from grade III -(Recovery time)
Group A: bupivacaine + normal saline, Group B: bupivacaine + fentalnyl
Table 3: Patient's judgment of block as per sensory scale
A
B
C
D
Group A(n=30)
23
7
0
0
Group B (n=30)
25
5
0
0
Group A: bupivacaine + normal saline, Group B: bupivacaine +
fentalnyl
Table -3 shows comparison of Patient's judgment of
block as per sensory scale in bothe the groups.
Table 4: Pre-operative hemodynamic parameters
(mean)
Parameter
Pulse (beats / min)
SBP/DBP) mmHg
SPO2%
RR (per min)
Group A(n=30)
79.4
126.6 / 81
98.4
14.2
Group B (n=30)
77.03
127.53 / 84.33
98.5
13.8
Gr A: bupivacaine + normal saline, Gr B: bupivacaine+fentalnyl
Table -4 shows comparison of mean values of perioperative hemodynamic parameters in bothe the
groups.
Table5: Early intra operative hemodynamic parameters (mean)
Time (min)
Group A(n=30)
Group – B (n=30)
Pulse* SBP/DBP@
SPO2 %
RR#
Pulse*
SBP/DBP@
SPO2 %
RR#
5
80.73
131.8/84.3
99
13
97.06
123.4/76.13
99
13
10
77.33
114./46 / 79
98.5
13.5
81.76
115.33/74.36
98.5
13.5
15
75.13
108.9/73.67
99
13.5
77.8
113/88.26
99
13
20
77.13
110/73.4
99
13
76.76
111.46/74
98.5
13.5
25
76.67
111.73/76.67
98.5
13.5
80.26
117.53/78
99
13.5
30
80.67
114.6/74.8
99
13.5
78.93
120.73/77
99
13
45
89.53
123.8/77.34
99
13.5
78
118.13/76
98.5
13
60
87.33
120.86/84
98.5
13
77.5
117.4/76.8
99
13.5
Group A: bupivacaine + normal saline, Group B: bupivacaine + fentalnyl; *rate per minute;@Systolib BP / Diastolic BP
in mmHg; #Respiratory rete per minute
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Table 6 Early post-operative hemodynamic parameters (mean)
Time (min)
Group A (n=30)
Group B (n=30)
Pulse* SBP/DBP@
SPO2 % RR#
Pulse* SBP/DBP@ SPO2 % RR#
Imme diate in PACU 82.26
121.66 / 79.26 99
13.5
80.06
115.73 / 75.8 99
13
30
77.53
122 / 80.3
98.5
13
78.8
118.26/74.67 99
13.5
60
79.3
146.8/80.6
99
13.5
75.26
115.66/75
98.5
13
90
78.06
124.06 / 81.46 99
13
76.73
119.67/76.67 99
13.5
120
82.46
127.2/80.46
98.5
13.5
78.8
121.86/77.46 99
13
Group A: bupivacaine + normal saline, Group B: bupivacaine + fentalnyl; *rate per minute;@Systolib BP / Diastolic BP
in mmHg; #Respiratory rete per minute
Table 7 Comparison of analgesia, complications and response in both groups
Variable
Recovery and analgesia
Mean Time to feel first pain (T3)
Mena Time to feel unbearable pain or time of analgesic requirement (T4) - VAS > 25 mm
Duration of analgesia
T3 - T2
T4 - T2
Intraoperative complications
Hypotension (H)
Bradycardia (B)
Nausea and Vomiting (V)
Post-operative complications
Hypotension (H)
Vomiting (V)
Pruritis (Pr)
Urinary retention (RU)
Patient response (subjective)
Good
Fair
Poor
The table shows that there is no significant difference
in hemodynamic parameters in early intra-operative
period in both groups. Oxygen saturation and respiratory rate are unaffected in both groups. This suggests that even addition of 25 mcg fentanyl intrathecally does not cause respiratory depression and does
not alter hemodynamic parameters.
The time to feel first pain and time of analgesic requirement is prolonged significantly compared to
Group A in group B. (P < 0.001) Only 3 patients
were having urinary retention post-operatively. 2
were relieved with hot water and one patient was
catheterised. The patients were shifted to the ward
immediately as soon as unbearable pain is felt after
giving oral / parenteral analgesic. The patients’ response to intrathecal fentanyl 25 µg along with 0.5%
Bupivacaine was superior to plain 0.5% Bupivacaine
with 0.5 cc normal saline. (table -6)
DISCUSSION
Majority of studies for intrathecal fentanyl were done
for 10, 20 and 25 µg. In this study we selected 25 µg
fentanyl intrathecally20,28,30,18. Intrathecal route is better because drug is readily available in CSF to saturate opioid receptors in central nervous system, no
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Gr A(n=30) Gr B (n=30)
202 ± 9.8
234 ± 14.2
299 ± 17.3
364 ± 15.4
11.4
45.6
93
158.4
4
4
1
5
3
2
1 (3.33%)
1 (3.33%)
0
1 (3.33%)
5 (16.6%)
0
3 (10%)
2 (6.66%)
0
6
24
26
4
0
separate injection has to be given as the drug is injected with Bupivacaine 0.5% at the time of lumbar
puncture and low dose is needed. In our study there
was marginal difference between onset of sensory [ 7
± 2.4 min (A) vs 7.2 ± 3 min (B) ] and motor [8.6 ±
4.1 min (A) vs 8.4 ± 3.2 min (B) ] blockade between
group A and B. This suggests that onset of sensory
and motor blockade is not affected by addition of
fentanyl. H. Singh et al31,30 found that the onset of
bupivacaine induced spinal block was not enhanced
in fentanyl treated patients.
In our study the volume of drug was kept constant in
both groups and median block height was T 6 in both
groups27,30 (median range T 6-10 ). As the drug and
dose of Bupivacaine 0.5% heavy was similar for both
groups, block intensity as indicated by degree of motor blockade and time to reach highest sensory level
was unaltered in both groups. This suggested that
addition of fentanyl intrathecally with Bupivacaine
0.5% does not alter intensity of motor and sensory
blockade in SA. The judgement of sensory block as
per sensory scale3 is same in both groups (Table-5).
In our study the duration of sensory spinal blockade
as measured by 2 segment regression and S 2 segment
of wear off time in group A are considered standard
and compared with group B. The 2 segment sensory
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NATIONAL JOURNAL OF MEDICAL RESEARCH
wear off time was higher in group B compared to
group A. (P < 0.001) [150 ± 7.4 / 162 ± 8.2 and
180±12.4 / 206 ± 6.4], 12 and 14% respectively (Table-4). Thus initiation of sensory reversal begins at an
average 158 min. with 2.5 cc of 0.5% Bupivacaine
heavy35.
Roussel JR31 studied addition of fentanyl to Bupivacaine 0.5% for spinal blockade and concluded that
fentanyl does not enhance onset of sensory and motor block produced by 12.5 mg of intrathecal
Bupivacaine 0.5%. Our study goes parallel with his
conclusion. This suggests that addition of fentanyl
with Bupivacaine 0.5% intrathecally does not alter
onset of spinal blockade. The duration and recovery
time of motor blockade were almost equal in both
groups3 (Table-6). H. Singh et al31 found that addition of fentanyl 25 µg does not enhance onset of
sensory and motor block. The time required for 2
segment regression and sensory regression to L 1
dermatome was 74 ± 18 min and 110 ± 33 min vs 93
± 22 and 141 ± 37 min in group A with Bupivacaine
0.75% - 13.5 mg and group B with 0.75% - 13.5 mg
Bupivacaine + 25 µg fentanyl respectively (P < 0.05)
showing increased duration of sensory block in fentanyl treated patients.
Bruce Ben - David et al3 found that in patients receiving 0.5% 1 cc Bupivacaine and 0.5% 1 cc
Bupivacaine with 10 µg Fentanyl intrathecally in knee
arthroscopic surgeries, the mean times to two segment regression was 53 vs 67 min (P < 0.01) and 120
vs 146 min. (P < 0.05) respectively. Our study also
found significant difference (P < 0.001) in 2 segment
regression and S2 segment regression time.
Hypotension and bradycardia are normal physiological responses during spinal anaesthesia. In our study
we found that addition of fentanyl in group B does
not altered the hemodynamic parameters. We found
the higher incidence of hypotension in group B (5)
compared to group A (4). Incidence of bradycardia
was found more in group A (4) than group B (3).
This suggests that addition of fentanyl intrathecally
causes marginal hypotension as associated with SA.
The early intra-operative hemodynamic parameters
are depicted in graph and Table 8 and 9. (P > 0.05)
Shanon MT32 et al studied hypotension after intrathecal fentanyl with Bupivacaine 0.5% heavy and
observed that SBP and MAP decreased 10% and
14% respectively following intrathecal fentanyl. No
patient from either group needed any treatment for
hypotension. He concluded that intrathecal fentanyl
produces minimal hemodynamic changes with /
without prior fluid administration. The graph-I show
that pulse rate and BP are stable in both groups.
Respiratory rate and oxygen saturation are unaffected
in both groups implying that intrathecal fentanyl 25
µg is safe. Belzarena et al7 found that fentanyl > 0.5
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µg/kg intrathecally is associated with decreased respiratory rate and increased incidence of pruritis.
The early post-operative hemodynamic parameters
are depicted in graphII and table 10 show that these
parameters were stable in both groups. Assessment
of pain has always been troublesome for clinical investigators for years. Till today there is no reliable
method to evaluate pain. Wolfe stated, 'it is not easy
to measure something if one is not sure that one is
measuring'. This applies to whole field of pain management. As discussed earlier pain is notoriously
variable in different individuals and same surgical incision can elicit a several fold variation among different individuals. The easiest to use and most studied
tool is the Visual Analgesic Scale45 (VAS). It is a simple tool, which measures the subjective pain of the
patient at a given time. The scale consists of a ruler
with markings from 0-10 or 0-100. The patient is
asked to state their present perception of pain, assuming 0 to be no pain at all and 100 to be worst
possible they could imagine. The pain score before
and after treatment are useful to know the efficacy of
treatment modality as well as a research tool. VAS
was used for the assessment for depth of analgesia.
Post operative pain started at around 200 min in
group A which was considered as standard. After
this, all the patients were scrutinised every 15 min.
Main tool for assessment of analgesia were patients
facial expression, Hemodynamic data, respiratory
rate and SPO 2 , movement of limbs in bed, sedation
if present. Pain started at around 300 min group B.
The intensity of pain was highest for 93 minutes after sensory wear off in group B compared to group
A which was at 11.4 min. Patients in group B were
comfortable by look, vitals were stable, patients were
awake and able to move limbs in bed. An absolute
VAS score ≤25 mm was defined as an analgesic success. (Table-12)45. The mean value of SPO 2 was
comparable in both groups at different time intervals. None of the patients in any group showed hypoxia (SPO 2 < 94% for > 12 min/hr) at any time
during study. Our study correlates with Grant P
Raymer et al Wooper DW et al39. Who found that
intrathecal fentanyl upto 25 µg does not cause respirattory depression. The reasons may be interpreted
as- 1) Analgesia was excellent to adequate in group
B. 2) Study included minimal dose of fentanyl. 3) Patients were awake and comfortable in group B which
added safety factor in relation to respiratory depression. 4) The operations involving lower abdominal
organs, which excluded ribs, diaphragm or upper abdominal muscles, respiratory pattern and rate were
not altered at all.
A study of Herman NL16 et al, on analgesia, pruritis
and ventilation after intrathecal fentanyl concluded in
a dose response relationship of analgesia with the
drug, concluding higher the dose, more the complications. In this regard, S2 segment wear off time (T2)
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and time to feel first pain (T3) were suggesting requirement for analgesia as sensory blockade has been
reversed. But in group B, as addition of fentanyl
provided pain relief for some period after S2 segment wear off, time difference between T2 and T3
found more than that of group A. These values
showed pattern of A T3-T2 < B T3-T2 (Table-12), T 3 - T 2
for group A and group B were 11.6 min. and 93 min.
respectively. (Table-12). As personal interpretation,
expression and explanation of pain varied a lot, total
duration of post-operative analgesia is considered
from S2 segment wear off time (T 2 ) to requirement
of analgesic supplementation (T 4 ). This showed
group A T4-T2 < group B T4-T2 (Table-12) (P<0.01).
Hence post-operative analgesia due intrathecal drugs
administration i.e. T 4 - T 2 was found to be more in
group B than in group A. Ashok Kumar B, Newman
LM2 conducted a study for intrathecal administration
of fentanyl for post-operative analgesia and observed
the analgesia time of 94.5 min with 25 mcg Fentanyl
in 2.5 cc 0.5% Bupivacaine. Our study goes parallel
with their observations. Thus addition of Fentanyl
caused almost 4 times increase in total duration of
analgesia. (P < 0.01) The efficacy of drug is justified
by side effects and complications associated with it.
The patients were observed in PACU for most
common side effects of spinal anaesthesia and
opioids. The most common side effect of fentanyl
observed were hypotension, vomiting, urinary retention, respiratory depression, pruritis and sedation.
(Table-13). It was considered as fall in BP more than
30% of baseline which found in 3.33%(1) and 16.6%
(5) patients post-operatively in group A and B respectively. It is a known complication of SA, so
whether fall in BP occurred due to Bupivacaine 0.5%
or fentanyl is matter of debate. No patient required
any specific treatment. (P > 0.05) PONV after lower
abdominal surgery and SA are common complications which occurred in 3.33%(1) in group A but
none in group B. In contrast to I.V. fentanyl which is
usually expected to cause CTZ stimulation and vomiting, intrathecal fentanyl has opposite effect. None
of the patient in group B required antiemetic treatment for PONV23. It is a known complication of
spinal anaesthesia. In our study among group A and
B, 3.33% (1) and 6.66% (2) were having retention of
urine, respectively, 14 of our patients, had undergone
urosurgical surgery and they were catheterised intraoperatively, whether retention was due to SA or intrathecalfenttanyl is not concluded and yet to be followed up for more conclusion. 10%(3) of patients in
group B developed compared to group A in which
none complained the same. Patients were reassured
and I.V. injection chlorpheniramine maleate 22 mg
was given. It might have occurred as a part of pharmacological effect of fentanyl. In the study by
Vaghadiaet al41, pruritis was also found to be of mild
to moderate intensity. Bruce Ben David et al3,7 studied intratthecal fentanyl with Bupivacaine and found
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12% incidence of pruritis in patients. Out study parallels his study.
None of our patients had even mild degree of hypoxia during spinal anaesthesia. This suggested thatt
even 25 mcg fentanyl intrathecally does not cause
any degree of respiratory depression in patients. The
reasons may be-All surgeries were elective, All patients were ASA grade I and II, Patients were fully
awake, not sedated.,Fentanyl given intrathecally acts
on µ 2 opioid receptors (spinal cord) and not on µ 1
receptor (Brain). So respiratory depression does not
occur, the dose of fentanyl was 25 µg which is far
less to cause significant depression of respiration.
None of the patients in our study complained of
post-dural puncture head ache or transient neurological symptoms. Varassiet al42 demonstrated that
the subarachnoid administration of 25µg fentanyl
during spinal anaestthesia in non premedicated men
did not alter respiratory rate, end tidal CO 2 , minute
ventilation, respiratory drive and SPO 2 . Our study
correlates with this study.
CONCLUSION
It was concluded that - - There is no difference in
onset of sensory and motor blockade in both groups.
- The duration of motor blockade is unaffected by
the addition of fentanyl.The time to reach the highest
sensory level is same in both groups. The time of
sensory wear off was prolonged by fentanyl. Addition of fentanyl provides analgesia after reversal of
sensory blockade. Intra-operative hemodynamics
were unaltered even with addition of 25 μg fentanyl
in group B compared to group A, suggesting that
fentanyl provides hemodynamic stability without altering maximum block height.The incidence of
PONV is decreased in group B suggesting antiemetic
effect of intrathecal fentanyl. Acceptability amongst
patients in group B was very good as they were
awake, comfortable and satisfied compared to group
A suggesting good quality analgesia.
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ORIGINAL ARTICLE
SCIENTIFIC VALIDATION OF DISEASE DIAGNOSIS SYSTEM,
USINGHUMAN ENERGY FIELD (AURA) FOR GIT CASES
Rajeev Pahwa1, Uday Kumar Jejurikar2, Menka P. Kuril1, Barkha P. Kuril1
Authors’ Affiliations: 1Alternative Therapy Practitioner, Roopantaran Samajik Evam Jankalyan Sansth, Ujjain, 2 Professor, Dept. of Genera; Surgery, R. D. Gardi Medical College, Ujjain
Correspondence: Menka Kuril Email: [email protected]
ABSTRACT
Introduction: HEF or Aura is our spiritual signature. Traditionally, energy-field or aura is a protective psychic and spiritual energy field that surrounds the physical body. Energy from an aura is usually not static. It is
constantly flowing, flashing, vibrating, expanding, and decreasing. Biopulsar-Reflexograph is a modern day
instrument used as a human energy-field (Aura) measuring device, based on the latest computer technology
combined with the scientific basis of the biofeedback, reflex-zone and energy meridian teachings and with ancient healing sciences.
Methodology: The biofeedback system Biopulsar-Reflexograph is a highly sensitive, biomedical measuring
device, certified according to the European Guidelines for Medical Devices CE Class IIa. It is based on the
latest computer technology combined with ancient healing sciences. The biofeedback sensor is a receiver for
high-resolution, biomedical signals, which are taken from the reflex zones of the hand´s palm. For this particular study, we have compared general cases between the age group 20-80 years block as compare to prediagnosed cases of Dr. Uday Kumar Jejurikar. All these cases have been categorized into 10 divisions and 10
different organs are taken into consideration for the assessment of confirmation in gastro-intestinal system.
The study gives the confirmation on the cases prescribed by doctor.
Conclusion: It was found that the aura diagnosis machine helped a lot in confirmed diseased cases and its
symptoms diagnosis for GIT cases. The technology played major role in our research and helped in the validation of our age old traditional knowledge.
Key word: HEF, Aura, Gastro-intestinal System, Reflex Zones, Biofeedback, energy meridians, BiopulsarReflexograph.
INTRODUCTION
The aura is the multidimensional, invisible soul radiation of a person and consists of different vibrations.
The physical body does not radiate the aura as commonly supposed, but the aura contains the physical
body. The physical body is nothing else than condensed vibrations, which cannot be seen with the
normal eye. Biopulsar-Reflexograph is a highly sensitive, biomedical measuring device, offers dynamical
biofeedback of 43 organ reflex zones of the hand
and support a clear and detailed syndrome diagnosis.
The Biopulsar-Reflexograph not only expands your
energy analysis capabilities, allowing you to Identify a
wider range of existing and potential conditions,
which helps to improve patient's communication,
comprehension and case acceptance.
The word ‘biofeedback’ is an indication for biomedical control mechanisms. It is composed by the Greek
word bio = life, life processes and by the English
word feedback = reaction. Reflex zones are areas on
NJMR│Volume 6│Issue 1│Jan – Mar 2016
the skin surfaces, which have connections to the internal organs and body structures. For over thousands of years, Western and Eastern cultures have
applied the knowledge of reflex zones in diagnoses
and therapy. Indian and Chinese holistic healing
sciences assume that the hand reflex zones are not
only connected to the organs but also to the consciousness, the energy meridians, the energetic field
(Aura) and the chakras of a person. The interpretation of the energetic situation of a reflex zone serves
for diagnosis and therapy of the regulating state of
the internal organs and the psyche.
METHODOLOGY
Study Area – Patidar Hospital and Research Centre,
Ujjain. Before conducting the study, permission was
taken from Institutional Ethical Committee.
Study Population - We have totally observed 212
cases for this particular study and these cases are
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compared with total 100 control cases, including
both sexes, belonging to different caste, culture and
occupation within age range of 20 – 80 years.
Aura Picture
Study Tool - Biopulsar-Reflexograph
The Biopulsar-Reflexograph uses only low frequency
currents for the measuring of the skin resistance.
During the measuring, the body cannot be inflicted
with any harmful or disturbing impulses. Each of the
48 biomedical sensor pegs is an interface, conducting
the measured biofeedback parameters of each individual organ zone to the PC every 500 milliseconds
(synaptic real-time measuring). Then the data is
processed and presented by the software as biofeedback graphs, aura colors of the organs, dynamical
chakra activity and more.
A complex measuring of the whole body lasts about
1 minute. The patient does not have to undress. As
the therapist does not touch the patient, no outside
energies can influence the measuring of the patient’s
energy field. In a very short period of time, the therapist receives a clearly arranged individual syndrome
diagnosis of the entire organic network of the body.
Through the organ biofeedback and the dynamic aura of the whole body, the therapist can get precise
information concerning vitality as well as physical
and psychological constitutions.
Study Technique – We have totally observed 211
cases for this particular study and these cases are
compared with total 100 control cases, including
both sexes, belonging to different caste, culture and
occupation within age range of 20 – 80 years.
All these general and pre-diagnosed cases have been
categorized into 10 divisions and 10 different organs
are taken into consideration for the assessment of
diseased/ infected/ imbalance state of organ in Gastro-Intestinal System. It was imbalance of 10 organs
of GIT from esophagus to rectum except heart in
the presentation of diseases while recording.
The process of the graph, with its fine amplitudes, corresponds to the organic pulse wave. Vitality, pulse wave
and performance of the elements give information about the constitution of the organs as well as of the
whole body of the person. Therefore, you can derive the physical and psychological disposition of
diseases.Common Energy Patterns of the Biofeedback Graphs
Biofeedback amplitude ranges along
harmony line:
the green
Harmony, pleasant lightness, homeostasis, balanced organ
function. Ideal organ energetics.
Ayurveda: Tridosha balance = Vata – Pitta – Kapha in
harmony
Biofeedback graph drops precipitously into the grey
region:
Cannot maintain energy and expends it quickly. Rapid
exhaustion due to chronic weakness, particularly if stressed.
Emptiness – inflammation. Is open, unprotected, and
vulnerable. Tendency towards energetic emptiness = organ
coma, even shock!
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The biofeedback curve represents the
flow of life energy in the organ.
Harmony Line or Homeostasis
Organ
Total Case Studies
Organ
Esophagus
Stomach
Liver
Small Intestine
Colon
Rectum
Total
Total
35
70
20
16
45
26
212
RESULTS
General readings are selected randomly from the
common public, then compared and analyzed with
the pre-diagnosed cases of doctor. In general cases,
balanced state is more as compared to cases of diseased recordings.
Here, we are analyzing organs of GIT system, such
as, esophagus, stomach, small intestine, colon and
rectum. In our study, categorization is done on the
basis of primary complaints that the patient is coming up with to the doctor, which is compared with
the other main organs of GIT system.
Stomach/ 40-60/ Total -23 (in percentage)
Organ
Esophagus Heart Stomach Pancreas Liver Small In- Colon Rectum
testine
Balance state
5
5
14
9
27
26
13
21
Imbalance/Diseased
95
95
86
91
73
74
87
79
State
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In the above table, Pre-diagnosed cases of
stomach, age group 40-50, total cases 23 are
shown, and are compared with other organs of
GIT, and state of balance and imbalance are
analyzed. It shows that among 23 cases of
stomach, 86% confirmed cases were diagnosed
correct.
Energy Meridian
of Stomach
In this way, all the other organs are compared
simultaneously. The above table also shows
the multiple involvements of other organs in
cases of stomach.
Lastly, the figure shows the track of energy me-
The criteria for selection are as follows – For our
study, doctor used to note his observation about cases, on the basis of his pre-diagnosed GIT cases, and
then suggested the cases for aura diagnosis. They
were categorized on the basis of the organ diagnosed
by doctor. He did the assessment every 15 days and
on the basis of his observations, cross-confirmed his
diagnosis with aura observations given by Biopulsar-Reflexograph. On the basis of Dr. Uday Kumar
Jejurikar’s findings, he has given following conclusions.
“Firstly, it is observed that beyond 50 yrs, one infected organ affects multiple organs, so this gives us
a theory of multi-organ involvement i.e. whenever
patient complaints of any specific symptoms involved with certain organ, we should also look for
other organs for causes and their condition.
Secondly, high level of imbalance in pancreas again
gives us a very important study because this organ is
hidden behind the intestine, the posterior peritoneum. Normally, we are not able to look into the
diseased condition of this organ except in such a
graphic presentation where we are able to assess
pancreas by different tools and different methods.
Thirdly, the data seems to be extremely useful as it
proves beyond doubt that extremely diseased cases
of stomach and colon can be easily picked up by
Biopulsar graphical presentation. This was the most
important observation in the present study. This is
very rewarding for all of us that even if the patient is
complaining of the any specific organ, you can look
and compare the condition of other organs also.”
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CONCLUSION
Biopulsar-Reflexograph can be used as a disease diagnosis tool with an additional advantage that it
shows energetic organ changes long before a disharmony shows itself on the physical level. Therefore, it
can be used for the prevention of illness as well.
In a nutshell, this health management tool is of great
help in getting a preview of possible and probable
health conditions, before your body experiences
them in a physical way. The Aura scan machine also
gives you a quick snapshot of your individual chakras, your general aura and the vitality level of various organs in the body.
REFERENCES
1. Dr. Karl Erdt, Medical Doctor and Surgeon, Massing, Germany.
2. Pierrakos, J C (1977). The Core Energetic Process; New
York, Institute of the New Age (Monograph).
3. Pierrakos, J. C. (1971). The Energy Field in Man and Nature;
New York. Institute of Bioenergetic Analysis.
4. Brennan. B., Function of the Human Energy Field in the
Dynamic Process of Health, Health and Disease. New York,
Institute for the New Age, 1980.
5. Burr, H. S. 1944. “The Meaning of Bio-Electric Potentials”.
Yale J. Biol. Med. 16: 353-360.
6. Dobrin R., Conway (Brennan) B. and Pierrakos J., “New
Electronics Methods for Medical Diagnosis and Treatment
Using the Human Energy Field.”
7. Linda Ward, Rudolf Schinnerl, Karin Kraft. Biopulsar®
Technology Use in a Chinese Medicine Practice. Electrobiology Energy Therapy.
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ORIGINAL ARTICLE
EVALUATION OF STRESS URINARY INCONTINENCE
AMONG NON PREGNANT FEMALE PATIENTS IN A
TERTIARY CARE HOSPITAL
Shraddha Agarwal1, Ashwin Vacchani2, Jigisha Chauhan3, Sneha .C. Halpati4
Author’s Affiliations: 1Assistant Professor; 2Associate.Professor; 3Assistant Professor; 4Ex Senior Resident, Department
of Obst and Gynec, SMIMER, Surat
Correspondence: Dr. Shraddha Agarwal Email: [email protected]
ABSTRACT
Background: Urinary incontinence has been defined by the international continence society as a condition in
which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable. Stress urinary
incontinence is the most common form of transurethral urinary incontinence in women.
Objective: To study the probable etiological factors in diagnosed cases of Stress urinary incontinence among
non pregnant female patients attending outpatient department of Gynecology in SMIMER, Surat and to evaluate the cure rate of non-surgical and surgical treatment among them
Method:This study was conducted in the department of Obst amd Gynec, SMIMER, Surat from May2010 to
december2012. Non pregnant patients demonstrating SUI with full bladder were included in the study. Total
40 patients were studied.
Observation: Out of 40 cases 32 (80%) cases belonged to the age group of 40 to 59 years, 22 (55%) were in
peri-menopausal age group and the median parity of the patients was 3. Other important observation was that
29(54.7%) patients had associated utero-vaginal prolapse with SUI and maximum had third degree prolapsed.
Both non-surgical and surgical treatment was offered to patients with good results.
Conclusion: This study indicates that SUI is quite common in peri-menopausal age group, it has strong association with multi parity and UV prolapse. Non-surgical management is still the acceptable mode of treatment.
The TVT-O appears to be safe and effective surgical treatment for SUI.
Key words: Stress urinary incontinence (SUI), TVT-O, menopause, multi parity, Utero-vaginal prolapsed
Abbreviations: SUI stress urinary incontinence, UV
prolapse-uterovaginal prolapse, VH-vaginal hysterectomy, HRT-hormone replacement therapy, UTIurinary tract infection
INTRODUCTION
Definition of SUI- The international continence society defines stress continence as a symptom, a sign
and a condition. The symptom indicates the patient’s
statement of involuntary urine loss during physical
exertion, the sign is the objective demonstration of
urine loss from the urethra synchronous with a physical exertion and condition is called “Genuine” Stress
Incontinence and the urodynamic demonstration of
the loss of urine when intravesical pressure exceeds
the maximum urethral pressure in the absence of detrusor contraction.1
Urge Incontinence-Leakage of large amount of urine
at unexpected times, including during sleep. SUI results from the anatomic displacement of the UV
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junction and proximal urethra outside the normal intra-pelvic location above the urogenital diaphragm.2
There are three major determinants related to the
condition SUI. These include -1. The resting urethral
pressure 2.The pressure transmission ratio which is
the percentage of bladder pressure increase with
stress that reaches the urethra and is determined by
anatomic relationship.3.The amplitude of the rapid
increase in intra-abdominal pressure .Most of the
surgical procedures for SUI primarily affect pressure
transmission ratio. There are many factors responsible for loss for pelvic support which can lead to SUI.
These factors may be developmental weakness, child
birth trauma3, post menopausal estrogen deficiency4,
obesity5, spinal cord lesion6, UTI, drugs side effects7,
etc.
To demonstrate SUI, Stress Test is done in which
the patient with full bladder is asked to cough. If the
patient loses a spurt of urine synchronous with
cough and ending abruptly with cessation of cough,
almost certainly she has pure anatomical incontiPage 73
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nence. The investigations8 which may be needed in
the patient’s assessment are urine, routine, microscopic and culture sensitivity, USG9, uroflowmetry10,
cystometry10, urethral pressure and urethral closure
pressure profile10 etc. Urodynamic testing is not necessary in women with pure SUI(society of obstetrics
and gynecologists, canada2013)
There are various non-surgical and surgical methods
of treatment for SUI depending upon it’s severity.
Non-surgical methods include lifestyle changes,
pharmacological agents, prosthesis, Kegel’s exercises11, 12urinary bladder training etc. The latest surgical procedure for SUI are midurethral sling procedures13 which can be TVT (tension free vaginal tape) or
TVT-O (transobturator approach)14-17. TVT-O is
comparatively easier and has lesser complication rate.
METHODOLOGY
This prospective retrospective study was conducted
in dept. of Obst & Gynec, SMIMER Hospital, Surat
from May 2010 to Dec 2012. Total 40 patients were
studied fulfilling the inclusion criteria i.e. demonstrable SUI with comfortably full bladder & patient’s
consent for study .Patients with pregnancy, urge incontinence or voiding difficulty were not included.
All subjects were inquired for detailed menstrual &
obstetric history with special emphasis on the number and mode of delivery. Past history of bronchialasthama, bronchitis & chronic constipation was
looked for. H/O smoking, tobacco, antihypertensive
drug was noted. Detailed general, systemic &local
examination was done in all subjects . Local examination was done in dorsal position with comfortably
full bladder, after repositioning of utero-vaginal prolapse when the patient was asked to cough, a spurt of
urine through external urethral meatus on coughing
was considered as a positive objective evidence of
SUI. Thus SUI was confirmed by stress test.
Routine investigations were done for surgical fitness.
Special attention was given to urine analysis to exclude UTI. All patients were counseled and given option for non-surgical and surgical management of
SUI. In non-surgical methods antibiotics, HRT, local
estrogen, kegel exercises and Duloxetine was given
according to the need on outpatients bases. In surgical management TVT-O (trans obturator ap-
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proach) was done along with other surgeries like vaginal hysterectomy, anterior and posteiror colporrhaphy as needed. The time taken for TVT-O was noted
from opening to closure of the sub urethral vaginal
mucosa only.
Intra operative complications like heavy bleeding,
bladder injury, urethral injury etc were noted. Early
postoperative complication (up to 14 days) like
UTI,fever, local hematoma, urinary retention was
noted. The indwelling Foley catheter was removed
on the second post op day. On the day of discharge
the postvoid residual urine was measured which if
less than 100ml was considered normal. Patients
were followed on 7th post op day, at 3 months,6
months and 12 months after surgery. A negative
stress test was the objective measure of success used
in this study. The outcome of treatment was classified in four categories-cure of SUI, improvement,
failure and recurrence.
Cure of SUI after the procedure was defined as the
absence of a subjective complaint of leakage and absence of objective leakage on Stress Testing.
Improvement was defined as no urine loss on the
Stress Test plus the subject’s report of some leakage
but there was overall subject satisfaction.
Failure- No improvement or symptom aggravation.
Recurrence- The development of leakage again during the follow-up after initially achieving a cure.
The study was approved by institutional ethical
committee.
RESULTS
Out of 40 subjects the median age of the patients
was 46.5 years with the range between 35 to 56
years.32 patients(80%)belonged to age group of 40
to 59 years. The mean parity of the patient was 3
with the SD of 0.87. The median parity of the patient
was 3 with range between 2 to 5.28 patients (70%)
with SUI were third para or above. In our study
22(55%) of the subjects were in peri-menopausal age
group, which shows that SUI is quite common before menopause. According to the place of delivery
25(62.5%) of the subjects had home delivery leading
to repeated trauma to ligaments and hence and increased incidence of SUI.
Table 1: Distribution according to type of non-surgical treatment taken and its out come
Variable
Antibiotics (UTI)
HRT
No.
3
2
3 months
No SUI
No SUI
Duloxetine + exercise
7
3-not improved
2-partially improve
2-totally improve
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6 months
No SUI
1-No SUI
1-partially improve
2-surgical treat
2-loss of follow up
3-totally improve
12 months
No SUI
1-no SUI
1-loss to follow up
4-no SUI
3-loss to follow up
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Table 2: Distribution of subjects according to
intra-operative complications
Variable
Difficulty in passing needle
Excessive bleeding
Bladder/urethral injury
Total
No. (%)
3 (10.00)
2 (6.67)
0
5
Table 3: Distribution of subjects according to
objective assessment of SUI
Result of objective
assessment
No SUI
SUI present
Lost to follow-up
Not completed 12
months after treatment
Total
3
Months
38/38
00
02
00
6
Months
33/33
00
06
01
12
months
29/29
00
08
03
40
40
40
Table 4: Distribution of subjects according to
final outcome of surgery
Outcome
of surgery
Cure
Improved
Failure
Recurrence
3 months
(%)
34/38 (89.47)
4 (10.53)
0
0
6 months
(%)
31/33 (93.55)
2 (6.45)
0
0
12 months
(%)
29/29 (100)
0
0
0
We found that , 29(54.7%)of subjects had associated
urogenital prolapse which may be due to common
etiological factors like trauma due to repeated child
birth.13 out of 40(32.5%) had 3rd degree uterineprolapse ,while 9 out of 40(22.5%)had second degree
prolapse, 13(24.5%) subjects had isolated SUI,27
subjects(67.5%)had a cystocele with SUI. As seen in
table-1, out of 40 patients 12(30%) had non-surgical
management and 28(70%) had surgical management.
Out of 12 managed conservatively,3 was given antibiotics for UTI,2 were given HRT for menopausal
symptoms and 7 were treated with tablet Duloxetine
+ Kegel exercise. After 12 months, 8 patients were
totally improved of which 2 had surgery due to intolerance to Duloxetin & 4 subjects lost to follow up.
TVT-O was done for SUI alone or along with concomitant surgery like VH, NDVH, ant colporraphy,
AP repair etc. The intra-operative time taken for
TVT-O in 21 subjects (70%) was 5-10 minutes, in 4
subjects (13.34%) time taken was 10 -15 minutes, only in 5patients more than 15 min were taken. As
shown in table 2,
Intra-operative complications noted were difficulty
in passage of needle (in 3 patients i.e.10%)
&heamorrhage (in 2 patients i.e. 6.67%).No case had
bladder or urethral injury. Early post operative complications were urinary retention & fever. Late post
operative complications were tape erosion, groin
NJMR│Volume 6│Issue 1│Jan – Mar 2016
pain, dyspareunia & de novo urgency. The median
hospital stay of the patient was 4 days with range of
2 to 5 days. After surgical and no-surgical treatment,
patients were followed at 3 months, 6 months and 12
months. As shown in table 3, all patients examined at
3 months (n=38), 6 months (n=31) & 12 months
(n=29) showed no objective evidence of SUI when
they were examined in supine as well as erect position ,giving an objective cure rate of 100%.
As shown in table4, at three months follow up,
34/38 subjects (89.47%) were completely cured i.e.
they neither had subjective nor objective evidence of
SUI and 4/38 subjects (10.53%) had improvement
i.e. though subjectively they reported some degree of
urinary incontinence, there was no evidence of SUI.
At 6 months, 31 out o 33 available subjects had cure,
2 out of 31(6.45%) had improvement. And at 12
months follow up, 29 out of 29 available subjects
had cure.
DISCUSSION
In our study maximum number of subjects
(45%)were from 40-49 years which indicates increased incidence of SUI in the elderly women which
can be due to decreased urethral vascularity and abnormal smooth and skeletal muscle efficiency resulting in low resting urethral pressure and abnormal
stress response. 70% subjects had parity of 3 and
above indicating SUI more common in mutiparous
patients. This is because repeated vaginal deliveries
causes damage to pelvicfloor and permanent elongation of pubourethral supporting ligaments. In our
study SUI was common in premenopausal and
postmenopausal suggesting estrogen deficiency to be
the cause of SUI. SUI was associated with uterovaginal prolapse in 54.9% cases, in which 3rd degree
utrine descent was most common. This association
could be because the contributory factor to both has
been seen to be multi-parity leading to repeated
trauma during child birth.
Out of 12 subjects who accepted medical treatment 8
subjects were completely improved. Most common
concomitant surgery associated with TVT-O was
VH+AP repair (11 subjects that is 36.7%). In 70%
patients TVT-O was completed in 5-10 minutes with
minimal complications. So TVT-O is a relatively safe
surgery as far as intraoperative complications are
concerned.The false passage was the only intraoperative complication noted in 3 subjects(1o%) which
was slightly higher as compared to studies of TeoR
etal14 (4.9%), Sola et al15 (0%), and Lim et al17 (0%).
None of the subject had an objective evidence of
SUI on 3, 6 and 12 months follow up-giving cure
rate of 100%.
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CONCLUSION
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8.
DC Dutta : Textbook of Gynec (3rd ed.),New Delhi ,JayPee
Pblisher,1994. P-358
This study of Evaluation of SUI indicates that SUI s
9. Shashi Gupta.PK Gupta:Perineal @ introital sonography for
quite common in perimenoposal age group, assoevaluation of SUI.obs&gynec today vol-3 no, 10 ,oct
ciated with multi parity and utreovaginal prolapse.
1998,626-627
Non-surgical management is still the acceptable 10. Emil A tanagho, marsell I Stoller;Urodynamic cystometry
mode of treatment. The TVT-O appears to be a safe
and urethral closer pressure profile, urogynecology and uroand effective surgical modality of treatment and can
dynamic, theory and practice (3rd ed), William & wilkins,
1991,122-142.
be performed with other gynec surgery.
REFERENCES
1.
L. Lewis Wall. Urinary stress incontinence Te-Linde’s Operative Gynecology, 10th edition.Lippincott Williams & Wilkins;
2012. p 942-959.
2.
Richard C. Bump: Urinary tract disorders. Post reproductive
Gynecology; 1990.p 301-354.
3.
Dietz HP, Bennet MJ, The effect of child birth on pelvic
organ mobility,Obstet gynecol 2003; 102;223.k
4.
Grodestein F, Lifford K, rensik NM et al Postmenopausal
hormone therapy and risk of developing urinary incontinence,obstet gynec 2004; 103; 254.
5.
Sudak LL, whitcomb E shen H et al Weight loss; a novel and
effective treatment for incontinence, journal urol 2005; 174:
190.
6.
Narender N. Bhatia: Neurologogy and Dynamics sphincter
electromyography and electrophysiologocal testing. Urogynecology and Urodynamics; Theory and practical, 3rd Edition, William & wilkins, 1991, 143-162
7.
Viktrup I bump RC, Pharmological agent used for treatment
for stress incontinence ,Curr med res opin, 2003;19;485
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11. Kegel AH progressive resistant exercise in the functional
restoration of perineal muscle. Am jour obs gynec,
1948;56:238
12. Kegel AH. Stress incontinence of urine in women; physiologic treatment. J int coll, surg,1956;25,p 487
13. Nicolette s horback; suburethral sling procedura; urogynaecology and urodynamic theory and practice, William & wilkins, 1991,102-107
14. Teo R:randomized trial of TVT and TVT-O for the treatment of female incontinence,2nd ed urodynamic stress incontinence in women;Eur Urol,2003,44:724-730
15. Vicente Sola; TVT vs. TVT-O for minimally invasive surgical
correction of SUI; international Braz J Urol, vol 33 (2),
March April 2007. 246-253.
16. Nader gad: The TVT-O procedure with the cough test in
theatre; Pelviperineology, a multidisciplinary pelvic floor
journal, 2008.27:135 to 138.
17. Lim J, Cornish A, Carry M: clinical and quality of life outcomes in women treated by TVT-O.BJOG 2006;113: 13151320
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ORIGINAL ARTICLE
INCIDENCE AND TREATMENT ABANDONMENT IN TEEN
AND YOUNG ADULT CANCERS
(Col) Prakash.G Chitalkar1, Rakesh Taran2,. Prashant Kumbhaj3, Deepak Singla3
Author’s Affiliations: 1Professor; 2Associate Professor; 3Senior Resident, Department of Medical Oncology, Sri Aurobindo Institute of Medical Sciences,Indore,Madhya Pradesh
Correspondence: Dr Prashant Kumbhaj Email: [email protected]
ABSTRACT
Background: The cancer patterns in teen and young adults (TYA) differ from those in children and older
adults. The incidence of those affected is increasing rapidly although this has not been much focus of attention in cancer control and prevention .Treatment abandonment is the common problem in teen and young
adult cancer patients, reasons of treatment anandonement varies depending upon socioeconomic background.
Material and method: It is a a retrospective observational study and data were collected from records of
TYA Patients registered from January 2013 to December 2015 at cancer center Sri Aurobindo Medical College and postgraduate Institute Indore. TYA Patients age between 15 to 39 were included in the study. The
cases were analyzed for Age, sex, number of cases year wise , diagnosis of malignancy according to international classification of disease (ICD),number of undiagnosed and abandoned cases .The findings were compared with other similar studies
Results: On analyzing data of three years ,hematolymphoid malignancy(28%) cases are the most common
cases seen followed by Breast (10%) and head and neck (10%),cervix(6%),CNS(5%) ,Bone( 4%). 38% TYA
cancer patients abandoned treatment . Telephonic tracking, financial support, counseling of whole family are
methods employed in reducing abandonment.
Key words- Teen and young adolescents, hematolymphoid cancer,treatment abandonment.
INTRODUCTION
Patients aged 15 to 39 years old at their initial diagnosis constitute the adolescent and young adult
(TYA) cancer population, which includes approximately 700,000 patients diagnosed each year, or 2
percent of all invasive cancers diagnosed and less
than 10 percent of all cancer survivors1 .The cancer
pattern in Teen and young adults (TYA) differ from
those in children and older adults 1.The cancers involved are more likely related to genetic predisposition, specific health behavior / lifestyle among young
people exposing themselves to causative agents2.
When diagnosed,TYA suffer from adverse psychosocial effects 3. Survival rates for AYAs have not
improved to the extent that they have for younger
children or older adult cancer populations 4. Some
data suggest that the poorer outcomes in AYAs (particularly those with colon or breast cancer) are in part
related to their biology, including different genomic
risks, tumor histopathology, oncogenic pathway deregulation, and chemotherapy sensitivities 5,6.In addition, there appears to be a tendency for AYA patients to be diagnosed at later stages compared with
older patients 7,8. Although the incidence of invasive
NJMR│Volume 6│Issue 1│Jan – Mar 2016
cancer in AYAs is lower than in younger children or
older adults, the psychosocial needs of AYAs often
exceed those seen in older adults. TYA suffer from
adverse psychosocial effects because most of their
potential years of life ahead of them has to be spent
with effects of cancer, its treatment or tragically
shortened lives with major repercussions on their
families and society in general2-3The psychosocial effects has components of worry about recurrence,
hypervigilance about symptoms, concerns about
family and finances, and the stress of managing
health needs, as well as changes in self-perceptions,
body image, and feelings of vulnerability. Treatment
abandonment is the common problem in teen and
young adult cancer patients ,reasons of treatment
anandonement varies from psychological issues to
socioeconomic background.The incidence of those
affected is increasing rapidly although this has not
been much focus of attention in cancer control and
prevention 11.We have done a retrospective observational study of incidence and treatment abandonment TYA cancer patient’s at Sri Aurobindo Medical
college ,Indore.
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METHODOLOGY
It is a retrospective observational study and data
were collected from records of TYA Patients registered from Jan 2013 to December 2015 at cancer
center Sri Aurobindo Medical College and postgraduate Institute Indore.It is a medical college hospital
including a multi disciplinary cancer centre. Patients
from 17 districts have access to this centre.TYA Patients age between 15 to 39 were included in the
study.The cases were analyzed for Age, sex,year wise
number of cases, diagnosis of malignancy,number of
undiagnosed and abandoned cases .The findings
were compared with other similar studies. Institutional ethical clearance was obtained for conducting
this study.
Approximately 800 new cancers patients present to
this centre every year. During years 2013, 2014 and
2015 a total of 2376 patients with a cancer diagnosis
were enrolled for a cancer diagnosis, out of which
947 were TYA age group. The median age was 22
years (range 2-87years), 591 were males and 356 females, 604 from rural background and 343 from urban background.
Table 1 shows Age, sex, socioeconomic status wise
proportion of TYA patients. It also shows socioeconomic background of abandoned TYA patients. Of
947, TYA patients 62% were male and 38% female .
Table 1: TYA Patients demographics
Abandoned at Diagnosis
and therapy
Male (%)
60(10.0)
67(11.0)
110(19.0)
140 (23.0)
214 (36.0)
591(62.0)
Urban(%)
343(36.0)
Urban(%)
56(15.0)
Female(%)
50(14.0)
40(11.0)
70(20.0)
90(25.0)
96(27.0)
356(38.0)
Rural(%)
604(64.0)
Rural(%)
312(85.0)
Table 2: Showing total number & types of TYA
cancer cases
TYA Cancer
Total
Hematolymphoid(C-81-96)
Head & Neck (C-00-14)
CNS (C-71)
Breast (C-50)
Cervix (C-53)
Bone (C40-41)
Undiagnosed
Abandoned
In males 36 % were in the age group of 35-39, much
more amenable to factors of lifestyle.Followed by 23
% in the age group of 30-34 yrs, while in female 27%
in age group of 35-39 yrs, followed by 25% in the
age group of 30-34 yrs.
Table 2 TYA Cancers shows data about site wise
TYA cancer patients coming to SAIMS Year 2013,
2014, 2015,number of patients abandoned diagnosis
and therapy .On analyzing data of three years
,hematolymphoid malignancy (C-81-96) (28%) cases
are the most common cases seen followed by breast
(C-50) (10%) and head and neck(C-76) (10%), cervix
(C-53) (6%), CNS (C-72) (5%), Bone (C40-41) (4%).
Surprisingly 38% TYA cancer patients abondoned
treatment.
DISCUSSION
RESULTS
Age in Years
15-19
20-24
25-29
30-34
35-39
Total
Socioeconomic Status
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2013
267
80(38.0)
23(8.0)
16(6.0)
20(8.0)
7(2.0)
7(2.0)
114(36)
137(52)
Figure in parenthesisi indicate percentage.
2014
337
69(21.0)
27(8.0)
19(6.0)
30(9.0)
26(7.0)
20(6.0)
146(43)
151(47)
NJMR│Volume 6│Issue 1│Jan – Mar 2016
2015
343
120(35)
40(12.0)
15(5.0)
40(12.0)
25(7.0)
13(3.0)
90(26)
80(23)
Approximately 69,212 adolescents and young adults
(AYAs) ages 15–39 were diagnosed with cancer in
20119.It is six times the number of cases diagnosed
in children ages 0–14. Specific cancer types incidence
varies dramatically across the TYA age continuum.
Leukemia, lymphoma, testicular cancer (germ cell
tumors), and thyroid cancer are the most common
cancer types in younger TYAs (15–24 years old). By
ages 25–39, breast cancer and melanoma comprise a
growing share of cancers among TYAs10. Transitions
in anatomy, the evolving hormonal milieu, maturing
development, increase demand in work place, family
responsibility and acquiring new lifestyle and habits
in a particular region before the old do and also the
short period of exposure between the beginning of
life and cancer diagnosis giving rise to unique cancer
pattern in TYA11.There is increase use of tobacco
and alcohol in both genders with onset of this habit
at very young age especially in low socioeconomic
group. Majority of our patients belong to rural background socioeconomic group. The incidence is increasing faster than the increase in either children or
older adults and not been much focus of attention in
cancer control and prevention11.The risk factors responsible in this age group are infection, adolescent
growth spurts, hormones, growth and development
factors associated with genetic predispositions . This
is the age of cross over from predominance of nonepithelial cancers in childhood to predominance of
epithelial cancers in older adults 11.
In our study hematolymphoid cancer is the most
common in TYA 28%,breast and head and neck
both comprising 10% of total AYA population followed by Cervix cancer(6%) and CNS tumors(5%).
The pattern of incidence of TYA is quite similar in
our study compare to TYA cancer showing in SEER
data .Our study is showing hematolymphoid cancer
as a maximum diagnosis in TYA Population whereas
SEER data also showing leukemia lymphoma as
maximum no of cases. In compare to germ cell tuPage 78
NATIONAL JOURNAL OF MEDICAL RESEARCH
mor and thyroid cases which are common in 15-24
years in SEER Data , our study does not have such
cases. After hemotolymphoid case our study has
breast and head & neck cases in majority which has
been also supported by SEER Data.In our study
head and neck cases are also common in TYA population but this is not shown as a common cancer in
AYA population in SEER data. This is due to very
common practice of chewing tobacco and smoking
habits in Indian population. In contrast to SEER data we don’t find any melanoma cases in our study
which is very rare in Indian population. Our study
showed 38% TYA cancer patients abandoned treatment . Abandonment of treatment is very common
in Indian TYA population. The reason behind in
most of the cases are lack of awareness, lack of financial sources for treatment , distance, lack of
transportation facility , cultural beliefs. 85% abandoned cases were of rural background, where as 15%
cases were from urban background. Abandonment in
rural areas is particularly frequent ( 85%) ,and is consequent to factors like, close and hierarchical family
structure, interdependency of the extended family.
and inability to multi task, while balancing the pressure of cancer and the need to earn a living . In contrast, the urban patient tend to manage the pressure
of keeping treatment appointments and other needs,
due to inherent lifestyle characteristics and better resources and awareness and fear of loosing fertility are
some reasons for treatment delay and abandonment .
In low- and middle-income countries, treatment abandonment has been consistently reported as an important contributor to treatment failure and
death12,13.
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lowed by breast and head and neck both comprising
10% of total TYA patient population.Abandonment
of treatment is very common in TYA population due
to lack of awareness, Distance ,lack of transportation
, lack of financial sources for treatment and cultural
beliefs.
REFERENCES
1.
Bleyer A, Viny A, Barr R (2006). Cancer in 15 to 29 years
olds by Primary site. Oncol, 11, 590-601
2.
Cancer incidence in young adults.Special topic from Canadian Cancer Statistics 2002. 2003-2005 National Cancer Institute of Canada (Last updated on 09 August 2003).
3.
Vickie Williams (2005). Cancer in young adults. Oncology,
50. (9/12/2009
4.
Bleyer A, O'Leary M, Barr R, et al. Cancer epidemiology in
older adolescents and young adults 15 to 29 years of age, including SEER incidence and survival: 1975 - 2000. Bethesda,
MD, National Cancer Institute, 2006. NIH Pub. No. 06-5767
5.
Blanke CD, Bot BM, Thomas DM, et al. Impact of young
age on treatment efficacy and safety in advanced colorectal
cancer: a pooled analysis of patients from nine first-line
phase III chemotherapy trials. J Clin Oncol 2011; 29:2781.
6.
Bleyer A, Barr R, Hayes-Lattin B, et al. The distinctive biology of cancer in adolescents and young adults.Nat Rev Cancer
2008; 8:288.
7.
Hubbard JM, Grothey A. Adolescent and young adult colorectal cancer. J Natl Compr Canc Netw 2013;11:1219.
8.
Steele SR, Park GE, Johnson EK, et al. The impact of age on
colorectal cancer incidence, treatment, and outcomes in an
equal-access health care system. Dis Colon Rectum 2014;
57:303.
9.
An estimated projection calculated by the Surveillance, Epidemiology and End Results (SEER) Program using SEER
18, 2007-2011.
Table.2 shows percentage of abandoned cases declining per year, as in 2013 total abandoned cases were 10. Data from the SEER Program.1975-2000.
52% of TYA Population followed by 47% in 2014
Wu, Frank D Groves, Colleen C Mclaughlin, et al
and 23% in 2015. There is thus a declining trend in 11. Xiaocheng
(2005). Cancer incidence patterns among adolescents and
abandonment on preliminary analysis among TYA
young adults in the united states. Cancer Causes Control, 16,
cancer patients at our centre .Telephonic tracking,
309-20.
financial support, counseling of whole family are me- 12. Gupta S, Yeh S, Martiniuk A, Lam CG, Chen HY, Liu YL, et
thods employed in reducing abandonment.
al. The magnitude and predictors of abandonment of therapy
CONCLUSION
This epidemiological study helps to know the incidence of cancer and treatment abandonment in AYA
in the western part of the Madhya Pradesh. Hematolymphoid cancer is the most common in TYA fol-
NJMR│Volume 6│Issue 1│Jan – Mar 2016
in paediatric acute leukaemia in middle-income countries: A
systematic review and meta-analysis. Eur J Cancer. 2013.
Epub 2013/04/20. doi: 10.1016/j.ejca.2013.03.024 .
13. Arora RS, Eden T, Pizer B. The problem of treatment abandonment in children from developing countries with cancer.
Pediatr Blood Cancer. 2007;49(7):941–6. Epub 2007/01/26.
doi: 10.1002/pbc.21127.
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ORIGINAL ARTICLE
A RADIOGRAPHIC STUDY OF RIB ANOMALIES IN
PATIENTS OF VARIOUS CHEST DISEASES BELONGING TO
NORTH INDIAN POPULATION AT A TERTIARY CARE
CENTRE
Darshan K Bajaj1, Shailesh K Singh2, Abhishek Dubey3, Anand Srivastava1, Surya Kant4, Ajay K Verma1, Ved Prakash5, Mona Asnani6
Author’s Affiliations: 1Assistant Professor, 3Research Associate; 4Professor; 5Associate Professor, Dept. of Respiratory
Medicine; 2Assistant Professor, Dept. of Radio-diagnosis; 6Assistant Professor, Dept. of Obstetrics & Gynaecology, King
George’s Medical University, Lucknow
Correspondence: Dr Surya Kant Email: [email protected]
ABSTRACT
Background:Though congenital rib anomalies are reported to be of rare occurrence, these are now and then
encountered as an incidental finding in chest X-rays, however in most of these cases patients are having other
health issues rather than things directly related to the rib anomalies.
Aims: The aims of the study were to observe the detection rate of various kinds of rib anomalies, their
association with gender, body side, other thoracic bony anomalies and associated symptoms.
Material and methods:5,000 plain chest skiagrams were studied including 2,628 males and 2,372 females
from September 2013 to September 2015.
Results:Out of 5,000 total patients 82 patients (1.64%) were found with cervical rib, 22 patients out of 82
were having bilateral cervical rib(0.44%), bifid ribs were found in 59 patients(1.18%) out of which 3 patients
(0.06%)were having both the anomalies, only one patient was seen with fused rib(0.02%),one with two ribs
having less space in between(0.02%) and one patient was having rib with spur(0.02%). The occurrence
(detection rate) of cervical rib on either side as well as bilaterally was higher in males. Bifid rib detection rate
was higher on the right side in males and on left side in females.None of these patients were having any
symptom related to their rib anomalies.
Conclusion: there was a little higher detection rate seen regarding the presence of cervical rib in north Indian
population however it was observed that the symptoms reported in literature in relation to the rib anomalies
seemed to be overreported.
Key words: Cervical rib,bifid rib,anomalies,supernumerary
INTRODUCTION
Though congenital rib anomalies are reported to be
of rare occurrence, these are now and then
encountered as an incidental finding in chest X-rays,
however in most of these cases patients are having
other health issues rather than things directly related
to the rib anomalies. “Cervical or neck rib” is an
extra or supernumerary rib which is generally smaller
and runs from 7th cervical vertebra to the first true
rib or to the sternum but usually it is present
posteriorly to a short distance. It is present since
birth but is usually incidentally diagnosed until and
unless it is a cause of neurovascular compression at
the thoracic inlet with which it has an inconstant
association of roughly 10%.1 Sometimes diagnosis of
NJMR│Volume 6│Issue 1│Jan – Mar 2016
cervical rib is difficult when just a fibrous band is
present. Many times the treating clinician may miss
this incidental finding as he is more focused towards
his area of interest. “Bifid rib” or bifurcated rib or
sternum bifidum is a congenital abnormality of rib
cage in which muscles and nerves can also be
involved although rarely and occurs in about 1.2% of
humans.The sternal end is cleaved into two parts and
it is almost always unilateral. In samoans i.e a
polynesian ethnic group of the samoan islands
sharing genetics, language history and culture the
occurrence of bifid ribs was seen upto 8.4%.2 Bifid
ribs doesn’t cause any symptoms usually and are
often incidentally discovered like cervical ribs on
chest skiagrams however very rarely effect of this
neuroskeletal anomaly can include respiratory and
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neurological difficulties. Another association of this
anomaly has been seen with jaw cyst and may
become a part of nevoid basal cell carcinoma
syndrome. Other anomalies of the ribs may include
fusion of adjacent ribs, supernumerary intrathoracic
and transthoracic ribs have also been described
previously although very little data and research is
available. Purpose of the study was to study the
detection rate of various kinds of rib anomalies, their
association with gender, body side, other thoracic
bony anomalies and associated symptoms in studied
subjects.
METHODOLOGY
After taking ethical clearance from institutional etical
committee(IEC) of the institute, a careful thorough
examination of 5,000 chest skiagrams was carried out
inclusive of 2,628 males and 2,372 females.The
subjects were patients who presented to the
department of respiratory medicine for various chest
related ailments or referrals during the period from
September 2013 to September 2015. All the
radiographs were seen thoroughly on a view box
with systematic approach, the skiagrams were seen
combinedly by chest specialist and radiologist
(Department of Radiodiagnosis) from the same
institute. Chest radiographs were especially seen for
the presence of congenital rib anomalies, the other
structural deformities secondary to the respiratory
diseases were not included in the study however
those patients were dealt carefully for their ailments.
The data regarding age, sex and presence of cervical
rib, bifid rib, fused ribs and any other suspected
deformity was taken into account. The data analysis
was done using Pearson's chi-squared test applying
statistical setting at p<0.05 using SPSS.
Settings and Design:A hospital based cross
sectional study
Statistical analysis used: Pearson's chi-squared test
applying statistical setting at p<0.05 using SPSS.
RESULTS
In 5,000 studied subjects, 82 patients (47 males and
35 females) were seen with cervical rib. Cervical rib
was seen on right side in 28 patients (17 males and
11 females) and on left side in 32 patients (18 males
and 14 females). Cervical rib was seen bilaterally in
22 patients (12 males and 10 females). A total of 59
patients out of all studied subjects were having bifid
ribs. In these 59 patients, 33 patients were males
while 26 patients were females. Bifid rib was seen on
right side in 36 patients (22 males and 14 females)
and on left side in 23 patients (11 males and 12
females). Only 3 patients were having presence of
both the bifid and cervical ribs and all of them were
males. One male patient was seen with fused rib on
the right side and one male patient was seen with
reduced intercostal space in between two ribs on
right side in total studied population.One patient was
having rib with spur in same population. The
occurrence (detection rate) of cervical rib on both
sides as well as bilaterally was higher in males(Table
1). Bifid rib detection rate was higher on the right
side in males and on left side in females (Table 2).
Table 1: Cervical rib analysis (N=5000)
Subjects with cervical rib
Number (%)
Total
82(1.64)
Bilateral
22(0.44)
Right side
28(0.56)
Left side
32(0.64)
OR=Odds ratio, CI=Confidence interval
Male (%)
(n=2628)
47(1.79)
12(0.46)
17(0.65)
18(0.68)
Females (%)
(n=2372)
35(1.47)
10(0.42)
11(0.46)
14(0.59)
OR (CI)
p-Value
1.22(0.78-1.89)
1.08(0.467-2.512)
1.40(0.653-2.990)
1.16(0.576-2.341)
0.384
0.852
0.386
0.675
Table2: Bifid rib analysis
Subjects with bifid rib
Number (%)
Total
Right side
Left side
59(1.18)
36(0.72)
23(0.46)
Male (%)
(n=2628)
33(1.25)
22(0.84)
11(0.42)
DISCUSSION
Congenital rib anomalies are reported to be of rare
occurrence 3Cervical rib or neck rib is
asupernumerary rib which arises from the costal
element of the seventh cervical vertebra.4-6It is
usually an incidental finding on chest skiagrams. The
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Females (%)
(n=2372)
26(1.09)
14(0.59)
12(0.50)
OR (CI)
p-Value
1.15(0.684-1.924)
1.42(0.726-2.785)
0.83(0.364-1.877)
0.602
0.302
0.649
detection rate of cervical rib has been seen in
different population like prevalence in a London
population was 0.74% out of 1,352 chest radiographs
examination.7 In a chennai population based study
the percentage of its occurrence was 1.16%.8Other
studies done on central Indian population and
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NATIONAL JOURNAL OF MEDICAL RESEARCH
Population around Lucknow claimed the incidence
to be 1.2%and 0.6%respectively.9-10 According to the
embryologists it is reported to be present always in
fetuses and disappears just before birth.11
Association of cervical rib with Thoracic Outlet
Syndrome (TOS) is reported which is claimed to be
overdiagnosed and underdiagnosed by few authors.
In general the clinicians have a lack of knowledge
regarding the rib anomalies, they may discover it
incidentally but have least of idea as to what to do
further and may probably correlate them with
something they are not associated with, sometimes
patients are referred from these practitioners giving a
lot of undue importance to the anomalies making the
patients unnecessarily anxious, coming to cervical rib
which has been found to be associated with TOS
which is a term used to describe a group of disorders
occurring due to compression, injury or irritation of
nerves and/or blood vessels in lower neck and upper
chest area, this syndrome can be due to presence of
an extra first rib or collarbone fracture, apart from
these other risk factors include tumors or enlarged
lymph nodes, injury to shoulder, neck or back,
improper weightlifting, defective postures and sleep
disorders. The signs and symptoms of TOS are pain,
tingling and numbness. Pain of TOS is to be
differentiated from angina pain which worsens on
walking or exertion in the latter whereas increases on
raising the affected arm in the former. TOS most
commonly affect the nerves however uncommonly it
may affect veins and arteries. The arterial TOS is
least common but most serious. Most of the cases of
neurogenic TOS, which is the most common of the
three, respond to physiotherapy and pain relieving
medications, surgery may be required in a few cases.
Cervical ribs can also cause symptoms by
compression of subclavian artery causing ischaemia
of the arms and brachial plexus causing neurogenic
symptoms.4,5 Pain is the main symptom and
treatment ranges from conservative to surgical
resection depending on the severity and vascular
symptoms like ischaemia.5,6Cervical ribs are reported
to be associated with brachial plexus pathology in
infants, studies are ongoing regarding the association
of childhood cancer and cervical ribs. Bifid rib or
sternum bifidum is a congenital abnormality of the
anterior chest wall with the sternal end cleaved into
two. It is frequently asymptomatic and like the
cervical rib it is too an incidental finding on the chest
skiagram however very rarely effect of this
neuroskeletal anomaly can include respiratory and
neurological difficulties. The estimated overall
prevalence of bifid rib is 0.15% to 3.4% and it
accounts for 20 percent of all congenital rib
variations.12Since the rib has mesodermal origin,
malformation in organs like heart and kidney may be
associated
congenital
anomalies.13
Another
association of this anomaly has been seen with jaw
cyst and may become a part of Gorlin-Goltz
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syndrome
(nevoid
basal
cell
carcinoma
syndrome).13,14 Apart from these well known rib
anomalies there can be presence of supernumerary
ribs, short ribs, defect in bone density and abnormal
rib shapes.15We observed cervical ribs, bifid ribs,
fused rib, rib with spur and ribs with lesser
intercostal space in between in our study of 5,000
subjects. The clinical significance of the rib
anomalies lies in the fact that though they are
uncommonly related with neurogenic or vascular
implications but their association can’t be denied and
if the patients presents to the clinician with
symptoms as described above then one should look
for these anomalies. Secondly this study gives an
insight to the clinicians about the detection rate of
rib anomalies and other very rare associations like
that of bifid rib with the Gorlin-Goltz syndrome.
Some other anomalies were also found which were
probably seen for the first time and the previously
reported literature doesn’t give much detail about
them.The patients presenting to the clinicians with
rib anomalies are from different backgrounds, there
are many patients in which it is incidentally
discovered, these patients have come to consult the
clinician for something else, some patients come to
the doctor specifically questioning for the rib
anomalies, these are the candidates who should be
appropriately counselled,reassured and can be
advised to avoid sports injuries and defective
postures which apart from cervical rib are other risk
factors for TOS.
CONCLUSIONS
Few relevant conclusions were drawn from this study
like the detection rate of cervical ribs unilateral as
well as bilateral was higher in north Indian
population(1.64%) than the previously reported data
in available literature. Its possible explanation may be
missing out of these incidental findings by the
treating doctors who are rather more focused for
their area of interest. Bifid rib detection rate (1.18%)
co-related with the previously reported literature and
was found mostly on the third and fourth ribs on the
right side. No significant difference was observed in
detection rate of cervical &bifid rib between studied
male and female subjects. Rest of the congenital
anomalies are extremely rare, none of the patients
had any complaints in relation to the rib anomalies
which suggests that the previous literature for
association of cervical rib with thoracic outlet
syndrome may be overreported so most of the times
the patients who present to the doctor with the
incidental rib anomalies may be simply reassured. No
association of rib anomalies with other thoracic bony
anomalies was observed except that both cervical rib
and bilateral rib were found in 3 patients.
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REFERENCES
1.
Leffert RD. Thoracic outlet syndromes. Hand Clin. 1992;
8:285-297.
2.
Michael P McKinley,Valerie Dean O'Loughlin. Human
Anatomy,2nd ed . Newyork, US: McGraw-Hill; 2008. p 214.
3.
4.
5.
6.
Galis F. Why do almost all mammals have seven cervical
vertebrae?Developmental Constraints,Hox genes, and
cancer.JExpZool. 1999; 285:19-26.
Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer
PS Jr. Thoracic outlet syndrome: A controversial clinical
condition. Part 1: anatomy, and clinical examination/
diagnosis. J Man ManipTher. 2010; 18:74-83.
Ravikumar BL, Jose V. Francisco Menezes. “Cervical RIBUpper Limb Ischaemia”. J. Evolution Med. Dent. Sci.2014;
3:1732-38.
Cooke RA. Thoracic outlet syndrome-aspects of diagnosis
in the differential diagnosis ofhand-arm vibration
syndrome. Occup Med (Lond). 2003; 53:331-336.
7.
Brewin J, Hill M, Ellis H. The prevalence of cervical rib in
London population. Clin Anat.2009; 22:331-336.
8.
Venkatesan V,Prabhu KP, Ram Kumar B, Joseph C
Incidence of cervical rib in Chennai population World J.
Med. Sci.2014; 10 : 250-253.
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9.
Sharma DK, Vishnudutt, Sharma V, Rathore M. Prevalence
of ‘Cervical Rib’ and its association with gender, body side,
handedness and other thoracic bony anomalies in a
population of central India. Indian Journal of Basic and
Applied Medical Research. 2014; 3:593-597.
10. Gupta A, Gupta DP, Saxena DK, Gupta RP. Cervical Rib:
It’s prevalence in Indian Population around Lucknow(UP).
J. Anat. Soc. India .2012 ; 61: 189-191.
11. Keith L. Moore. The Developing Human-Clinically
oriented Embryology,7thed.Philadelphia, US :Saunders;
2003. p393.
12. Charles I, Scott J. Pectoral girdle, spine, rib and pelvic
girdle,1sted.New York,US :Oxford University Press; 1993.
p655.
13. Song WC, Kim SH, Park DK, Koh KS. Bifid rib:
Anatomical considerations in three cases. Yonsei Med J.
2009; 50:300-303.
14. Scheepers S,Andronikou S- Beware the bifid rib! SA Journal
of Radiology. 2010;4:104.
15. Glass RB, Norton KI, Mitre SA, Kang E. Pediatric ribs: A
spectrum of abnormalities.Radiographics. 2002;22:87-104.
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ORIGINAL ARTICLE
STUDY OF CLINICAL PROFILE AND COMPLICATIONS OF
DENGUE FEVER IN TERTIARY CARE HOSPITAL OF PUNE
CITY
Pradnya Mukund Diggikar1, Prasanna Kumar Satpathy1, Gaurav Dinesh Bachhav2,
Kanishka Dinesh Jain2, Anuja Mukesh Patil2, Prafull Chajjed2
Author’s Affiliations: 1Professor; 2Resident, Dr. D. Y. Patil Medical College and Research Centre, Pune
Correspondence: Dr Pradnya Mukund Diggikar Email: [email protected]
ABSTRACT
Background: Dengue is an important mosquito borne infection in terms of morbidity and mortality. In recent years it has become a major public health concern. The present study was conducted with an objective to
study to the clinical profile, laboratory profile and presentations of dengue fever.
Methodology: The study was conducted in Padmashree Dr.D.Y.Patil hospital and Research center, Pimpri,
Pune from June 2011 to October 2013. A total number of 50 adult patients were included and their clinical
and laboratory profile are noted.
Results: The various symptoms associated were fever (100%), myalgia (80%), Arthralgia (46%), Retero orbital
pain (26%), vomiting (22%), skin rashes (22%), headache (20%), bleeding tendancies (10%), Malena (12%),
hematuria (6%), altered senses (2%). In this study, 92% (46 cases) recovered, whereas mortality was noted in
remaining 8% (4 cases), the cause of mortality being MODS and ARDS.
Conclusion: Fever was the most common symptom followed by myalgia, arthralgia, retero-orbital pain, vomiting, skin rashes, headache, malena, and hematuria. The most common age group affected was 21-30 years
with male preponderance.
Key words: Dengue fever, clinical profile, laboratory profile
INTRODUCTION
Dengue is an important mosquito borne infection in
terms of morbidity and mortality. In recent years it
has become a major public health concern. The dengue virus is a anthropod borne virus arbovirus, belonging to the family Flaviviridae and genus Flavivirus. It is a mosquito borne viral infection and is
transmitted, primarily by Aedes aegypti and sometimes by Aedes albopictus.1 Dengue is caused by four
distinct serotypes of viruses; DEN-1, DEN-2, DEN3 and DEN- 4.2 Dengue virus causes a spectrum of
illness ranging from inapparent, self-limiting classical
dengue fever (DF) to life threatening dengue hemorrhagic fever (DHF) and dengue shock syndrome
(DSS).2
From being a sporadic illness, epidemics of dengue
have become a common occurrence worldwide.
Dengue fever and dengue hemorrhagic fever is endemic in areas of South East Asia i.e. Bangladesh,
India, Indonesia, Maldives, Myanmar, Srilanka and
Thailand. Dengue is a major cause of hospitalization
and death, especially among children in these regions.3
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India is endemic for DF and DHF. All the four serotypes are found in the country. Case fatality rates in
endemic countries are 2.5%.3 During epidemics of
dengue, attack rates among susceptible are 4090%.The incidence of dengue and global distribution
of dengue have greatly increased in recent years.4 The
present study was conducted with an objective to
study to the clinical profile, laboratory profile and
presentations of dengue fever.
METHODOLOGY
The study was conducted in Padmashree
Dr.D.Y.Patil Hospital and Research Center, Pimpri,
Pune from June 2011 to October 2013. A total number of 50 adult patients were included in this study.
Adult male and female patients having the clinical
manifestations of dengue fever as mentioned in the
clinical case definitions of dengue with serological
evidence in the form of dengue IgM or both IgM
and IgG positive by MAC-ELISA, and/ or dengue
Ns1 antigen were included in the study. Dengue positive patients less than 12 years of age were excluded.
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Patients who were IgG positive but IgM negative;
that is those who did not have recent evidence of
dengue infection were excluded from the study. A
written informed consent of each patient at the time
of admission was obtained.
Patients who were seropositive for dengue were classified on the basis of WHO criteria as follows: Dengue fever (DF), Dengue fever with unusual bleed
(DFB)-bleeding tendencies not satisfying WHO criteria for DHF, Dengue Haemorrhagic fever (DHF)including patients with Fever, Haemorrhagic manifestations including a positive tourniquet test, Thrombocytopenia and Haemoconcentration and Dengue
shock syndrome (DSS)-DHF along with evidence of
peripheral circulatory failure.
The patients were assessed for their demographic
features (age/sex etc.) and clinical profile (various
signs and symptoms). Patients of DHF and DSS
were closely monitored for the progression of fever,
blood pressure, level of consciousness, hydration,
and bleeding tendency; and the complications occurring at any stage were studied.
Hess’s capillary fragility test was performed in all the
patients. The patients were subjected to usual laboratory tests like, Hb, TLC, DLC, Haematocrit, Platelet
count, Liver function tests, Renal function tests, PT,
Serum Proteins like serum albumin, urine routine
and microscopy. Their ECG’s and CXR were also
studied. Serological confirmation of dengue was
done with the help of MAC-ELISA kit (PAN-BIO)
which gave titres for dengue IgG and IgM. For the
Ns1 antigen detection the commercial platelet Dengue Ns1 Ag EIA assay (Bio rad) kit was used.
RESULTS
Among the 50 cases, total of 12% cases were noted
in the month of July, 36% cases were noted in the
month of August and 30% in September respectively. It is clear that majority of the cases have occurred
during the months of July, August and September
i.e., in the monsoon and post- monsoon season.
There were 37 males (74%) and 13 females (26%)
were observed and the male:female ratio was found
to be 2.84:1. From table 2 and graph 2, it is clear that
majority of the cases having dengue infection belong
to the age group of 21-30 years, wherein 38 % belong to 21-30 years age group and 30% belong to 3140 years age group and 28% belong to the age group
of 11-20 years.
It was seen that all the cases had fever (100%), myalgia (80%), arthralgia (46%) and retro-orbital pain
(26%) (Table 2). The duration of fever varies from 29 days, where maximum cases (34%) presented with
5 days of fever.
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Table 1: Age wise distribution of dengue positive
cases (n=50)
Age group
11 – 20 yrs
21 – 30 yrs
31 – 40 yrs
41 – 50 yrs
Male
11
13
12
1
Female
3
6
3
1
Total (%)
14 (28)
19 (38)
15 (30)
2 (4)
Table 2: Symptom wise presentation of cases
Symptoms
Fever
Myalgia
Arthralgia
Headache
Retro orbital pain
Vomiting
Skin rashes
Bleeding tendencies
Abdominal pain
Malena
Hematuria
Altered senses
Frequency (%)
50 (100)
40 (80)
23 (46)
10 (20)
13 (26)
11 (22)
11 (22)
5 (10)
5 (10)
6 (12)
3 (6)
1 (2)
Table 3: Platelet level among the dengue suspected cases
Platelets range
Less than 20000
20000 -40000
40000 – 60000
60000 – 80000
80000 – 100000
1 - 1.2 Lac
1.2 - 1.4 Lac
Above 1.4 La
Frequency (%)
2 (4)
5 (10)
14 (28)
12 (24)
6 (12)
5 (10)
2 (4)
4 (8)
Table 4: Clinical Spectrum of Dengue cases
Diagnosis
Dengue Fever
Dengue Shock Syndrome(DSS)
Dengue Haemorrhagic Fever (DHF)
DSS +AKI
DSS+DIC+ARDS
DSS+ARDS
DSS+MODS
P.Vivax + Dengue Fever
No (%)
38 (76)
2 (4)
5 (10)
1 (2)
1 (2)
1 (2)
1 (2)
1 (2)
It was found that 24% of cases had platelets in the
range of 40-60 thousand and 4% of cases had severe
thrombocytopenia (platelets <20,000) (Table 3).
It is seen that 76% of the cases had Dengue fever,
12% cases had Dengue Dengue Sock Syndrome,
10% had Dengue haemorrhagic fever, 2% had dengue fever associated with plasmodium vivax malaria
(table 4). Outcome of Dengue cases shows that improvement was observed in 92% of the cases and
death was observed in 8% and the relation between
them was not significant (p > 0.05).
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Diagnostic evaluation shows that 74% of the cases
were positive for Ns1 antigen testing method and
52% cases were positive for Dengue IGG and IGM
antibodies and the relation between them was significant (p < 0.05). Temperature distribution shows that
36% cases had temperature of 1000 f, 28% of cases
had temperature of 990f and 24% cases had temperature of 1010f.
DISCUSSION
The South East Asian regions have recorded increasing incidence of dengue and have contributed to the
major portion of global disease burden. Dengue hemorrhagic fever and dengue shock syndrome are endemic to these regions and pose a severe threat to
global health. The most common age group affected
in this study was 21 – 30 years (21- 30 = 38%). This
was comparable to the study of Sing NP5, where the
mean age of the patients was 26 +/- 10 years. Similar
study done by Joshi PT6, revealed that all age groups
and both the genders were affected equally 33.3%.
However other studies of Gore MM7 and Dash PK
et al2 revealed a high number of cases in the pediatric
age group. This indicates that the virus had been introduced to a non-exposed population and disease
was not endemic.
In this study the disease was more seen in case of
males (74 %) than to the females (26 %). This was
corresponding to the other studies by Dash PK et al2
and Neeraja M et al1. The reason for this may be due
to more exposure of the males to the bite of vector
Aedes aegypti, due to their clothing habits or outdoor activities. In this study, total of 92% (46 cases)
recovered whereas mortality was observed in 8% (4
cases), in comparison with Agarwal A8, where mortality of 6% was observed. In the the study done by
Singh N P5, a mortality of 2.7% was observed.
This was corresponding to the study done by Neerja
M et al1 where the patients with dengue infection
manifested with DF (85%), DHF (5%) and DSS
(10%). The study done by Pancharoen et al9 showed
more number of DHF and DSS patients and less
number of DF patients . The study done by Aggar-
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wal et al8 showed 67% of cases of DHF and 33% of
cases of DSS.
CONCLUSION
Fever was the most commonest symptom followed
by myalgia, arthralgia, retero-orbital pain, vomiting,
skin rashes, headache, malena, hematuria. The most
common age group affected was 21-30 years with
male preponderance. Maximum number of patients
was observed to have Dengue fever, whereas the incidence of Dengue hemorrhagic fever and Dengue
shock syndrome was comparatively less.
REFERENCES
1. Neeraja M, Lakshmi V, Teja VD, Umabala P and Subbalakshmi MV.Serodiagnosis of dengue virus infection in patients presenting to a tertiary care hospital. Indian J Med Microbiol 2006; 24: 280-2.
2. Dash PK, Saxena P, Abhavankar A, Bhargava R and Jana
AM. Emergence of dengue virus type 3 in Northern India.
Southeast Asian J Trop Med Public Health 2005; 36: 370-77.
3. Park K. Epidemiology of Communicable Diseases. In: Park’s
textbook of Preventive and Social Medicine. 19th ed. Jabalpur, India: M/s Bhanarsidas Bhanot; 2007: 206-9.
4. Chaturvedi UC, Shrivastava R. Dengue hemorrhagic fever: A
global challenge. Indian J Med Microbiol 2004; 22 (1): 5-6.
5. Sing NP, Jhamb R, Agarwal SK, Gaiha M, Dewan R, Daga
MK. The 2003 outbreak of dengue fever in Delhi, India.
South east Asian J Trop Med Public Health 2005; 36 (5):
1174-78.
6. Joshi PT, Pandya AP and Anjan TK. Epidemiological and
entomological investigation in dengue outbreak area of Ahmedabad district. J Commun Dis 2000; 32 (1): 22-27.
7. Gore MM. Need for constant monitoring of dengue infection. Indian J Med Res 2005; 121: 9-12.
8. Aggarwal A, Chandra J, Aneya S, Patwari AK and Dutta AK.
An epidemic of dengue hemorrhagic fever and shock syndrome in children in Delhi. Indian Pediatr 1998; 35: 727-32.
9. Panchareon C and Thisyakora U. Neurological manifestations in dengue patients. Southeast Asian J Trop Med Public
Health 2001; 32 (2): 341-45.
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ORIGINAL ARTICLE
A STUDY OF VISUAL PROBLEMS IN CHILDREN SCORING
LOW GRADES AND THOSE WITH LACK OF
CONCENTRATION AT SCHOOL IN PUNE CITY
Radhika Ramchandra Paranjpe1, Rupali Darpan Maheshgauri2, Shraddha Ramadhar Yadav3,
Bhargav Jitendra Kotadia4, Nimrita Gyanchand Nagdev4, Kanisha Girish Jethwa4
Author’s Affiliations: 1Assistant Professor; 2Associate Professor; 3Intern; 4PG Student, Dept. of ophthalmology,
Dr.D.Y.Patil Medical College, Pimpri, Pune
Correspondence: Dr Radhika Ramchandra Paranjpe Email: [email protected]
ABSTRACT
Background: A good vision is important for a student to reach his/her full academic potential. Roughly 80
percent of what a child learns in school is information that is presented visually, hence good vision is essential.
Methodology: The present study was a cross-sectional study conducted on 100 children within the age group
of 5 to 10 completed years and scoring low grades at school exams. The study was conducted with the help of
predesigned semi-structured questionnaire which was to be filled by parents. The selected students also undergone vision testing, Colour vision testing, refractive errors, Anterior and Posterior segment examination,
squint evaluation by us.
Results: Out of the 100 children, 35% children were without any eye problem whereas 65% children showed
some kind of vision related problem. It was seen that 55% boys had vision problems compared to 45% in
girls. The major visual problems are allergic conjunctivitis (15%), Myopia (22%), convergence weakness
(22%), squint (4%) and hypermetropia (4%). Roughly 60% parents were aware about some vision problem in
their child.
Conclusion: Of 100 students with low performance in our study, 65% had treatable visual problems. The
low performance can be attributed to the low vision but long term follow up is needed to see the improvement in scores and studies.
Key words: visual problem, school children, low grades
INTRODUTION
A good vision is important for a student to reach
his/her full academic potential. Roughly 80 percent
of what a child learns in school is information that is
presented visually, hence good vision is essential.1
Children may suffer from myopia, hypermetropia or
astigmatism which are refractive errors. These can be
corrected with eye glasses or contact lenses. Deficits
of functional visual skills can cause blurred or double
vision, eye strain and headaches that can affect learning.2 Convergence insufficiency is a specific type of
functional vision problem that affects the ability of
the two eyes to stay accurately and comfortably
aligned during reading. Visual perception includes
understanding what you see, identifying it, judging its
importance and relating it to previously stored information in brain.3 Colour blindness can also cause
problems if colour matching or identifying specific
colours is required in classroom activities. For this
reason, a colour blind examination should be done
prior to starting school.4
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The U.S. Individuals with Disabilities Education Act
(IDEA) says learning disabilities do not include
learning problems that are primarily due to visual,
hearing or motor disabilities.5 Mental retardation and
emotional disturbances are also excluded as learning
disabilities, along with learning problems related environmental, cultural or economic disadvantage. But
specific vision problems can contribute to a child’s
learning problems, whether he has been diagnosed or
not diagnosed as a “learning disabled”. In other
words, a child struggling in school may have a specific learning disability,a learning related vision problem or both. 6
Early recognition and referral to qualified professionals for evidence based evaluations and treatments are necessary to achieve the best possible outcome. The present study was conducted with an objective to identify children with learning disabilities
or those with poor grades in school by means of a
questionnaire and subject them for eye examination
and evaluate which ocular problems are predominant
in that group.
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MATERIALS AND METHODS
DISCUSSION
The present study was a cross-sectional study conducted on 100 children within the age group of 5 to
10 completed years. The study was conducted with
the help of predesigned semi-structured questionnaire which was to be filled by parents. The students
which were selected for the study were those who
scored low grades at school exams. The selected students also had undergone vision testing, Colour vision testing, refractive errors (myopia, hypermetropia, and astigmatism), Anterior and Posterior
segment examination, squint evaluation by us. Children with the known history of suffering from Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, Dyslexia and Learning disabilities
were also included in the study. This was done to
conclude whether poor performance was due to vision problems or other learning disability. Children
above 10 years and less than 5 years of age, without
valid consent and scoring high grades at school are
excluded from the study. The study was conducted
in June-July 2014. The Institutional ethics committee
clearance was undertaken before beginning the study.
During ophthalmic examination, 63 children gave
vision on Snellens chart, 12 gave on Kay picture
chart and the rest were not co-operative for vision. A
total of 22 myopes were found of which 17 were using spectacles already but 6 of which were old
glasses. Four children were given spectacle correction. A very high percentage of children suffering
from allergic conjunctivitis were found in our study
(15%) who was irritable and constantly rubbing their
eyes which led to led to lack of concentration. They
were treated with anti-allergic and lubricating eye
drops. Four children suffering from squint were given spectacle correction and one was advised pencil
push up exercise. Two children had hypermetropia
which was corrected with glasses and occlusion therapy. However the improvement of performance in
school needs to be followed up long term. Similar
to7 other studies, the childs IQ score was not taken
consideration in our study. Moreover since our study
group consisted of normal school children, congenital ocular abnormalities, optic atrophy and nystagmus
were not found.
RESULTS
CONCLUSION
Out of the 500 questionnaire which was distributed
in the school to be filled by parents and teachers, 130
children were evaluated as slow learners. Among
these 130 students, 100 turned at the OPD of our
hospital of ophthalmic examination. This indicates
lack of awareness or interest in parents. The eye
problem of the participants is as shown in table 1.
Of 100 students with low performance in our study,
65% had treatable visual problems. The low performance can be attributed to the low vision but long
term follow up is needed to see the improvement in
scores and studies.
Table 1: Proportion of students having visual
problems (n=100)
Eye problem
Normal
Allergic conjunctivitis
Myopia
Convergence weakness
Squint
Hypermetropia
Number
35
15
22
22
4
2
Out of the 100 children, 35% children were without
any eye problem whereas 65% children showed some
kind of vision related problem. Selection of children
for eye examination was based on the questionnaire.
About 65% were selected on the basis of question
filled by the parents and remaining 35% by the help
of information provided by the questionnaire filled
by teachers. It was seen that 55% boys had vision
problems compared to 45% in girls. Roughly 60%
parents were aware about some vision problem in
their child.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
REFERENCES
1. Emerson E, Robertson J. Estimating prevalence of visual
impairment among people with learning disabilities in the
UK. University:Centre for Disability Research, 2011.
2. Emerson E, Hatton C. People with Learning Disabilities in
England.CeDR Research 2008.
3. Joint Committee on Human Rights. A life like any other? the
Human rights of adults with learning disabilities,2008.
4. Sellar W. Who should care for people with learning disabilities.BMJ 2000;321:1297.
5. Emerson E,hatton C.Estimating the current need/demand
for support for people with learning disabilities in England.Lancaster,2004.
6. Rourke,B.P.”Neuropsychological Assessment of Children
with Learning Disabilities:Measurement Issues.”
7. Gogate P, Soneji FR, Kharat J, Dulera H, Deshpande M,
Gilbert C, Gogate P, Soneji FR, Kharat J, Dulera H, Deshpande M, Gilbert C. Ocular disorders in children with learning disabilities in special education schools of Pune, India.
Indian J Ophthalmol 2011;59:223-8.
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ORIGINAL ARTICLE
A STUDY ON COMPARISON OF INTRAVENOUS
BUTORPHANOL WITH INTRAVENOUS FENTANYL FOR
PREMEDICATION IN GENERAL ANESTHESIA
Hemangini M Patel1, Bansari N Kantharia2
Author’s Affiliations: 1Associate Professor; 2Additional Professor, Dept. of Anesthesia, Government Medical College,
Surat, Gujarat
Correspondence: Dr Hemangini M Patel Email: [email protected]
ABSTRACT
Background: An ideal premedicant drug is anxiolytic, sedative, amnesic, reduces salivary and respiratory tract
secretions, analgesic as well as residual post-operative analgesia. The present study was undertaken to compare
the effects of intravenous butorphanol and intravenous fentanyl as a premedicant drug in general anesthesia.
Methodology: A comparative study between butorphanol and fentanyl was conducted in 100 patients of either sex at Government Medical College, Surat who belong to ASA physical status I or II, in the age group of
18-65 years. Post-operatively respiratory rate, tidal volume, sedation score, oxygen saturation and assessment
of pain score was done in the recovery room.
Results: When comparing both the groups the patients in the butorphanol group were found to be more sedated upto 60 minutes postoperatively. The difference between the two was statistically significant (p<0.001).
In group F, 82% patients had analgesia for 60-120 minutes while remaining 18% of patients had analgesia for
121-180 minutes. In group F, 44% patients had analgesia for 121-180 minutes while 56% of patients had analgesia for 181-240 minutes. In group F, 82% patients had pain (VAS ≥5) by 30 minutes in the postoperative
period whereas none of the patients in Group B had significant pain (VAS ≥5) by 30 minutes.
Conclusion: We conclude that Butorphanol 20 µg/kg gives better attenuation of the hemodynamic response,
longer duration of postoperative pain relief, without producing excessive sedation and with negligible side effects in comparison with fentanyl 1 µg/kg when given intravenously as premedicant for general anesthesia.
Key words: Premedicant, fentanyl, butorphanol, general anesthesia
INTRODUCTION
Premedication refers to the administration of drugs
before induction and maintenance of anesthesia.1 An
ideal premedicant drug is anxiolytic, sedative, amnesic, reduces salivary and respiratory tract secretions,
analgesic as well as residual post-operative analgesia.2
Although morphine like alkaloids had been used for
analgesia and sedation for centuries, the problem
with these drugs were respiratory depression, addition, nausea and vomiting.3 These side-effects were
overcome by the introduction of mixed agonistantagonist opioid analgesics like butorphanol. Butorphanol is a morphinan chemically related to analgesic
levorphanol. It is considered to be safer than pure
agonist opioids because of their ceiling effect for
respiratory depression and their lower addiction potential. Butorphanol also produces significantly lesser
gastrointestinal effects like nausea and vomiting than
morphine. Moreover, it produces neither pruritis nor
urinary retention.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
The present study was undertaken to compare the
effects of intravenous butorphanol and intravenous
fentanyl as a premedicant drug in general anesthesia.
The hemodynamic response to laryngoscopy and intubation, the effects on respiration as well as postoperative sedation and analgesia were evaluated.
METHODOLOGY
A comparative study between butorphanol and fentanyl was conducted in 100 patients of either sex at
Government Medical College, Surat. All the patients
belonged to ASA physical status I or II, in the age
group of 18-65 years. Informed consent was obtained from all the subjects. Patients with liver, renal
or hematological disease, females of childbearing age,
and patients with a history of tolerance of or dependence on narcotic drugs and those judged to be mentally of limited competence, with poor physical sta-
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tus, neurosurgery and cardiac surgery were excluded
from the study.
On the day before operation, preoperative assessment was carried out. A complete systemic examination was carried out, to rule out any major systemic
dysfunction. All the patients were premedicated with
Inj.Glycopyrrolate 0.2 mg intramuscularly half an
hour before induction of anesthesia. In the preoperative holding area vital signs and tidal volume
were noted. All the patients were familiarized with
the visual analogue scale. Patients were randomly divided into two groups of 50 patients each. Two minutes before induction of anesthesia, patients received the study drug.
In Group B: Inj.Butorphanol 20 ug/kg intravenously
In Group F: Inj.Fentanyl 1 ug/kg intravenously
Induction of anesthesia was done with
Inj.Thiopentone sodium 4-7mg/kg intravenously upto to the loss of eyelid reflex followed by tracheal intubation facilitated with Inj.Succinylcholine 2mg/kg
i.v. Anesthesia was maintained with 60% nitrous
oxide in oxygen, isoflurane and Inj.Vecuronium
bromide. At the end of the procedure, residual neu-
romuscular blockade was reversed with Inj. Neostigmine 0.05 mg/kg intravenously and Inj. Glycopyrrolate 0.008 mg/kg intravenously.
Intra-operatively, pulse rate, oxygen saturation via
pulse oximetry, systolic and diastolic blood pressure
were monitored continuously. Post-operatively respiratory rate, tidal volume, sedation score, oxygen saturation and assessment of pain score was done in the
recovery room. Presence of any adverse effects was
noted following direct questioning of the patients in
the recovery room. Sedation was assessed on the basis of Ramsay scale of sedation score and pain was
assessed on the basis of visual analogue scale.
All the patients were interviewed 24 hours after the
operation in the ward to get the information regarding their experiences of post-operative pain and adverse effects if any.
RESULTS
In the fentanyl group, the mean age was 31.48±13.12
years and in Butorphanol group, the mean age was
25.56±7.78. Other parameters are as depicted in Table 1.
Table 1: Physical parameters of the study groups
Parameters
Age (yrs)
Weight (Kg)
Male
Female
Duration of Surgery (min)
Duration of anesthesia (min)
Group F
31.48±13.12
48.8±8.54
22 (44)
28 (56)
73.4±24.92
88.4±23.89
Group B
25.56±7.78
51.1±11.1
22 (44)
28 (56)
86.11±37.98
99.44±40.42
P value
>0.05
>0.05
Table 2: Postoperative sedation score
Parameters
Baseline
2 min after premedication
Postoperative
0 min
30 min
45 min
60 min
90 min
120 min
180 min
Group F
1.98 ±0.14
2.00 ±0
Group B
1.96 ±0.19
2.00 ±0
P value
>0.05
>0.05
2.12 ±0.59
1.94 ±0.55
2.04 ±0.19
2.00 ±0
2.00 ±0
1.98 ±0.14
2.00 ±0
2.90 ±0.30
2.72 ±0.45
2.26 ±0.53
2.04 ±0.34
1.98 ±0.32
2.00 ±0
2.00 ±0
<0.05
<0.001
<0.001
<0.05
>0.05
>0.05
>0.05
The mean pulse rate before the administration of
premedication was 89.54 15.2 in Group F and 91.98
13.91 in Group B. The difference between the
groups was statistically insignificant. (p>0.05) On
comparing the two groups, the rise in pulse rate was
more in the fentanyl group compared to the butorphanol group. The difference between the two
groups was statistically significant for upto 5 minutes
NJMR│Volume 6│Issue 1│Jan – Mar 2016
after intubation (p<0.01). Thereafter it was insignificant upto 30 minutes (p>0.05). In postoperative period also, the increase in the mean pulse rate in fentanyl group was highly significant compared to butorphanol group (p<0.001).
The mean respiratory rate before the administration
of premedication of drug was 17.92±1.51 in Group
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F and 18.00±2.21 in group B, which was statistically
comparable (p>0.05). Postoperatively, there was insignificant difference between mean respiratory rate
between the two groups for various time intervals for
3 hours. (p>0.05)
The mean tidal volume before the administration of
premedication was 472±59.0 ml in group F and
451±62.2 ml in group B, which was statistically
comparable (p>0.05). In the postoperative period,
no statistically significant difference was observed
between the two groups at various intervals of time
(p>0.05)
When comparing both the groups the patients in the
butorphanol group were found to be more sedated
upto 60 minutes postoperatively. The difference between the two was statistically significant (p<0.001).
Thereafter the difference was insignificant upto 3
hours postoperatively.
Table 3: Assessment of total postoperative pain
by visual analogue scale
Time
0
15
30
45
60
90
120
180
>180
Group F (%)
9 (18)
19 (38)
13 (26)
5 (10)
3 (6)
1 (2)
-
Group B (%)
4 (8)
7 (14)
10 (20)
9 (18)
12 (24)
8 (16)
In group F, 82% patients had analgesia for 60-120
minutes while remaining 18% of patients had analgesia for 121-180 minutes. In group F, 44% patients
had analgesia for 121-180 minutes while 56% of patients had analgesia for 181-240 minutes. In group F,
82% patients had pain (VAS ≥5) by 30 minutes in
the postoperative period whereas none of the patients in Group B had significant pain (VAS ≥5) by
30 minutes (Table ).
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minutes and in Group B it was 208±29.57 minutes.
The total requirement analgesia in the postoperative
period did not differ much in both the groups. Beverly K Phillip4 compared butorphanol 20 µg/kg and
fentanyl 1µ g/kg in general anesthesia. They noted
90% postoperative pain in Group B and 93% in
Group F. The requirements for additional analgesia
in the postoperative period were also not different.
In the study conducted by Hammad Usmani5, significant postoperative pain in the recovery room was
experienced by 12 (40%) patients receiving fentanyl
and in only 5 (17%) patients in butorphanol group
(p<0.05).
In our study, there was statistically significant difference (p<0.001) in the sedation score in butorphanol
group upto 45 minutes postoperatively. More patients in the butorphanol group had sedation score
≥2 than in the fentanyl group. Our findings correlate
with Beverly K Philip4 who noted more sedation in
butorphanol group than fentanyl for 45 minute in
the recovery room as well as long time for return to
baseline levels of sedation at 60 minutes. Hammad
Usmani5 noted excessive drowsiness in 7 patients
who received 40 µg/kg butorphanol and in 5 patients
in fentanyl group, who received 2 µg/kg of fentanyl,
one hour after admission to the recovery room.
CONCLUSION
We conclude that Butorphanol 20 µg/kg gives better
attenuation of the hemodynamic response, longer
duration of postoperative pain relief, without producing excessive sedation and with negligible side
effects in comparison with fentanyl 1 µg/kg when
given intravenously as premedicant for general anesthesia
REFERENCES
1. Tripathi KD. Essential of Medical pharmacology, 3rd ed; 7.
2. Paul Arun Kumar. Drugs and equipments in anesthetic practice, 3rd edition; 3.
For postoperative analgesia, injection diclofenac sodium 1.5 mg/kg intramuscularly was given when
pain score ≥ 5. 24 hours post-operative analgesia
consumption was similar I both groups (p>0.05)
3. Atkinson RS, Rushman GB and Davies NJH. Lee’s synopsis
of Anesthesia, 11th ed;86.
DISCUSSION
5. Usmani Hammad, Quadir A, Jamil SN. Comparison of butorphanol and fentanyl for balanced anesthesia in patients
undergoing laproscopic cholecystectomy. J Anesthesia Clin.
Pharmacol. 2004: 20 (3):251-254.
The difference in the total duration of analgesia was
statistically significant in Group F it was 108±22.15
NJMR│Volume 6│Issue 1│Jan – Mar 2016
4. Philip Beverly K, Scott David A, Freiberger Dubraka et al.
Butorphanol compared with fentanyl in general anesthesia
for ambulatory laproscopy. Can J Anesthesia.1991, 38:2;1836.
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ORIGINAL ARTICLE
COMPARISON OF HAEMODYNAMIC FLUCTUATION OF
INTRAVENOUS KETAMINE WITH INTRAVENOUS PROPOFOL –
FENTANYL COMBINATION IN SHORT SURGICAL PROCEDURE
Madhavi S Mavani, Sudevi Desai
Author’s Affiliations: Assistant Professor, Department of Anaesthesia, GCS Medical College, Ahmedabad
Correspondence: Dr Madhavi S Mavani E-mail: [email protected]
ABSTRACT
Background: An increasing interest in intravenous anesthetic agent has resulted from the availability of more
effective intravenous agents.
Objectives: Comparison of intravenous Ketamine with combination of intravenous Propofol and Fentanyl in
ASA Gr. 1 patients of middle age in minor surgical procedures, To compare the haemodynamic fluctuation of
intravenous Ketamine with intravenous propofol – fentanyl combination in short surgical procedure and to
compare recovery and side-effective in postoperative period of intravenous Ketamine with intravenous propofol- Fentanyl combination in short surgical procedures.
Methodology: This observational study includes 20 patients of ASA Grade I of either sex, especially those
who were coming for minor surgery. Patients divided in group A: Patients were preoxygenated with 100%
oxygen. Induction was done with injection Ketamine 2 mg/kg intravenous. O 2 was given throughout surgery
and group B: Patients were preoxygenated with 100% oxygen. Induction was done with inj. Fentanyl citrate I
µg/kg over 1 minute followed after 3 minute by propofol 2.5 mg/kg O 2 was given throughout surgery.
Results: Highest patients belong to 21-30 years age group. Female were higher in both the group that male.
Most of (18) patients belongs to 51 to 40 kg group. Falling in blood pressure and pulse was more in Group B
than Group A patients. Post-operative side effects more seen Group A than Group B patients.
Conclusion: Inspite of more side effects and more change in hemodynamics parameters in Propofol-fentanyl
group than Ketamine group, Both Ketamine and Propofol–fentanyl combinations produce rapid, pleasant
and safe anesthesia with only a few untoward side effects and only minor hemodynamic effects.
Key word: Ketamine, Propofol, Fentany, Minor Surgical Procedures, Haemodynamic Fluctuation
INTRODUCTION
An increasing interest in intravenous anaesthtic agent
has resulted from the availability of more effective
intravenous agents. Ketamine1-5 has intrinsic analgesic and amnestic properties, protects airway reflexes,
and can be administered by multiple routes of administration. However, it has the potential for undersirable side effects that include unpleasant emergence
sequelae, hallucinations and emesis6 Ketamine is alos
relatively contraindicated in patients with hypertension, inceased intracranial pressure, respiratory tract
infection, or underlying neurosychiatric condition
such as sezures or psychoses.7
Propofol is an intravenous (IV) sedative-hypnotic
agent with amnesic properties that causes loss of
consciousness reliably and rapidly. It is structurally
unrelated to other hypnotics such as barbiturates and
benzodiazepines and represent a new class of sedative hypnotics called diisopropyphenol. It has been
shown to have a synergistic hypnotic effect when
NJMR│Volume 6│Issue 1│Jan – Mar 2016
used in conjunction with other classes of analgesic/
sedative agents as barbiturates, benzodiazepines,
opioids, and Ketamine8-10. So this study was conducted with the objectives of to comparison of intravenous Ketamine with combination of intravenous
Propofol and Fentanyl in Americal Society of Anesthesiologist (ASA) Gr. 1 patients of middle age in
minor surgical procedures, To compare the haemodynamic fluctuation of intravenous Ketamine with
intravenous propofol – fentany combination in short
surgical procedure, To compare recovery and sideeffective in postoperative period of intravenous Ketamine with intravenous preopofol- fentranyl combination in short surgical procedures.
METHODOLOGY
The study includes 20 patients of ASA Grade I of
either sex, especially those coming for minor surgery.
Selection of Patients: Patients scheduled for minor
surgical procedures were selected. Exclusion Criteria:
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Patients below 20 years of age, pregnant women, lactating mothers, patients with a history of epilepsy or
any convulsive disorder, psychosis, hypertension,
major cardiac problems, those with a known allergy
to these drugs.
Pre-anesthetic Check Up: A pre-anesthetic check
up was done including detailed history and physical
examination, Baseline measurements of pulse, systolic and diastolic blood pressure, respiratory rate and
body weight, routine investigations. The proposed
anesthetic technique and induction procedure were
explained to the patient. After obtaining their consent they were advised overnight fasting as with routine anesthesia.
Premedication: Patients divided in Group A and
Group B. In Group A: Patients were preoxygenated
with 100% oxygen. Induction was done with injection Ketamine 2 mg/kg intravenous. O 2 was given
throughout surgery. In Group B: Patients were
preoxygenated with 100% oxygen. Induction was
done with inj. Fentanyl citrate I µg/kg over 1 minute
followed after 3 minute by propofol 2.5 mg/kg O 2
was given throughout surgery. Injection glycopyrrolate 0.2 mg i.v. and injection Midazolam 1 mg i.v was
given to all patients in group A and B 5 minutes before induction of anaesthesia. Injection xylocard 2%
2 CC.I. given 1 minute before inj. Propofol to reduce
pain during propofol injection.
Induction: Patients to be operated were reexamined
for pulse, blood pressure find and consent checked
prior to commencement of anaesthesia I.V line was
secured. Findings were duly recorded in Performa.
ECG monitor and pulse oximetry were attached.
Maintenance of Anaesthesia: Pulse rate, blood
pressure and respiratory rate were recorded every
five minutes throughout the operative procedures.
Other parameter noted were involuntary movements,
hypertonicity, lacrimation, salivatin, nausea and vomiting. At the end of operation, duration of surgery,
duration of anaesthesia and type of supplementation
needed was noted in proforma.
Postoperatively: Upto 12 hours level of consciousness and vital signs were monitored. Incidence of
nausea, vomiting, delirium and presence of hypertonic reflexes were observed and tabulated. 12 hours follow up was done for any memory of preoperative,
intra operative and immediate postoperative events,
incidence of nausea, vomiting. Dizziness, blurred vision and irrational behavior were noted.
RESULTS
Highest patients belong to 21-30 years age group (table 1). Female were higher in both the group that
male and higher patients belongs to 51 to 40 kg
group. Group A have comparatively more significant
NJMR│Volume 6│Issue 1│Jan – Mar 2016
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change that group B regarding pulse and blood pressure. In Group A, Abut 60% patients showed rise in
pulse rate upto 10/min while 40% showed rise in
pulse rate of more than 10/min and in group B, 10%
patients had a rise in pulse rate upto 10/min while
90% patients has a fall in pulse rate upto 10/min.
20% patients had a rise in B.P. upto 10 mm Hg. In
group B, 10% patients had a significant (<0.05) rise
in pulse rate upto 10/min while 90% patients has a
fall in pulse rate upto 10/min. Almost 20% patients
had a significant (<0.05) rise in B.P. upto 10 mm Hg
while 80% had a fall in B.P. upto 10 mmHg.
Table 1: Socio-demographic characteristics and
clinical parameters of Participants (N= 40)
Variable
Group A Group B P value*
Age
21-30 years
9
8
0.68
31-40 years
6
4
45-50 years
5
7
Gender
Male
9
7
0.74**
Female
11
13
Weight (kg)
31-40
3
2
0.78
41-50
9
8
51-60
8
10
Type of surgery
STG
8
9
0.85
Dressing
5
3
Incision and Drainage
5
5
Dilation and Evacuation 2
3
Duration of Surgical Intervention (minutes)
Up to 10
6
4
0.7
10 to 20
8
8
20 to 30
6
8
Total Dose (mg)
100-150
9
2
0.0001
150-200
11
4
200-250
0
7
250-300
0
7
Post- operative change in Pulse (per minute)
Rise (0-10)
12
2
0.0001
Rise (>10)
8
2
Fall (0-10)
0
18
Post- operative change in Pulse (mmhg)
Rise (0-10)
7
4
0.0001
Rise (>10)
13
0
Fall (0-10)
0
16
Incidence of post-operative side effects
Salivation
4
0
0.34
Nausea
4
2
Delirium
2
0
Hyper-tonicity
1
0
Hallucination
5
0
Group A -Ketamine Group) & Group B-Propofol Fentanyl)
* Chi-square test ** Fisher’s Exact test
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Post-operative side effects were more in group A
than group B but change was non-significant. Propofol – Fentanyl combination is more suitable in minor
surgical procedures because of Stable hemodynamics, Less post operative nausea and vomiting, Rapid
recovery, Less postoperative psychomotor disturbances.
DISCUSSION & CONCLUSION
The present study compares the effect of i.v. Ketamine with i.v. Propofol –F Fentanyl combination for
minor surgincal procedure. A total of 40 patients
were divided in 2 groups of 20 patients each with
group A receiving inj. Ketamine and grop B receiving Inj. Propofol – Fentanyl combination. The advantages of a Propofol - Fentanyl combination are :i)
Rapid onset of action. ii) Short duration of
action. iii) Easily controllable. iv) No significant accumulation. Effect on blood pressure & Pulse :
Study was found that after i.v. Ketamine, there was
an increase in pulse rate and blood pressure. This
findings are consistent with the findings of study
fone by Suri YV (1982)9 & Virtue Alanis (1967)10
which was found that the effect of Ketamine infusion increase the pulse rate, blood pressure. Study
was found that after i.v. Propofol , there was an decrease in pulse rate and blood pressure. This finding
are consistent with study done by Thomas JE et.al.
199211 who had also observed larger decline in blood
pressure (almost 8 mmhg in systolic and 4 mmhg in
diastolic blood pressure). Similar findings had also
observed by Sukhminder JSB et.al 201012, Mayor M
et.al 199013, Mi WD et.al. 199814, Billard V. et.al.
199415. Side effects : Group A had much more incidence of side effects compared to group B. In group
A 20% patients had increased salivation, 20% patients had nausea, 5% patients had hypertonicity,
10% patients had delirium and 25% patients had hallucinations. This finding are almost consistent with
study done by Ghabash M. et.al. 199616. Inspite of
more side effect and more change in hemodynamics
parameters in Propofol-fentanyl group than Ketamine group, Both Ketamine and Propofol–fentanyl
combinations produce rapid, pleasant and safe anesthesia with only a few untoward side effects and only
minor hemodynamic effects.
REFERENCES
1.
Adams H.A. Ketamine. Circulatory interaction during total
intravenous anaesthesia and anaigesia sedation Anasthetis
1997 Dec. 46(12) : 108-7.
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2.
Cohen, Dale MD et, at. Modulating effects of propofol on
metabolic and cardiopulmonary response to stressful intensive care unit procedures. Critical care medicine 24 : 612617 April 1996.
3.
Crozier TA, et al, The effect of total intravenous anaesthesia with Ketamine / propofol on hemodynamic endocrine
and metabolic stress reaction in comparison with alfentanil
/ propofol in laparotomy. Anaesthetis 1996 Nov 45(11) :
1015-23.
4.
Kato H. et at, The effect of propofol on left ventricular
systolic and diastolic function during induction of anaesthesia – a thoracic echocardiographic study Masui : 2004 Jul
53(7) : 761-6.
5.
L.D. Sanders et at, propofol in short gyndecological procedures. Anaesthesia 1991 volume 46, page 451-455.
6.
Mayer M, The effect of propofol – Ketamine anaesthesia
on hemodynamics and analgesia in comparison with propofol fentanyl, Anaesthesist 1990 Dec 39(12): 609-16.
7.
Paul S. Myles et al, Serum lipid and glucose concentrations
with a propofol infusion for cardiac surgery, Journal for
cardiothoracic, and vascular Anaesthesia Vol. 9 No. 4 (Aug)
1995; pp 373-378.
8.
Romano R et at Effect of propofol on human heart electrical system: a transesophageal pacing electrophysiologic
study. P Acta Anaesthesiol Scan. 1994 Jan, 38(I) : 30-2.
9.
Suri Y V et al, Anaesthestic technique of Ketamine infusion
: clinical and biochemical evaluation J. Postgrad. Med 198228 184-93.
10. Virtue RW, Alanis JM, Mori M, La-Fargue RT, Vosel JH,
Metcalf DR. "An Anaesthetic Agent: 2-(0-chloropyhenyl)-2(methylamino) cyclohexanone Hcl (CI581) Anesthesiology.
1967;28:823–823.
11. Thomas JE, Judith E, Hall MA. The effects of increasing
plasma concentration of dexedetomidine in humans. Anesthesiology. 2009;93:382.
12. Sukhminder JSB, Sukhwinder KB, Jasbir K. Comparison of
two drug combinations in total intravenous anesthesia:
Propofol–ketamine and propofol–fentanyl. Saudi J Anaesth.
2010; 4(2): 72-79.
13. Mayer M, Ochmann O, Doenicke A, Angster R, Suttmann
H. The effect of propofol-ketamine anesthesia on hemodynamics and analgesia in comparison with propofol-fentanyl.
Anaesthesist. 1990;39:609–16. [PubMed]
14. Mi WD, Sakai T, Takahashi S, Matsuki A. Haemodynamic
and electroencephalograph responses to intubation during
induction with propofol or propofol/fentanyl. Can J Anaesth. 1998;45:19–22. [PubMed]
15. Billard V, Moulla F, Bourgain JL, Megnigbeto A, Stanski
DR. Hemodynamic response to induction and intubation:
Propofol/fentanyl interaction. Anesthesiology. 1994; 81:
1384-93. [PubMed]
16. Ghabash M, Matta M, Kehhaleh J. Depression of excitatory
effects of propofol induction by fentanyl. Middle East J
Anesthesiol. 1996;13:419–25. [PubMed]
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ORIGINAL ARTICLE
TRENDS OF NOSOCOMIAL INFECTIONS IN A PRIVATE
HOSPITAL OF SURAT, GUJARAT
Latika N Purohit1, Prashant V Kariya2
Author’s Affiliations: 1Assistant Professor, Dept. of Microbiology; 2Assistant Professor, Dept. of Pediatric,
Government Medical College, Surat, Gujarat
Correspondence: Dr Latika N. Purohit Email: [email protected]
ABSTRACT
Background: Nosocomial infection or hospital acquired infection refers to the infection occurring in patients
after admission at the hospital that was neither present nor incubating at the time of admission. Infection occurring more than 48 hours after admission is usually considered nosocomial. These nosocomial infections
(NI) occur among 7-12% of the hospitalized patients globally with more than 1.4 million people suffering
from the infectious complications acquired in the hospital.
Methodology: The current study was done in a multi speciality hospital of Surat, Gujarat. This hospital is
having Surgery, Obs & Gynec, Medicine, Orthopedic speciality under one roof. All patients admitted in the
hospital from January 2015 to June 2015 were analysed for Nosocomial Infections. CDC (Centre for disease
control & prevention) guidelines were used to identify nosocomial infections. Total 125 patients were enrolled
in the study.
Result: In our study, total 125 patients were diagnosed as having nosocomial infections in two years. Out of
these, 58 (46.4%) were female and 67 (53.6%) were male. Thus, male predominance was observed. We observed that Urinary tract infection (UTI) was the most common Nosocomial infection. Out of total 125 patients, 48 (38.4%) were having UTI. Surgical site infection (SSI) was the second most common culprit. SSI
was observed in 32 (25.6%) patients. It was followed by sepsis (20%). It was observed that E.Coli was the
most common micro-organism isolated from UTI and SSI patients. Whereas, Staph. Aureus and Klebsiella
were the most common micro-organism isolated from patients of Sepsis and LRTI respectively. In patients of
UTI and SSI, Psedomonas and Klebsiella were other common organisms isolated. From many samples, more
than 1 micro-organism was isolated.
Key words: Nosocomial Infection, Surgical site infection, Urinary tract infection
INTRODUCTION
Nosocomial infection or hospital acquired infection
refers to the infection occurring in patients after admission at the hospital that was neither present nor
incubating at the time of admission. Infection occurring more than 48 hours after admission is usually
considered nosocomial. It is one of the public health
problems throughout the world. The infection causes
the patient’s physical and mental sickness that makes
the patient stay longer in the hospital without necessity.1
Studies throughout the world document that nosocomial infections are a major cause of morbidity and
mortality. A high frequency of nosocomial infections
is evidence of a poor quality of health service delivery, and leads to avoidable costs. Many factors contribute to the frequency of nosocomial infections
hospitalized
patients
are
often
immunoNJMR│Volume 6│Issue 1│Jan – Mar 2016
compromised, they undergo invasive examinations
and treatments, and patient care practices and the
hospital environment may facilitate the transmission
of microorganisms among patients. The selective
pressure of intense antibiotic use promotes antibiotic
resistance. While progress in the prevention of nosocomial infections has been made, changes in medical
practice continually present new opportunities for
development of infection.
Infections acquired in the hospital account for major
causes of death, morbidity, functional disability, emotional suffering and economic burden among the
hospitalized patients. These nosocomial infections
(NI) occur among 7-12% of the hospitalized patients
globally with more than 1.4 million people suffering
from the infectious complications acquired in the
hospital.2 The most frequent nosocomial infections
are infections of surgical wound, urinary tract infections and lower respiratory tract infections.3 Surgical
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NATIONAL JOURNAL OF MEDICAL RESEARCH
site infections (SSI) are the third most commonly reported nosocomial infection and they account for
approximately a quarter of all nosocomial infections.4
Surgical site infections are the most common nosocomial infections in surgical patients- accounting for
about 24% of the total number of nosocomial infections. 4,5,6 It’s rate has varied from a low of 2.5% to
high of 41.9%.7
The present study was done with objective of documenting rate of Nosocomial infections and identifying common micro-organisms associated with it in
specified population.
METHODOLOGY
The current study was done in a multi speciality hospital of Surat, Gujarat. This hospital is having Surgery, Obs & Gynec, Medicine, Orthopedic speciality
under one roof.
All patients admitted in the hospital from January
2015 to June 2015 were analysed for Nosocomial Infections. CDC (Centre for disease control & prevention) guidelines were used to identify nosocomial infections.8
Permission was obtained from hospital administration. Written informed consent was taken from patients after explaining the study.
All patients admitted in hospital for more than 7 days
were checked for possible Nosocomial infection.
Clinical and demographic information of each patient
was noted . Clinical specimens like urine, pus, blood,
sputum, pleural fluid, other fluids & tips of invasive
devices were processed in microbiology laboratory.
Identification of clinical isolates & their antimicrobial
profile was performed by standard microbiological
methods.9
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Total 145 patients were identified as having Nosocomial Infections. Out of these, 20 were not ready to
give informed written consent and those patients
were excluded from the study. Thus, 125 patients
were enrolled in the study.
RESULTS
In our study, total 125 patients were diagnosed as
having nosocomial infections in two years. Out of
these, 58 (46.4%) were female and 67 (53.6%) were
male. Thus, male predominance was observed. Most
of the patients were from the age group of 30 to 40
years.
Table 1: Distribution of patients according to
type of Nosocomial Infections (N=125)
Type of Infection
Urinary tract Infection (UTI)
Surgical site infection (SSI)
Sepsis
Lower respiratory track infection (LRTI)
Liver Abscess
Other
Cases (%)
48 (38.4)
32 (25.6)
25 (20.0)
9 (7.2)
4 (3.2)
7 (5.6)
Table 1 shows distribution patients according to type
of Nosocomial infections. We observed that Urinary
tract infection (UTI) was the most common Nosocomial infection. Out of total 125 patients, 48
(38.4%) were having UTI. Surgical site infection
(SSI) was the second most common culprit. SSI was
observed in 32 (25.6%) patients. It was followed by
sepsis (20%). Thus, UTI, SSI and sepsis together
constitute 84% of Nosocomial infection. Apart from
these, Lower respiratory track infection (LRTI),
Liver abscess etc. were also having share in Nosocomial infection.
Table 2: Distribution of micro-organism according to identified site
Microorganism
E.Coli
Acinetobacter
Psedomonas
Klebsiella
Proteus
Staph. Aureus
Candida
Other
More than 1
UTI
46.2%
6.2%
20.2%
16.8%
4.5%
2.1%
6.4%
3.0%
15.4%
SSI
22.4%
15.8%
20.5%
17.2%
7.5%
18.5%
7.2%
2.5%
12.4%
Table 2 shows distribution of micro-organism according to identified site. It was observed that E.Coli
was the most common micro-organism isolated from
UTI and SSI patients. Whereas, Staph. Aureus and
Klebsiella were the most common micro-organism
isolated from patients of Sepsis and LRTI respectively. In patients of UTI and SSI, Psedomonas and
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Sepsis
10.2%
12.1%
0
11.4%
0
36.4%
12.3%
15.2%
18.2%
LRTI
14.8%
10.0%
20.0%
25.5%
0
0
12.4%
7.2%
14.7%
Liver Abscess
35.2%
0
6.8%
52.4%
0
3.1%
2.8%
3.5%
10.8%
Klebsiella were other common organisms isolated.
From many samples, more than 1 micro-organism
was isolated.
From liver abscess, most common organism isolated
was Klebsiella (52.4%). E.coli was also isolated from
35.2% of patients of Liver Abscess.
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DISCUSSION
Nosocomial infection is emerging as a new threat to
public health. This depends on severity of illness,
length of hospital stay, therapeutic procedure, irrational use of antimicrobial agents etc.
We found that among nosocomial infections, UTI,
SSI, Sepsis and LRTI are most common. In a similar
study done by Mukherjee et al, urinary infection
(45%) was the most common infection followed by
pulmonary infections (30%), blood stream infections
(16%) & skin infections (3.75%). 10 Our SSI rate was
favorably compared with SSI rate of Shrivastava et al
(10.19%), shaw et al (16.9%) and desa LA et al
(18.92%). 11, 12, 13
Predominance of skin & surgical site infection in our
study could be due to the reason that majority of patients were from surgical ward & were using invasive
devices. Another study by Rosineide et al reported,
skin & surgical site infection (56%) as the most frequent infection and most of the patients were from
surgical wards. 14
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this phenomenon can be extensive & indiscriminate
use of antibiotics.15
CONCLUSION
It was concluded from this study that Urinary tract
infections and Surgical Site Infections were the most
common Nosocomial infections. E.Coli, Pseudomonas and Klebsiella were the mast common microorganisms isolated from the specimens.
REFERENCES
1. Luksamijarulkul P, Parikumsil N, Poomsuwan V, et al. Nosocomial Surgical Site Infection among Photharam. J Med
Assoc Thai 2006; 89 (1): 81-9.
2. Kamat US, Ferreira V, Savio R, et al. Antimicrobial resistance
among nosocomial isolates in a teaching hospital in Goa. Indian J Community Med 2008; 33(2): 89-92.
3. Ducel G, Fabry J, Nicolle L. Prevention of hospital acquired infections - a practical guide, 2 nd ed. Geneva:
WHO; 2002.
One of the most common risk factor of Nosocomial
infection may be the use of invasive devices In 56.9%
patients, nosocomial infections were associated with
use of invasive devices such as urinary & CVP catheters, ventilators & surgery. These findings indicate
that nosocomial infections are often associated with
the use of invasive devices. Therefore to effectively
reduce burden of these infections, the use of invasive
devices should be minimized and specific disinfection
precautions should be taken during application of
devices. The length of hospitalization, which is a well
known risk factor related to severity of disease and
affects health costs, was also a risk factor for development of hospital acquired infections. Use of antibiotics prior to infection and associated chronic
morbidities were other risk factors for nosocomial
infections in elderly patients. Similar risk factors were
implicated in a study reported by Mukherjee et al.10
4. Green J, Wenzel RP. Post operative wound infection. Ann
surg. 1977; 185: 264-8.
In our study we found that E.Coli was the most
common micro-organism isolated from UTI and SSI
patients. Whereas, Staph. Aureus and Klebsiella were
the most common micro-organism isolated from patients of Sepsis and LRTI respectively. In patients of
UTI and SSI, Psedomonas and Klebsiella were other
common organisms isolated. From many samples,
more than 1 micro-organism was isolated. In contrast
to this mukherjee et al reported Pseudomonas and
Richards et al reported Candida as most common organism associated with UTI. 10, 14 These differences
could be explained by differences in geographic location & health care system.
10. Mukherjee T, Pramod K, Gita S, Medha YR. Nosocomial infections in geriatric patients admitted in ICU. J. of Ind,Acad.
of Geriatircs 2005;2:61-64
Multi drug resistance was also observed in our study.
Similar observations were also reported by Mohanasundaram et al. The most likely explanation for
15. Mohanasoundaram KM. Retrespective analysis of the incidence of nosocomial infections in the ICU. J of Clinical &
Diagnostic Research 2010; 4:3378-3382.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
5. Haley RW. The scientific basis for using surveillance and risk
factor data to reduce nosocomial infection rates. J Hosp infect 1995; 30(suppl): 3-14.
6. Everett JE, Wahoff DC, Statz CL, et al. Characterization and
impact of wound infection after pancreas transplantation.
Arch Surg. 1994; 129: 1310-17.
7. Lilani SP, Jangale N, Chaudhary A, et al. Surgical site infection in clean and clean-contaminated cases. Ind J Med Microbiol 2005; 23(4): 249-52
8. Gamer JS, Jarvis WR, Horan TC, Hughes IM. CDC definitions of nosocomial infections. Am J Infect Control 1988;
16:128-140
9. Performance Standards for Antimicrobial Susceptibility Testing; 20th Informational Supple- ment, Clinical and Laboratory Standards Institute (CLSI) M100-S20: Vol. 30,
No.1.Wayne, PA: Clinical and Laboratory Standards Institute;
2010
11. Shrivastava SP, Atal PR and singh RP. Studies on hospital
infection. Ind J Surg 1969; 31: 612-21.
12. Shaw D, Doig CM and Douglas D. Is airbone infection in
the operating theatre an important cause of wound infection in general surgery? The Lancet 1973; 1: 17-21.
13. deSa LA, Sathe MJ and Bapat RD. Factors influencing
wound infection (a prospective study of 280 cases). J Postgrad Med 1984; 30 (4): 232-6.
14. Rosineide M, Ribas & Paulo, Gontijo Filho. Comparing hospital infections in elderly vs younger adults.The Brazilian J of
Infect Dis 2003;7:210-215.
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REVIEW ARTICLE
USING THE METHODOLOGY OF WAVELET ANALYSIS FOR
PROCESSING IMAGES OF CYTOLOGY PREPARATIONS
Vyacheslav V Lyashenko1, Asaad Mohammed Ahmed abd allah Babker2, Oleg A Kobylin3
Author’s Affiliations: 1Laboratory “Transfer of Information Technologies in the risk reduction systems”; 2Department
of Informatics Kharkov National University of RadioElectronics, Kharkov, Ukraine; 3Department of Medical Laboratory
Science, Al-Ghad International Collage for Medical Sciences, Al-Madinah AlMunawarah, Sudia Arabia
Correspondence: Asaad Mohammed Ahmed abd allah Babker E-mail: [email protected]
ABSTRACT
Processing of microscope images in medicine is one of the priority research areas. This is due to the fact that
such studies allow conducting comprehensive diagnosis of human health state, identifying and preventing the
development of diseases in the early stages, providing additional research in non-standard symptomatic forms
of rare diseases. In this connection, first of all image processing of cytology preparations holds a special place
as one of the common set of microimages in medicine. However, the specific complexity of visualization
process of cytology preparations and their subsequent processing with the use of automated processing determines the necessity to study new possibilities to use new approaches to image processing. Exactly this fact
was the basis for considering the possibility to use wavelet analysis as a tool for processing cytology preparations images. On certain examples of cytology preparation images the results of application of one of the
wavelet analysis procedures is shown.
Keywords: wavelet analysis, image, contrast enhancement, cell, medicine, cytology preparation.
INTRODUCTION
Processing real objects’ images, processes and phenomena is one of the ways of perception of the
world around us. At the same time, image processing
allows studying the processes that cannot be seen or
analyzed by means of human vision. One such directions of application of a common ideology of image
processing is medicine. In this case, images of real
objects are those of different organs, tissues, parts of
human skeleton, obtained with the help of special
methods of their visualization: X‐ray microtomography, positron emission tomography, ultrasonic analysis, light and electron microscopy.1-5
Among the many real objects that allow studying
human body, one can underline the cytology preparations images. It is connected with the following
facts. On the one hand, cytology preparations are objects of microcosm, which allow for a more in-depth
studies of the human body, to study the dynamics of
its operation and to diagnose possible diseases in the
early stages of their development; On the other
hand, these are special images that differ in their visualization of microcosm objects, which necessitates
the use of a variety of image processing techniques
to obtain information about objects, processes, and
phenomenon under study.
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The General Ideology of Post-Processing of Cytology Preparations Images (Literature Review)
As an example of separate works that use the ideology of imaging processing for studying of cytology
preparations the following research work can be
provided. B. Krawczyk and P. Filipczuk, which deals
with the cytological image segmentation to isolate the
cell nucleus.6 A. Gençtav, S. Aksoy and S. Önder,
discussing the issues of segmentation and classification of cells cytology preparations images, where
segmentation process involves automatic thresholding to separate the cell regions from the background.7 S. Singh and R. Gupta, which examines the
possibility of applying the texture analysis methods
for cytology preparations.8 E. Ensink et. al, who
study the issues of the selection of threshold for image segmentation of cytology preparations.9 Y. M.
George et. al, offering to conduct automated segmentation of cells in the images of the cytology
preparation under study, where authors talk about
the necessity to change the histogram of the input
image in order to enhance its contrast.10 R. Malviya
et. al, which deals with nucleus localization in the cytology preparations images under study.11
Nevertheless, the many authors point out that there
may be some ambiguity while localizing nucleus. The
reason for such ambiguity is the emerging difference
in the relative staining intensity of the clinical samples examined. Possible errors in segmentation of
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cells on cytology preparations images as a result of
the arising differences in relative intensity of their
staining is also studied by E. M. van Ingen et. al.12 At
the same time N. Dey et. al, talk not only about the
possible influence of the relative staining intensity of
the preparations under study on the quality of their
image processing.13 N. Dey et. al, determine the
whole range of problems connected with the
processing of microscopic images in medicine, where
the primary goal is to obtain high quality image for
its further thematic processing.13
Thus, the overall ideology of cytology preparations
image processing pursues its goal as the selection of
certain parts of the image (cells, nucleus) for further
study of their changes (changes in cell shape, the
change in the area of a cell) or for the calculation of
certain quantitative characteristics (number of cells,
the number of nuclei, cells’ area). At the same time,
particular attention is paid to the methods of cytology preparations source images (filtering, change of
contrast, histogram equalization) in order to enhance
the information they contain. However, it should be
noted that by simply changing the brightness, contrast or by filtering it is impossible to solve arising
issues with proper quality while processing cytology
preparation images. Based on noted above, the following objectives of this study can be pointed out:
– Explanation of method of cytology preparation
images processing;
– Reviewing the ideology of preprocessing of cytology preparation images for their processing method
under discussion;
– Conducting experiments based on the suggested
method of cytology preparation images processing.
Basics of Wavelet Analysis for Image Processing
In order to solve the set of issues connected with cytology preparations image processing the methodology of wavelet analysis will be considered. The selection of wavelet analysis method for further cytology
preparations images processing is based on the fact
that wavelet processing allows taking into account
the particular characteristics of the images under
study by decomposing source data into a plurality of
approximate and detail coefficients, in particular by
image edge detection.14 In addition, image processing
results obtained with the help of wavelet analysis, are
often more informative.15,16
Wavelet analysis is based on wavelet transform.
Wavelets are obtained by shifting and scaling a single
function – parent wavelet.17 If the signal is discontinuous, only those wavelets will have high amplitudes,
which maxima will appear near the discontinuity
point. This allows detecting image edge on the image
under study. The sharper the transition, the higher
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the derivative value is. Smooth transitions will have
small derivative values.
Behind the formalization of the continuous wavelet
transform (CWT) there’s the use of two continuous
and integrable along the whole axis t functions:17,18
– wavelet – function ξ ( t ) with zero integral value
∞
∫ ξ (t )dt = 0 ,
(1)
−∞
determining the details of the signal and generating
extended fractions;
– scaling function ϕ ( t ) with a unit value of integral
∞
∫ ϕ (t )dt = 1 ,
(2)
−∞
determining a rough approximation of signal and generating approximation coefficients.
However, CWT function can be applied only for
one-dimensional signals, and image is a twodimensional signal. Therefore, in order to be able to
apply CWT to detect image edges it is suggested to
consider the following analysis and edge detection
procedure:14
- let’s perform calculation for horizontal discontinuities of the original image F , represented by matrix
defined
by
its
readings
f ij ∈ {0,1,..., P}, i = 1,2,..., N, j = 1,2,..., M on a square lattice P × K . To do this, we use the following formula
to get the so-called matrix of wavelet spectrogram
W (based on the sequential processing of each line
of the original image F ):
W f ij =
[ ]
1
where
ξ(
+∞
t−b
∫ f ijξ ( a )dt ,
a −∞
(3)
t−b
) is a mother wavelet that meets the
a
condition (1),
a , b – scale and center of temporary localization which determine the scale and bias function
ξ ( t ) in accordance with the terms of scaling (2);
[fij ] indicates the number of the processed
string of the original image F to get a plurality of
values of its wavelet spectrogram.
Parameters a , b are chosen so that the corresponding linear dimensions of the matrix of wavelet spectrogram W correlate with linear dimensions of the
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original image F , and at the same time possible parameter of wavelet transform are taken into account.
Test Images and Their Preprocessing Before
Wavelet Analysis
Then, based on the analysis of the obtained spectrogram ( W for each raw of the original image F ) we
select its certain line PP based on the condition:
In order to identify the possibility of using wavelet
analysis as a processing tool for cytology preparations images, some images have been selected. The
images are publicly available on the Internet (Fig. 1
and Fig 2).
PP = max(
where
1 P
∑ w ij ) ,
P i =1
(4)
w ij is the element of wavelet spectrogram
of the analyzed row (line) of the original image F .
This selection is determined by the fact that we select
that part of spectrum of the original image row (line),
which corresponds to the largest discontinuity area
of the original signal between its readings (see comments above).
The selected in such a way line (row), will correspond to the line (row) in matrix Fg which characterized the matrix of horizontal discontinuities of the
original image F .
Processing of all lines of the original image F allows
obtaining the matrix of horizontal discontinuities Fg
through the following sequence of transformations:
Fig.1. Image No.1
F CWT lines W selection line Fg
- in a similar war we calculate the vertical discontinuities of the original image F for each column. For this
purpose, use formula (3) and the formula similar to
formula (4) to select certain line from the obtained
wavelet spectrograms of each column of the original
image F :
KK = max(
1 K
∑ w ij ) .
K i =1
(5)
Processing of all columns of the original image F allows as a result obtaining the matrix of vertical discontinuities Fv , due to the following sequence of
transformations:
F CWT column W selection column Fv .
- add matrixes of vertical and horizontal discontinuities into one matrix that displays the edge of the original image based on CWT methods. For visual clarity, matrixes are horizontal, vertical discontinuities, as
well as generalized matrix showing the edge of the
original image can be inverted.
In this work, to consider the possibility of using
wavelet analysis as a tool for processing cytology
preparations images, parameter a = 20 , and parameter b ( b = P or b = K ) correlates with the linear dimensions of the original image in accordance with
the procedure of constructing the matrix of wavelet
spectral pattern for rows and columns of the image
respectively.
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Fig.2. Image No.2
The presented images of cytology preparations are
different in their structure and complexity of perception, which allows evaluating the possibility of using
wavelet analysis methodology as a tool for their
processing. Moreover, all images are presented in
color. However, the implementation of certain functions of the general methodology of wavelet analysis
involves the work with gray-level images. Therefore,
all the original images must be submitted in the form
of corresponding gray-level (halftone) images. This is
the first stage of the original images pre-processing.
As noted above, one of the necessary stages of preprocessing of microscopic images in medicine is their
contrasting. Changing the contrast of the image allows improving both image perception accuracy, as
well as the accuracy (efficiency) of its further
processing. It is very important for microscopic images in medicine, an example of which are images of
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cytology preparations. Therefore, to further analyze
the halftone images, they all were contrasted.
At the same, the selection of different levels of contrast enhancement for the images under study is first
of all determined by the necessity to test the possibility of using wavelet analysis for cytology preparation
image processing.
Results of Wavelet Transform of Cytology Preparations Images and Discussion
Thus, wavelet transform of cytology preparations
images will be held on halftone images, one of which
is the source (primary) image obtained from the corresponding color image, and the second one is a contrasted image of the original grayscale (halftone) image. As a wavelet transform of cytology preparations
images the method of selecting special features of the
images was used, described in the part “Basics of
wavelet analysis for image processing”.
Fig. 4a). Results of wavelet transform for image No.2
Fig. 3 shows the results of wavelet transform for image No.1 (a – processing of the original halftone image, b – processing of contrasted halftone image).
Fig. 4b:. Results of wavelet transform for image No.2
Fig.3a). Results of wavelet transform for image No.1
Fig.3b). Results of wavelet transform for image No.1
Fig. 4 shows the results of wavelet transform for image No.2 (a – processing of the original halftone image, b – processing of contrasted halftone image).
NJMR│Volume 6│Issue 1│Jan – Mar 2016
As it can be seen from data on Fig. 3 and Fig. 4 the
described method of image wavelet transform allows
detecting first of all edges of separate objects
represented on the corresponding images. The used
wavelet transform also allows highlighting the specific features of cytology preparaions of separate objects (cells) in the images. At the same time, on basis
of shown in Fig. 3 and Fig. 4, it can be stated that the
use of the studied wavelet transform provides more
information for images that have been contrasted.
In the case where wavelet processing was applied to
a less contrasted image, the result was the allocation
of the darkest areas in the original images. This corresponds wither to cell edge detection (Fig. 4a).
In the case where wavelet processing was applied to
a more contrasted image, the result is not only more
accurate cell edge detection, but the allocation of the
internal structure of these cells (Fig. 3b). This allows
for a more detailed qualitative and quantitative analysis of the internal structure of the cells represented in
the images of cytology preparations. In particular, it
is possible to analyze the textural changes that occur
within the cell, to analyze in more details the individual elements of cells’ structure, to calculate the dynamics of change in the cell nucleus, the nucleolus,
intracellular filaments, etc.
Nevertheless, it is possible to combine the results of
wavelet processing of images with different contrast.
This will help solving different problems: from localizing only cell nuclei to the study of the internal
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structure of cells. Then the general ideology of the
procedure for the use of wavelet analysis as a tool for
cytology preparations images processing can be presented as follows:
2.
Gaemperli O, Shalhoub J, Owen D, Lamare F, Rimoldi OE,
Davies AH, Camici PG. Imaging intraplaque inflammation in
carotid atherosclerosis with 11C-PK11195 positron emission
tomography/computed tomography. European heart
journal. 2012;33.15:1902-1910.
the necessity to transform the original image is
determined;
color image is converted to halftone (gray-level)
image;
the necessity to change contrast of the original
halftone image is determined;
wavelet transform of the original halftone image
and of contrasted halftone image is conducted;
Conclusions are made on basis of wavelet transform results (additional processing procedures are
applied to the obtained images in this case: calculating cell nuclei, cells, cells’ area, etc.).
3.
Sikdar S, Rangwala H, Eastlake EB, Hunt I, Nelson A J,
Devanathan J, Pancrazio JJ. Novel method for predicting
dexterous individual finger movements by imaging muscle
activity using a wearable ultrasonic system. Neural Systems
and Rehabilitation Engineering, IEEE Transactions on.
2014;22.1:69-76.
4.
Eklund A, Dufort P, Forsberg D, LaConte SM. Medical
image processing on the GPU–Past, present and future.
Medical image analysis. 2013;17.8:1073-1094.
5.
Ciresan D, Giusti A, Gambardella LM, Schmidhuber J. Deep
neural networks segment neuronal membranes in electron
microscopy images. In Advances in neural information
processing systems. 2012:2843-2851.
6.
Krawczyk B, and Filipczuk P. Cytological image analysis with
firefly nuclei detection and hybrid one-class classification decomposition. Engineering Applications of Artificial Intelligence. 2014;31:126-135.
7.
Gençtav A, Selim A, Önder S. Unsupervised segmentation
and classification of cervical cell images. Pattern Recognition.
2012;45.12:4151-4168.
8.
Singh S, Gupta R. Identification of components of
fibroadenoma in cytology preparations using texture analysis:
a morphometric study. Cytopathology. 2012;23.3:187-191.
9.
Ensink E et al. Segment and Fit Thresholding: A New Me-
In any case, the discussed above one the procedures
of wavelet analysis shows that it is possible and feasible to use wavelet analysis as a tool for processing
cytology preparations images in order to obtain additional information to conduct diagnostics and assess
the state of human health.
CONCLUSIONS
thod for Image Analysis Applied to Microarray and ImmuIn summary, the paper deals with the possibility and
nofluorescence Data. Analytical chemistry. 2015;87.19:9715feasibility issues of applying wavelet analysis for
9721.
processing cytology preparations images. As a separate wavelet analysis procedure, which is proposed to 10. George YM, Bagoury BM, Zayed HH, Roushdy MI. Automated cell nuclei segmentation for breast fine needle aspirabe applied to processing of cytology preparations
tion cytology. Signal Processing. 2013;93.10:2804-2816.
images, the procedure of allocating specific features
11. Malviya R, Karri SPK, Chatterjee J, Manjunatha M, Ray AK.
on the presented images is discussed.
Computer assisted cervical cytological nucleus localization.
TENCON 2012-2012 IEEE Region 10 Conference. IEEE,
The proposed procedure of processing of cytology
2012:1-5.
preparations images allows to qualitatively (in terms
van Ingen EM, Leyte-Veldstra L, Al I, Wielenga G, Ploem IS.
of their visualization) allocating: cells’ edges, cell nuc- 12. Automated
Cytology Using a Quantitative Staining Method
lei, revealing in more detail textural features of cells’
Combined with a TV-based Image Analysis Computer. Canimages, which allows analyzing cell structure.
cer Control: Proceedings of the 12th International Cancer
At the same time, one of the specifics of application
of wavelet transform for cytology preparation images
analysis has been marked out. Such specific feature is
the necessity to process halftone images and
feasibility of changing contrast of halftone image.
Inparticular, the article shows different results of
wavelet processing for original and contrasted
halftone images. Nevertheless, it does not narrow,
but instead extends the potential of using wavelet
analysis for processing cytology preparations images
depending in the context of the problem.
REFERENCES
1.
Schlüter S, Sheppard A, Brown, K, Wildenschild D. Image
processing of multiphase images obtained via X‐ray
microtomography: a review. Water Resources Research.
2014;50.4:3615-3639.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
Congress, Buenos Aires, 1978. Elsevier, 2013:45-67.
13. Dey N, Ashour AS, Ashour AS, Singh A. Digital Analysis of
Microscopic Images in Medicine. Journal of Advanced Microscopy Research. 2015;10.1:1-13.
14. Kobylin O, Lyashenko V. Comparison of standard image
edge detection techniques and of method based on wavelet
transform. International Journal of Advanced Research.
2014;2(8):572-580.
15. Lyashenko V, Deineko Z, Ahmad A. Properties of wavelet
coefficients of self-similar time series. International Journal
of Scientific and Engineering Research. 2015;6(1):1492-1499.
16. Lyashenko V, Kobylin O, Ahmad MA. General Methodology for Implementation of Image Normalization Procedure
Using its Wavelet Transform. International Journal of
Science and Research (IJSR). 2014;3(11):2870-2877.
17. Kingsbury N. Image processing with complex wavelets. Philosophical Transactions of the Royal Society of London A:
Mathematical, Physical and Engineering Sciences.
1999;357(1760):2543-2560.
18. Heil CE, Walnut DF. Continuous and discrete wavelet transforms. SIAM review. 1989;31(4):628-666.
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CASE REPORT
ACUTE DISSEMINATED ENCEPHALOMYELITIS IN
CHICKEN POX
Arijit Sinha1, Suvrendu Sankar Kar2, Tirtha Pratim Purkait1, Uttam Kumar Pandit3
Author’s Affiliations: 1Assistant Professor; 3Resident, Department of Medicine, Infectious Disease Hospital; Assistant
Professor, Department of Medicine, R.G.Kar Medical College, Kolkata
Correspondence: Dr Suvrendu Sankar Kar Email: [email protected]
ABSTRACT
An 11 years old male was admitted with upper motor type of weakness of both lower limbs, retention of
urine, impaired consciousness, tremor and convulsion on 11th day after vesicular eruption of chickenpox. He
was investigated and treated. MRI Brain and Spine suggests encephalitis and myelitis. Other causes were excluded by relevant investigations. Patient was improved satisfactorily.
Key words: Chickenpox, Acute Disseminated Encephalomyelitis
BACKGROUND
Chickenpox or varicella is a contagious disease
caused by varicella zoster virus. Infections are usually
self limiting but complications may occur like pneumonia, encephalitis or secondary pyogenic skin infection etc. CNS complications rate varies from 0.1 to
0.7% in several series1 Acute disseminated encephalomyelitis (ADEM) is one of the rare CNS complications of chicken pox. ADEM is a demyelinating disease of the CNS which can occur following viral infections like chicken pox, measles, rubella, mumps,
influenza, Epstein Barr virus, HIV and mycoplasma;
following vaccination or spontaneously. Classically
ADEM is a monophagic disease but it may have a
recurring course also.2 It is associated with small foci
of scattered, perivenular inflammation and demyelination of brain and spinal cord.3 In our case, the patient was admitted at Infectious Disease Hospital,
Kolkata on 11thday of illness.
sent. His respiratory, cardiovascular, abdominal findings were within normal limits.
Figure 1: Hyperintensities on T2 image involving bilateral
parafalcine region of both frontal lobes with mild surrounding oedema (suggestive of encephalitis)
CASE REPORT
An 11 year male patient was suffering from Chickenpox and treated at home without antiviral drugs.
On 11thday he noticed sudden weakness of both
lower limbs with band sensation at nipple level of the
chest and retention of urine. Gradually his consciousness level became impaired, tremor of upper
limbs and convulsion developed. He was of average
built with normal birth and developmental milestones, not immunized against chickenpox, no history
of recent vaccination and no significant past illness.
Examination: Patient had impaired consciousness
(GCS 4); blood pressure (100/70), heart rate
(88/min) was normal. He was not pale and clubbing,
lymphadenopathy, icterous, oedema, fever were abNJMR│Volume 6│Issue 1│Jan – Mar 2016
Figure 2: MRI (T2 image) of cervico-dorsal spinal cord
showing long segment intramedullary hyperintensities
(long segment myelitis)
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Positive findings on examination of nervous system
were—impaired consciousness, lateral gaze nystagmus,tremor, loss of muscle power,flaccidity,loss of
abdominal reflex,extensor planter responseand diminished sensation below D4 dermatome.
Investigations: Patients investigation reports were
as follows : Haemoglobin 10.6 gm/dl, leucocyte
count 6400/cumm (N58, L40, E2), ESR50 mm, total
bilirubin 0.98 mg%, SGPT 46 IU /L, urea 36mg/dl,
creatinine 0.8 mg /dl, Na 136 Meq/L, K 4.8 Meq/L,
PO4 3.8 Meq/L, Mg 1.5 Meq/L, Ca 10.8 Meq/L,
HIV1 & 2 negative, ANF negative, antiphospholipid
antibody negative, IgM VZV positive in 1: 128 dilution, CSF cellcount 56/cumm with 90% lymphocytes, sugar 40 mg/dl, protein 68mg/dl, ADA 4
IU/L, no oligoclonal band. Chest X ray normal and
ECG were normal. MRI Brain and Spine revealed
abnormal T2 hyperintensities involving bilateral parafalcine region of both frontal lobes with mild surrounding oedema, suggestive of encephalitis (Figure1) and abnormal intramedullary long segment T2
hyperintensities involving the cervico-dorsal spinal
cord suggestive of long segment myelitis (Figure2).
Treatment and course: Patient was treated with injectable Acyclovir and methylprednisolone, phenytoin and other supportive management. He was improved satisfactorily and discharged on 7th day of
hospital admission with mild weakness of lower
limbs and mild dysarthria. On follow up after one
month he was fine, without any neurodeficit.
DISCUSSION
Encephalitis, cerebellitis, meningitis, optic neuritis, G
B Syndrome, transverse myelitis, stroke, mono or polyneuritis are common CNS complication of chickenpox. ADEM is a rare but serious complication of
chickenpox. Children are most sufferers.4,5 Association of ADEM following chickenpox may be delayed
up to two weeks.6 In our case age of the patient was
11 years and complication started on 11thday after
appearance of rash. ADEM following chickenpox is
abrupt in onset with rapid progression, usually when
examthema is fading. Fever, headache, meningismus,
seizure, ataxia, tremor, nystagmus, impaired consciousness are the usual presentation. There may be
features of hemiparesis, paraparesis, quadriparesis,
cerebellitis, extensor planter, loss or increased tendon
reflexes, sensory loss or brain stem involvement.
CSF shows lymphocytic pleocytosis with elevated
protein, transient oligoclonal band.7 CT scan Brain
may be normal.Clinical signs of cerebellar involvement may be normal in MRI. In ADEM there are
extensive changes in brain and spinal cord, whitematter hyperintense signal in T2, FLAIR sequence with
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gadolinium enhancement on T1 weighted sequences.8
Treatment of ADEM is supportive and use of high
dose of methyl prednisolone with tapering is beneficial. Plasma exchange and intravenous immunoglobulin may be used in steroid non responder cases.
Role of methyl prednisolone is established but of
acyclovir is controvertial.9
In our case, patient’s onset was acute and presented
with features of encephalitis, cerebelitis and myelitis
with rapid recovery on methyl prednisolone treatment. Follow up at one month was uneventful.
CONCLUSION
We present a case report on a 11-year old boy who
presented with neurological complications on 11th
day following the appearance of rash of chicken pox.
He was diagnosed as acute disseminated encephalomyelitis and was managed successfully with antiviral
and steroid.
Acknowledgment: I would like to acknowledge the
patient, his parents and record keeping staff of ID &
BG Hospital.
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encephalomyelitis exacerbated by varicella. Acta Paediatr Jpn.
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2. Marchioni E, Ravaglia S, Piccolo G et al. Postinfectious inflammatory disorders: subgroups based on prospective follow-up. Neurology. 2005 Oct 11;65(7):1057-65.
3. Alvord BC Jr: Demyelinating disease, In Vinken PJ, Bruyen
GW eds Handbook of Clinical Neurology, Elsevier PublisherBV, Amsterdam, 1985,3,467-502
4. Whitley J Richard, Varicella-Zoster virus infections, In Harrison’s Principles of Internal Medicine, 18th edition, vol 1,
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transverse myelitis in a previously vaccinated child, Pediatric
Neurol,208,38(5),370-72
7. deSeze J,Debouverie M, Zephir H et al, Acute fulminant
demyelinating disease: a descriptive study of 60 patients,
Arch Neurol 2007,64(10),1426-32
8. Hynson JL, Kornberg AL, Coleman LT et al ,Clinical and
neurologic features of acute disseminated encephalomyelitis
in children, NNeurology ,2001,56(10),1308-12
9. Saabire G, Hollenberg H, Meyer L,Huault G, Landrieu P,
Tardieu M, High dose methyl prednisolone in severe acute
myelopathy, Arch Dis Child,1997,76(2)167-68
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CASE REPORT
RETROCAVAL /CIRCUMCAVAL URETER: RARE
CONGENITAL ANOMALY OF URETER OR INFERIOR VENA
CAVA
Samir M Shah1, Chirag K Patel2, Smit M. Mehta2, Vikram B Gohil3
Author’s Affiliations: 1Professor & Head; 2Resident doctor; 3Associate Professor, Department of General Surgery,
Govt. Medical College, Bhavnagar
Correspondence: Dr Chirag K Patel Email: [email protected]
ABSTRACT
Retrocaval ureter also referred to as pre-ureteral vena cava is a rare congenital anomaly with the ureter passing
posterior to the inferior vena cava and coming medial to it. Though it is a congenital anomaly, patients do not
normally present with symptoms until the 2nd and 3rd decades of life from various presenting complain resulting due to hydronephrosis. We present a case reported in Bhavnagar, Gujarat; a 19-year-old male presented
with right flank pains of 2 yr and associated right moderate hydronephrosis. Diagnoses were confirmed with
intravenous pyelography (IVP) and computed tomography of abdomen with IVP. And patient was treated
with open surgery, including resection of stenosed retrocaval ureter and spatulated end to end ureterouereterostomy in front of IVC.
Key words: Retrocaval ureter, Circumcaval ureter, Flank pain, Hydronephrosis, uretero-ureterostomy
INTRODUCTION
Retrocaval ureter also referred to as circumcaval ureter or preureteral vena cava is a rare congenital anomaly with the ureter passing posterior to the inferior
vena cava. The ureter classically course medially behind the inferior vena cava winding around it and
then passes laterally in front of it to then course distally to the bladder. Though it is a congenital anomaly, patients do not normally present with symptoms
until the 2nd and 3rd decades of life, with various
complain resulting due to back pressure changes
leads to hydronephrosis. The hydronephrosis may be
due to kinking of the ureter, a ureteric segment that
is adynamic or compression of inferior vena cava. It
was initially considered as aberration in ureteric development; however current studies in embryology
have led to it being considered as an aberration in the
development of the inferior vena cava.1,2 Hence it is
being suggested that the anomaly be referred to as a
pre-ureteral vena cava.3
CASE HISTORY
A 19 year old male patient, presented with history of
right flank pain since 2 year, and taking analgesics
from general practitioner for right flank pain, gradually pain was increase. Patient had no any other
complains and no operative intervention in the past.
There were no significant findings on general and per
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abdominal examination. Full blood count, urinalysis
and blood urea and creatinine were normal. Abdominal ultrasonography revealed a right moderate hydronephrosis and right upper hydroureter. An intravenous pyelography showed right moderate hydronephrosis and hydroureter of the proximal ureter
with non-visualization of the rest of the right ureter
with normal left kidney and ureter (figure 1). As we
were suspecting a benign cause of ureteric stricture
or external compression of ureter, patient was subjected to computed tomography with intravenous
pyelography which was suggestive of right circumcaval ureter with right hydronephrosis and right upper hydroureter (figure 2). Patient was undergone laprotomy and excision of retrocaval stenosed segment
of right ureter and spatulated end to end ureterouereterostomy with double J stent kept insitu. Post
operative course was normal. Patient was discharge
from hospital on 4th post operative day. Stitch removal on 8th post operative day. Double J stent removed on 21th post operative day. Follow up ultrasonography after 2 month showed normal, no hydronephrosis and hydroureter. With normal renal
function test.
DISCUSSION
Retrocaval ureter is a rare congenital anomaly occurring with incidence of about 1 in 1500 people with a
three to four times male predominance in autopsy
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studies.4 Though few clinical cases have been reported worldwide. The first observed case of retrocaval ureter was described by Hochstetter in 18935.
Though initially thought of as an anomaly of ureteric
development studies in embryology has revealed an
anomaly related to the development of the inferior
vena cava. The appropriate term giving the correct
description of the anomaly is preureteral vena cava.
The anomaly predominantly involves the right ureter,
as was observed in this reported case. If it involves
the left ureter then it is usually associated with either
partial or complete situs inversus or duplication of
the inferior vena cava (IVC).6 The ureter typically deviates medially behind the inferior vena cava,
winding about and crossing in front of it from a
medial to a lateral direction, to resume a normal
course, distally, to the bladder. The renal pelvis and
upper ureter typically appear elongated and dilated in
a “J” or fishhook shape before passing behind the
vena cava. Although it is a congenital anomaly it
normally presents in the second and third decade of
life as typified by the ages of the presented cases.
Majority of patients presenting with symptoms,
present with flank or abdominal pain that can be intermittent, dull and aching and is commonly due to
ureteric obstruction and associated hydronephrosis.
Some patients may present with recurrent urinary
tract infection and haematuria. Renal calculi and
pyonephrosis may complicate the condition. Some
cases are found incidentally during radiographic imaging for other conditions.
Retrocaval ureter classify into two clinical types.
Type 1 is commonest and has moderate to severe
hydronephrosis in about 50% of cases with extreme
medial deviation of middle ureteric segment and the
ureter assuming an S or ‘fish hook’ deformity. Type 2
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has less medial deviation of the ureter with mild or
no associated hydronephrosis and forms about 10%
of cases7. Surgical management is reserved for the
type 1 cases that are usually symptomatic. Retrocaval
ureter has hence been defined as a rare congenital
anomaly that requires surgical correction in the
symptomatic patient.
Abdominal ultrasound demonstrates hydronephrosis.
IVU usually does not demonstrate the middle and
distal ureter may require a retrograde ureteropyelogram to demonstrate the ureter. Spiral CT scan may
define the ureter and inferior vena cava anomalies
obviating the need for a retrograde ureteropyelogram
and is considered an investigation of choice. Important differential diagnosis includes retroperitoneal
fibrosis and retro peritoneal masses displacing the
ureter from its normal course. Abdomino pelvic CT
scan is helpful in excluding these conditions.MRI can
nicely demonstrate the course of a preureteral vena
cava and may be a more detailed and less invasive
imaging modality, without exposure to radiation,
when compared with CT and retrograde ureteropyelography. Treatment is surgical and involves division
of the ureter and repositioning it anterior to the inferior vena cava. This may be achieved through an
anastomosis between the renal pelvis and the ureter
or a uretero-ureteric anastomosis over a double-J
stent. The segment behind the inferior vena cava
which may be aperistaltic is either excised or left in
situ. In this reported case, the segment was excised.
Surgical intervention is for symptomatic cases and
changes of hydronephrosis and altered renal function. Patients with minimal caliceal dilatation and no
significant symptoms do not need surgery but need
to be followed up.
Figure 1: Intravenous pyelography of patient, showing right side moderate hydronephrosis and upper hydroureter with kinking of upper ureter
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have been reported worldwide. Treatment is surgical
allowing for correction of the anomaly with resolution of symptoms. There is the need to research
whether it is developmental anomaly of ureter of inferior vena cava.
REFERENCES
Figure 2: CT Scan of abdomen with IVP showing
abnormal course of right ureter, coming posterior
and medial to inferior vena cava
CONCLUSION
1.
Chuang VP, Mena CE, Hoskins PA. Congenital anomalies
of the inferior vena cava. Review of embryogenesis and
presentation of a simplified classification. Br J Radiol. 1974;
47:206–213.
2.
Schlussel RN, Retik AB. Preureteral Vena Cava. In: Kavoussi LR, Novick AC, Partin AW, Peters CA, editors.
Campbell-Walsh Urology. 9th ed. Elsevier Saunders; 2007.
pp. 3418–3420. .
3.
Dreyfuss W. Anomaly simulating a retrocaval ureter. J Urol.
1959; 82:630.
4.
Heslin JE, Mamonas C. Retrocaval ureter: Report of four
cases and review of literature. J Urol.1951; 65:212–222.
5.
Olson RO, Austen G., Jr N Engl J Med. 1950; 242:963–
968.
6.
Watanabe M, Kawamura S, Nakada T, et al. Left preureteral
vena cava (retrocaval or circumcaval ureter) associated with
partial situs inversus. J Urol. 1991; 145:1047–1048.
7.
Bateson E, Atkinson D. Circumcaval ureter: a new classification. Clin Radiol. 1969; 20:173–177.
Retrocaval ureter is a rare congenital anomaly that
presents clinically late in the second and third decades of life. Very few clinically symptomatic cases
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CASE REPORT
MESENTERIC PANNICULITIS – A CASE REPORT
Amol Jagdale1, Saurav Mittal2, Krutik Patel2, Azhar Shaikh2
Author’s Affiliations: 1Professor & Head; 2Resident, Department of Radiology, Dr. Vasantrao Pawar Medical College,
Aadgaon, Nashik
Correspondence: Dr Saurav Mittal Email: [email protected]
ABSTRACT
Introduction: It is a benign fibro-proliferative process that involves the adipose tissue surrounding the mesentry.It is also known as Mesenteric lipodystrophy or scelrosing mesenteritis.1,2 It is sometimes called as a variant of Weber Christian Disease.1
Key words: Mesentery, Inflammation, Panniculitis, CT, USG, Fibrosis, Inflammation, Fat.
INTRODUCTION
CASE REPORT
Mesenteric panniculitis is a benign fibroinflammatory process involving the adipose tissue of
the mesentry and is characterized by fat necrosis,
chronic inflammation and fibrosis.1, 2, 3 It was first
described by Jura in 1924.4 It has a variety of synonyms most common being Mesenteric lipodystrophy and sclerosing mesenteritis.1, 2 When pathologic
component is inflammatory or fatty, the disease is
known as Mesenteric panniculitis.2,5 When fibrosis is
the dominant component, it is known as Retractile
mesenteritis.2, 4, 5
A 65 year old male came to the department of radiodiagnosis for sonography of abdomen and for the
complaints of pain in left hypochondrium and left
lumbar region since 1 year.The pain was nonradiating and had no aggravating or relieving factors.
There was no alteration in bowel and bladder habits.
The patient is under regular treatment for the past
three years for diabetes and hypertension. Sonography was performed on Siemens Acuson 300x machine.
Retractile mesenteritis is the more invasive form of
Mesenteric panniculitis, which is complicated by fibrosis and retraction. 5 Most patients present as a benign, slowly progressive course. The outcome of the
disease is usually favourable.3 It is a non-specific inflammation. 5 The cause of the disease is unclear 5, it
is said to be an auto-immune response to unknown
sources, or collagen vascular disease; Ischemia of the
mesentery may also be responsible. 4, 5
Mesenteric panniculitis is usually associated with idiopathic inflammatory conditions like retro-peritoneal
fibrosis, sclerosing cholangitis, reidel’s thyroiditis and
orbital pseudotumor. 2 Mesenteric panniculitis is also
reported in association with malignancy. It usually
involves the root of mesentery of the small bowel,
but can occasionally involve the mesocolon. 2
CLINICAL FEATURES
Patients may present with abdominal pain, intestinal
obstruction, ischemia, mass or diarrhea. 2
Increased ESR or anemia may be seen as the predominant laboratory finding. However, laboratory tests
are non-specific.
NJMR│Volume 6│Issue 1│Jan – Mar 2016
USG Findings: Ill defined hyperechoic diffuse area
seen in left lumbar region. The lesion was surrounded by a hypo-echoic rim, s/o tumour pseudocapsule. Vessels were seen traversing through the lesion. No bowel dilatation or ascites was seen. Considering ultrasound findings, diagnosis of mesenteric
panniculitis was suspected and patient was advised
CT scan abdomen for further evaluation.
Abdominal CT examination was performed on Siemens Somatom Emo 6 machine with 6 mm and 2
mm sections after bowel opacification using oral and
i.v iopamidol.
CT Findings: Ill defined area of increased attenuation was seen involving small bowel mesentry in central abdomen below the level of pancreas. The area
measured approx 13.0 x 7.5 x 1.4 cm and separate
firm adjacent normal mesenteric fat by tumor pseudocapsule. Mesenteric vessels appear traversing
through the lesion. Rim of mesenteric fat seen
around mesenteric vessels with surrounding increased density, s/o “ Fat ring sign.”
No obvious displacement of vessels. Few oval intralesional lymph nodes were seen. Adjacent small bowel loops appear normal. No bowel dilatation or ascites was noted.
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1a)
2b)
1b)
2c)
1c)
Fig 1a-c: Ultrasonography images of the case
2d)
Fig 2a-d: CT images of the case
2a)
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DISCUSSION
Mesenteric panniculitis can also be called as “Mesenteric manifestation of Weber Christian disease”.1
This is because of the pathologic microscopic similarity between the affected fatty tissue and that of
Weber Christian disease. 1 It mainly affects
males 2,3 and is usually seen between 6th and 7th decades of life. 3
It mainly affects the mesentery of small intestine,
large intestine is rarely involved. 1
CT Features in Mesenteric panniculitis. CT features
vary depending on the predominant tissue component (Fat ,inflammation ,fibrosis) 2 Two CT features
are somewhat specific for this disease. These are –
There is no specific treatment, it regresses spontaneously. 7 It usually responds to steroids, immunosuppressive threrapy and antibiotics. 1, 2, 7
CONCLUSION
Mesenteric panniculitis is a rare disease of unknown
etiology and is usually associated with idiopathic diseases.
Left half of the abdomen is more frequently involved
and this is consistent with orientation of jejunal mesentery. Mesenteric panniculitis has a propensity for
jejunal mesentery.
REFERENCES
1. FAT RING sign –
This sign reflects that fat around the mesenteric vessels are preserved.
2. TUMOR PSEUDOCAPSULE 3,7
Other CT features are
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2,5,7
1.
Popkharitov I Angel, Chomov N Georgi–Mesenteric panniculitis- A case report and review of the literature; Journal of
Medical case reports, 2007, 1:108.
2.
Horton M. Karen, Lawler Leo P, -CT findings in Mesenteric
panniculitis : Spectrum of disease, Radiographics, November
2003, volume 23, Issue 6.
3.
Ferrari Terresa Christina A,CoutoM.Carolina, FariaC.Louciana, VilacaTatiane S, Xavier Marcelo A. P –An
unusual presentation of Mesenteric panniculitis; Clinics volume 63, Number 6, Sao Paulo 2008.
4.
IssaIyad, Baydoun Hassan - Mesenteric panniculitis : Various
presentations and treatment regimens.
5.
Daskalogiannaki M. Voloudaki A. Prassopoulos P.Magkanas
E. Stefanaki K. Apostolaki E. Gourtsoyiannis N. – CT evaluation of Mesenteric panniculitis, Prevalence and associated
diseases, American Journal of Radiology, Feb 2000, Vol 174,
Number 2.
6.
Shah D.M, Patel S.B, Shah S.R,Goswami K.G -Mesenteric
panniculitis- A case report and review of literature,; Indian
Journal of Radiology and Imaging, 2005, volume 15, Issue 2.
7.
RummanNisreen, George Rumman, DisiNimer, Zagha Rami, SharabatiBarakat -Mesenteric panniculitis in a child misdiagnosed as appendicular mass: A case report and review of
literature; Springer plus 2014, 3:73.
–
- Solitary well defined mass composed of inhomogenous fatty tissue with CT attenuation higher
than those of retroperitoneal fat at the root of
small bowel mesentery.
- Engulfment of superior mesenteric vessels without vascular involvement.
- No evidence of invasion of adjacent small bowel
loops even if they are displaced.
- Calcification within the mass.
- Subtle increase in attenuation in the mesentery
without evidence of discrete soft tissue mass
(Misty mesentery). 2 It is not specific for Mesenteric panniculitis.
The diagnosis is mainly made by abdominal exploration. A biopsy is usually necessary for confirmation
of the diagnosis. 1, 3
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Reference Citation
Articles in Journals
a) Standard journal article (for up to six authors):
Shukla N, Husain N, Agarwal GG, Husain M. Utility of cysticercus fasciolaris antigen in Dot ELISA for the diagnosis
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Bazdar A, et al.
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